A Study to Explore the Efficacy of TRV027 in Patients Hospitalized for Acute Decompensated Heart Failure (BLAST-AHF)

Inclusion Criteria:

1. Men or women aged ≥21 years and ≤ 85 years 1a.Women of non-child-bearing potential
2. Able to provide written informed consent
3. Pre-existing diagnosis of heart failure and at least 30 days treatment with daily oral loop diuretics
4. Systolic blood pressure ≥105 mmHg and ≤ 160 mmHg within 30 minutes of randomization
5. Ventricular rate ≤125 bpm. Patients with rate-controlled persistent or permanent atrial fibrillation (aFib) at screening are permitted.

6. Presence of ADHF defined by:

   • BNP > 400 pg/mL or NT-proBNP > 1600 pg/mL

     • For patients with BMI >30 kg/m2: BNP > 200 pg/mL or NT-proBNP > 800 pg/mL
     • For patients with rate-controlled persistent or permanent aFib: BNP > 600 pg/mL or NT-proBNP > 2400 pg/mL
     • Congestion on chest radiograph (CXR)

   AND at least two (2) of the following:

   • Rales by chest auscultation
   • Edema ≥ +1 on a 0-3 + scale, indicating indentation of skin with mild digital pressure that requires 10 or more seconds to resolve in any dependent area including extremities or sacral region.
   • Elevated jugular venous pressure (≥8 cm H2O)
7. Receipt of a IV loop diuretic at a minimum dose 40 mg furosemide (or equivalent loop diuretic) for the treatment of dyspnea due to ADHF at least 1 hour prior to anticipated randomization and the initiation of study medication
8. Patient report of dyspnea at rest or upon minimal exertion during screening at least one hour after administration of IV loop diuretic

Exclusion Criteria:

1. Women who are pregnant or breast-feeding

2. Clinical presentation:

   1. Suspected ACS based on clinical judgment
   2. Coronary revascularization in the 3 months prior to screening or planned during current admission.
   3. Temperature >38.5oC
   4. Clinically significant anemia
   5. Serum sodium >145 mEq/L (145 mmol/L)
   6. Current or planned ultrafiltration, paracentesis, hemofiltration or dialysis at time of screening
   7. Any mechanical ventilation
   8. CPAP/BiPAP discontinued less than 1 hour prior to randomization
   9. History of LVAD or IABP within the last year
   10. Intravenous radiographic contrast agent within 72 hours prior to screening or presence of acute contrast induced nephropathy at the time of screening
   11. Presence of clinically significant arrhythmia
   12. Uncertainty of ability to complete follow up

3. Medications:

   1. nitroprusside or nesiritide
   2. Intravenous nitrates
   3. use of inotropes
   4. Use of ARBs within 7 days of prior to randomization
   5. Use of any investigational medication within 30 days
   6. clinically significant hypersensitivity or allergy to, or intolerance of, angiotensin receptor blockers

4. Medical history:

   1. Major surgery within 8 weeks prior to screening
   2. Stroke within 3 months prior to screening
   3. eGFR (sMDRD) <20 mL/min/1.73m2 or >75 mL/min/1.73m2 between presentation and randomization
   4. Post cardiac or renal transplant
   5. Listed for renal transplant or cardiac transplant with anticipated transplant time to transplant < 6 months
   6. History of severe left ventricular outlet obstruction (either valvular or sub-valvular), severe mitral valve stenosis or severe aortic regurgitation
   7. Cardiac valvular abnormality that requires surgical correction
   8. Complex congenital heart disease
   9. Hypertrophic or restrictive cardiomyopathy
   10. significant pulmonary or hepatic disease that could interfere with the evaluation of safety or efficacy of TRV027
   11. life expectancy of less than 6 months