RHYTHM (Formerly Escape II Myocardium)
Study Details
Study Description
Brief Summary
For aim 1, the proposed studies will be performed in 150 patients with RA and 25 subjects without RA (healthy volunteers) who will function as controls.
For aim 2, 25 of the patients enrolled in aim 1 (who are in need for further treatment due to increased RA activity despite their current treatment) will be recruited to continue in the study for an additional 24 (+/- 2) weeks (or 6 months). These patient will receive a TNF inhibitor in addition to their current treatment in an open label protocol for increased disease activity and in the context of standard of care.
The investigators hypothesize that anti-TNF agents in RA patients without heart disease will not adversely affect the heart (will not cause a detrimental change in heart structure or its function).
Condition or Disease | Intervention/Treatment | Phase |
---|---|---|
|
Phase 4 |
Detailed Description
Patients with Rheumatoid Arthritis (RA) have a shortened life expectancy compared to the general population. Cardiovascular disease (CVD), including heart failure (HF), is the primary cause of the extra deaths in RA. HF, in general, results from failure of the heart muscle to pump adequately. In other words the heart muscle in HF becomes "weak". In patients without RA, the heart muscle gets larger before symptoms of HF appear. Contrary to that, patients with RA have reduced heart size and reduced heart strength. This may mean that in RA the pathway to heart failure may be different compared to what happens in patients without RA. It is possible - for example - that in RA the heart muscle becomes smaller before it becomes weak (while in non-RA patients the heart muscle becomes larger before it becomes weak). It is possible that cells that create inflammation in the joints may also do the same in the heart muscle making it smaller, thinner and eventually weaker.
Patients with RA nowadays can be treated with a variety of medications for their joint inflammation. These medications are powerful and have reduced the risk of permanent joint damage and disability. However it is unknown what is the effect of these medications on the heart size and strength and whether they increase or decrease the risk for cardiovascular disease and heart failure.
Among the medications used for RA are medications called TNF inhibitors. They are usually prescribed to patients who have joint inflammation that has not responded to treatment with the first line medication Methotrexate. Data in non-RA patients with advanced heart failure suggest that anti-TNF agents may not help heart failure and may even be harmful. However, the effect of these agents on the hearts of RA patients has never been directly studied. Some observational studies suggest that RA patients treated with TNF inhibitors have a lower risk of developing heart disease. Overall the knowledge regarding the effect of TNF inhibitors on RA patients heart function is limited.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
---|---|
Experimental: Patients - DMARDs + TNF Inhibitors Patients will receive a TNF inhibitor in addition to their current treatment in an open label protocol for increased disease activity and in the context of standard of care. |
Drug: TNF inhibitors
TNF inhibitors are an FDA approved class of medications indicated for the treatment of RA when initial treatment (usually with methotrexate) has failed to achieve remission of RA disease activity. TNF inhibitors are part of the standard of care management of RA.
The possible TNF inhibitors are: Remicade, Humira, Enbrel, Cimzia, Simponi.
Other Names:
Drug: DMARDs
Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs.
Other Names:
|
Active Comparator: Patients - DMARDs only Patients will receive their current treatment in an open label protocol in the context of standard of care. |
Drug: DMARDs
Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs.
Other Names:
|
No Intervention: Healthy Volunteers Subjects without RA who will function as controls. |
Outcome Measures
Primary Outcome Measures
- Number of Participants With Myocardial FDG Uptake [Baseline]
This is designed to evaluate the baseline characteristics of the cross sectional RA cohort to understand the correlation of disease activity measured by the Clinical Disease Activity Index (CDAI) with myocardial inflammation measured by fluorodeoxyglucose (FDG) uptake in positron emission tomography (PET) scan at the baseline visit. Myocardial FDG uptake is classified as "diffuse" or "focal."
Secondary Outcome Measures
- Number of Participants With Myocardial FDG Uptake After Escalation of RA Pharmacotherapy [Baseline, 6-Month Follow-up]
This is designed to measure the myocardial inflammation, and its association with change in CDAI, after ramp-up of RA therapy over 6 months. Measurements are taken at baseline and 6-months post treatment escalation. Myocardial FDG uptake is classified as "diffuse" or "focal."
- LV Structure (Mean EDVI) in Association With Myocardial FDG Uptake [Baseline]
This is designed to evaluate the baseline characteristics of the entire RA cohort to understand the association of myocardial inflammation measure by FDG uptake with measures of left ventricular (LV) structure measured by 2D/3D echocardiogram at the baseline visit.
- LV Function (Mean Stroke Volume Index) in Association With Myocardial FDG Uptake [Baseline]
This is designed to evaluate the baseline characteristics of the entire RA cohort to understand the association of myocardial inflammation measure by FDG uptake with measures of left ventricular (LV) function measured by 2D/3D echocardiogram at the baseline visit.
Eligibility Criteria
Criteria
For RA patients (150 patients):
INCLUSION CRITERIA
-
Diagnosis of Rheumatoid Arthritis by 2010 American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) diagnostic criteria
-
Age>18 years old
-
Moderate to high RA disease activity defined by a Clinical Disease Activity Index (CDAI) of >10
-
Stable dose of Methotrexate for 6 weeks prior to enrollment
-
Stable doses of Nonsteroidal anti-inflammatory drug (NSAID) and prednisone (if already taking these medications) for 2 weeks prior to study
EXCLUSION CRITERIA
-
Prior self reported or physician diagnosed CV event (MI; angina; stroke or Transient Ischemic Attach (TIA); Heart Failure (HF); prior CV procedure (e.g., coronary artery bypass graft, angioplasty, valve replacement, pacemaker)
-
Contraindications to having a PET-CT scan or receive adenosine or Fludeoxyglucose (FDG)
-
Active treatment for Cancer
-
Uncontrolled hypertension
-
Diabetes
-
Smoking
-
Treatment with a TNF inhibitor or other biologic currently or within the last 6 months
-
Current treatment with "Triple Therapy" or within the last 2 months
-
Untreated positive purified protein derivative (PPD) tuberculosis skin test or active tuberculosis
-
History of Lymphoma and Melanoma
-
Ejection Fraction (EF) < 40% (if not known in advance then the Study Visit I Echocardiogram results will be used to exclude the patient from randomization and follow up)
-
Change in NSAID/Prednisone dosage in last 2 weeks
-
Participation in other research studies involving imaging/radiation exposure
For non-RA subjects (25 controls):
INCLUSION CRITERIA
-
Age>18 years old
-
Absence of diagnosis of RA
EXCLUSION CRITERIA
-
Prior self reported or physician diagnosed CV event (MI; angina; stroke or Transient Ischemic Attach (TIA); Heart Failure (HF); prior CV procedure (e.g., coronary artery bypass graft, angioplasty, valve replacement, pacemaker)
-
Contraindications to having a PET-CT scan or receive adenosine or FDG
-
Uncontrolled hypertension
-
Participation in other research studies involving imaging/radiation exposure
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | Columbia University Medical Center | New York | New York | United States | 10032 |
Sponsors and Collaborators
- Columbia University
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Investigators
- Principal Investigator: Joan M Bathon, MD, Columbia University
Study Documents (Full-Text)
More Information
Additional Information:
Publications
None provided.- AAAI1026
- 7R01AR050026-07
Study Results
Participant Flow
Recruitment Details | |
---|---|
Pre-assignment Detail |
Arm/Group Title | Patients - DMARDs + TNF Inhibitors | Patients - DMARDs Only | Healthy Volunteers | Patients - Cross Sectional (RA) |
---|---|---|---|---|
Arm/Group Description | Patients will receive a TNF inhibitor in addition to their current treatment in an open label protocol for increased disease activity and in the context of standard of care. TNF inhibitors: TNF inhibitors are an FDA approved class of medications indicated for the treatment of RA when initial treatment (usually with methotrexate) has failed to achieve remission of RA disease activity. TNF inhibitors are part of the standard of care management of RA. The possible TNF inhibitors are: Remicade, Humira, Enbrel, Cimzia, Simponi. DMARDs: Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs. | Patients will receive their current treatment in an open label protocol in the context of standard of care. DMARDs: Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs. | Subjects without RA who will function as controls. | A cohort of patients with Rheumatoid Arthritis will undergo the baseline study visit only (no randomization to treatment). Note, that those who were randomized, their data will be utilized in the full cross sectional analysis. |
Period Title: Overall Study | ||||
STARTED | 8 | 4 | 16 | 121 |
COMPLETED | 7 | 2 | 15 | 117 |
NOT COMPLETED | 1 | 2 | 1 | 4 |
Baseline Characteristics
Arm/Group Title | Patients - DMARDs + TNF Inhibitors | Patients - DMARDs Only | Healthy Volunteers | Patients - Cross Sectional (RA) | Total |
---|---|---|---|---|---|
Arm/Group Description | Patients will receive a TNF inhibitor in addition to their current treatment in an open label protocol for increased disease activity and in the context of standard of care. TNF inhibitors: TNF inhibitors are an FDA approved class of medications indicated for the treatment of RA when initial treatment (usually with methotrexate) has failed to achieve remission of RA disease activity. TNF inhibitors are part of the standard of care management of RA. The possible TNF inhibitors are: Remicade, Humira, Enbrel, Cimzia, Simponi. DMARDs: Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs. | Patients will receive their current treatment in an open label protocol in the context of standard of care. DMARDs: Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs. | Subjects without RA who will function as controls. | A cohort of patients with Rheumatoid Arthritis will undergo the baseline study visit only (no randomization to treatment). Note, that those who were randomized, their data will be utilized in the full cross sectional analysis. | Total of all reporting groups |
Overall Participants | 8 | 4 | 16 | 121 | 149 |
Age (Count of Participants) | |||||
<=18 years |
0
0%
|
0
0%
|
0
0%
|
0
0%
|
0
0%
|
Between 18 and 65 years |
8
100%
|
2
50%
|
15
93.8%
|
105
86.8%
|
130
87.2%
|
>=65 years |
0
0%
|
2
50%
|
1
6.3%
|
16
13.2%
|
19
12.8%
|
Age (years) [Mean (Full Range) ] | |||||
Mean (Full Range) [years] |
55.125
|
56
|
52
|
55.6
|
54.38
|
Sex: Female, Male (Count of Participants) | |||||
Female |
6
75%
|
4
100%
|
12
75%
|
105
86.8%
|
127
85.2%
|
Male |
2
25%
|
0
0%
|
4
25%
|
16
13.2%
|
22
14.8%
|
Ethnicity (NIH/OMB) (Count of Participants) | |||||
Hispanic or Latino |
3
37.5%
|
1
25%
|
4
25%
|
52
43%
|
60
40.3%
|
Not Hispanic or Latino |
5
62.5%
|
3
75%
|
12
75%
|
69
57%
|
89
59.7%
|
Unknown or Not Reported |
0
0%
|
0
0%
|
0
0%
|
0
0%
|
0
0%
|
Race (NIH/OMB) (Count of Participants) | |||||
American Indian or Alaska Native |
0
0%
|
0
0%
|
0
0%
|
0
0%
|
0
0%
|
Asian |
1
12.5%
|
0
0%
|
0
0%
|
4
3.3%
|
5
3.4%
|
Native Hawaiian or Other Pacific Islander |
0
0%
|
0
0%
|
0
0%
|
0
0%
|
0
0%
|
Black or African American |
2
25%
|
1
25%
|
5
31.3%
|
28
23.1%
|
36
24.2%
|
White |
5
62.5%
|
3
75%
|
11
68.8%
|
53
43.8%
|
72
48.3%
|
More than one race |
0
0%
|
0
0%
|
0
0%
|
36
29.8%
|
36
24.2%
|
Unknown or Not Reported |
0
0%
|
0
0%
|
0
0%
|
0
0%
|
0
0%
|
Outcome Measures
Title | Number of Participants With Myocardial FDG Uptake |
---|---|
Description | This is designed to evaluate the baseline characteristics of the cross sectional RA cohort to understand the correlation of disease activity measured by the Clinical Disease Activity Index (CDAI) with myocardial inflammation measured by fluorodeoxyglucose (FDG) uptake in positron emission tomography (PET) scan at the baseline visit. Myocardial FDG uptake is classified as "diffuse" or "focal." |
Time Frame | Baseline |
Outcome Measure Data
Analysis Population Description |
---|
2 RA patients and 1 healthy volunteer (control subject) were not included in this analysis population because the subjects withdrew study participation prior to scan (no data were collected). |
Arm/Group Title | Patients - Cross Sectional (RA) | Healthy Volunteers |
---|---|---|
Arm/Group Description | A cohort of patients with Rheumatoid Arthritis who underwent the baseline visit analysis and completed the visit in the full cross sectional analysis. | A cohort of healthy volunteers (those without an autoimmune or history of cardiac illness) was utilized. n=16 were recruited directly, while n=11 were recruited via the CUIMC Nuclear Cardiology archive. |
Measure Participants | 119 | 15 |
Diffuse FDG Uptake |
21
262.5%
|
4
100%
|
Focal FDG Uptake |
25
312.5%
|
1
25%
|
No FDG Uptake |
73
912.5%
|
10
250%
|
Title | Number of Participants With Myocardial FDG Uptake After Escalation of RA Pharmacotherapy |
---|---|
Description | This is designed to measure the myocardial inflammation, and its association with change in CDAI, after ramp-up of RA therapy over 6 months. Measurements are taken at baseline and 6-months post treatment escalation. Myocardial FDG uptake is classified as "diffuse" or "focal." |
Time Frame | Baseline, 6-Month Follow-up |
Outcome Measure Data
Analysis Population Description |
---|
2 TNFi, and 2 DMARDs and 1 healthy volunteer (control subject) were not included in this analysis population because the subjects withdrew participation prior to study completion or scan (no data were collected). |
Arm/Group Title | RA Patients - Pharmacotherapy Escalation (TNFi) | RA Patients - Pharmacotherapy Escalation (DMARD) | Healthy Volunteers |
---|---|---|---|
Arm/Group Description | Participants were randomized to TNFi or DMARD therapy. Patients will receive their current treatment in an open label protocol in the context of standard of care. TNFi: biologic treatment for RA, such as Humira, Enbrel, Remicade, | Participants were randomized to TNFi or DMARD therapy. Patients will receive their current treatment in an open label protocol in the context of standard of care. DMARDs: Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs. | A cohort of healthy volunteers (those without an autoimmune or history of cardiac illness) was utilized. n=16 were recruited directly, while n=11 were recruited via the CUIMC Nuclear Cardiology archive. |
Measure Participants | 6 | 2 | 15 |
Focal Baseline FDG Uptake |
1
12.5%
|
1
25%
|
1
6.3%
|
Focal Follow-up FDG Uptake |
1
12.5%
|
0
0%
|
NA
NaN
|
Diffuse Baseline FDG Uptake |
4
50%
|
1
25%
|
4
25%
|
Diffuse Follow-up FDG Uptake |
2
25%
|
0
0%
|
NA
NaN
|
Title | LV Structure (Mean EDVI) in Association With Myocardial FDG Uptake |
---|---|
Description | This is designed to evaluate the baseline characteristics of the entire RA cohort to understand the association of myocardial inflammation measure by FDG uptake with measures of left ventricular (LV) structure measured by 2D/3D echocardiogram at the baseline visit. |
Time Frame | Baseline |
Outcome Measure Data
Analysis Population Description |
---|
Only 119 out of 121 subjects had data analyzed due to 2 subject withdrawals prior to scan. |
Arm/Group Title | Patients - Cross Sectional (RA) | Healthy Volunteers |
---|---|---|
Arm/Group Description | A cohort of patients with Rheumatoid Arthritis who underwent the baseline visit analysis and completed the visit in the full cross sectional analysis. | A cohort of healthy volunteers (those without an autoimmune or history of cardiac illness) was utilized. n=16 were recruited directly, while n=11 were recruited via the CUIMC Nuclear Cardiology archive |
Measure Participants | 119 | 16 |
Mean (Standard Deviation) [ml/m^2] |
53.8
(11)
|
49.1
(12.9)
|
Title | LV Function (Mean Stroke Volume Index) in Association With Myocardial FDG Uptake |
---|---|
Description | This is designed to evaluate the baseline characteristics of the entire RA cohort to understand the association of myocardial inflammation measure by FDG uptake with measures of left ventricular (LV) function measured by 2D/3D echocardiogram at the baseline visit. |
Time Frame | Baseline |
Outcome Measure Data
Analysis Population Description |
---|
Only 119 out of 121 subjects had data analyzed due to 2 subject withdrawals prior to scan. |
Arm/Group Title | Patients - Cross Sectional (RA) | Healthy Volunteers |
---|---|---|
Arm/Group Description | A cohort of patients with Rheumatoid Arthritis who underwent the baseline visit analysis and completed the visit in the full cross sectional analysis. | A cohort of healthy volunteers (those without an autoimmune or history of cardiac illness) was utilized. n=16 were recruited directly, while n=11 were recruited via the CUIMC Nuclear Cardiology archive |
Measure Participants | 119 | 16 |
Mean (Standard Deviation) [ml/m^2] |
58.6
(13.9)
|
31.3
(7.5)
|
Adverse Events
Time Frame | For those who underwent the baseline scans only (RA cross-sectional cohort, Healthy Controls), the gathering of adverse events were determined from the events from the visit alone (either acute, or patient-reported follow-up); For the group escalated in treatment therapy (n=12), adverse events were collected from baseline visit/randomization to the end-of-study safety visit conducted 6-8 weeks after the 6-month study visit. | |||||||
---|---|---|---|---|---|---|---|---|
Adverse Event Reporting Description | An adverse event (AE) is any undesirable sign, symptom or medical condition occurring after starting study drug (or therapy). Medical conditions/diseases present before starting study treatment are only considered adverse events if they worsen after starting study therapy. In addition all adverse events regardless of whether they constitute unanticipated problems as well as AEs thought to be possibly related to study procedures will also be reported to IRB, safety officer, SMC, and NIH/NIAMS. | |||||||
Arm/Group Title | RA Patients - Pharmacotherapy Escalation (TNFi) | RA Patients - Pharmacotherapy Escalation (DMARD) | Healthy Volunteers | Patients - Cross Sectional (RA) | ||||
Arm/Group Description | Participants were randomized to TNFi or DMARD therapy. Patients will receive their current treatment in an open label protocol in the context of standard of care. TNFi: biologic treatment for RA, such as Humira, Enbrel, Remicade, | Participants were randomized to TNFi or DMARD therapy. Patients will receive their current treatment in an open label protocol in the context of standard of care. DMARDs: Standard of care treatment for RA, such as Methotrexate or other disease-modifying antirheumatic drugs. | Subjects without RA who will function as controls. | A cohort of patients with Rheumatoid Arthritis will undergo the baseline study visit only (no randomization to treatment). Note, that those who were randomized, their data will be utilized in the full cross sectional analysis. | ||||
All Cause Mortality |
||||||||
RA Patients - Pharmacotherapy Escalation (TNFi) | RA Patients - Pharmacotherapy Escalation (DMARD) | Healthy Volunteers | Patients - Cross Sectional (RA) | |||||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 0/8 (0%) | 0/4 (0%) | 0/16 (0%) | 0/121 (0%) | ||||
Serious Adverse Events |
||||||||
RA Patients - Pharmacotherapy Escalation (TNFi) | RA Patients - Pharmacotherapy Escalation (DMARD) | Healthy Volunteers | Patients - Cross Sectional (RA) | |||||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 1/8 (12.5%) | 0/4 (0%) | 0/16 (0%) | 0/121 (0%) | ||||
Respiratory, thoracic and mediastinal disorders | ||||||||
Shortness Of Breath | 1/8 (12.5%) | 1 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 0/121 (0%) | 0 |
Other (Not Including Serious) Adverse Events |
||||||||
RA Patients - Pharmacotherapy Escalation (TNFi) | RA Patients - Pharmacotherapy Escalation (DMARD) | Healthy Volunteers | Patients - Cross Sectional (RA) | |||||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 1/8 (12.5%) | 0/4 (0%) | 0/16 (0%) | 6/121 (5%) | ||||
Cardiac disorders | ||||||||
Mobitz II Heart Block | 0/8 (0%) | 0 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 1/121 (0.8%) | 1 |
Atrial Tachycardia | 0/8 (0%) | 0 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 1/121 (0.8%) | 1 |
General disorders | ||||||||
Worsening Migraine | 0/8 (0%) | 0 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 1/121 (0.8%) | 1 |
Angina | 0/8 (0%) | 0 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 1/121 (0.8%) | 1 |
Psychiatric disorders | ||||||||
Panic Attack | 0/8 (0%) | 0 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 1/121 (0.8%) | 1 |
Skin and subcutaneous tissue disorders | ||||||||
Thrombophlebitis | 0/8 (0%) | 0 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 1/121 (0.8%) | 1 |
Eczema | 1/8 (12.5%) | 1 | 0/4 (0%) | 0 | 0/16 (0%) | 0 | 0/121 (0%) | 0 |
Limitations/Caveats
More Information
Certain Agreements
All Principal Investigators ARE employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
Name/Title | Dr. Joan Bathon, MD |
---|---|
Organization | Columbia University Irving Medical Center |
Phone | 212-305-6327 |
jmb2311@cumc.columbia.edu |
- AAAI1026
- 7R01AR050026-07