NCT06405555

Midodrine in Heart Failure With Reduced Ejection Fraction With Hypotension

Midodrine in Heart Failure With Reduced Ejection Fraction With Hypotension: A Pilot, Open-label, Randomized Controlled Trial

• Status: Not Yet Recruiting
• Phase: Phase 2 / Phase 3
• Study type: Interventional
• Enrollment: 56 (estimated)
• Sponsor: Ottawa Heart Institute Research Corporation · Academic / Other
• Sex: All
• Age: 18 Years
• Healthy volunteers: Not accepted

Summary

The evidence-based pharmacologic treatments available for patients with heart failure with reduced ejection fraction (HFrEF) has been established over the last few decades of cardiovascular research. These treatments, termed Foundational Guideline-Directed-Medical Therapies (GDMT), prolong patient life, improve patient-reported symptoms, and reduce hospitalizations for heart failure. A direct effect of most medication classes encompassed within GDMT is the reduction in blood pressure due to their mechanisms of action. In addition, as patients with HFrEF become more advanced in their disease, a significant proportion develop hypotension related to pump failure and autonomic dysfunction, amongst other possible mechanisms. As a result, a significant proportion of HFrEF patients are not optimized on GDMT with hypotension as their limiting barrier that would otherwise have served to improve their heart function, heart failure symptoms, and mortality. Currently, there does not exist any evidence-based strategies to address the problem of hypotension in HFrEF patients who are not optimized on GDMT. Midodrine is an alpha-adrenergic agonist (α1-AR) that exerts its effects on peripheral venous and arteriolar vasculature to increase blood pressure. This medication has been used off-label by some clinicians in the hypotensive HFrEF population to increase blood pressure and has been reported to have beneficial effects in improving GDMT utilization as well as increasing left ventricular ejection fraction (LVEF) in published case reports/case series. There does not exist any randomized prospective data on the use of midodrine in the hypotensive HFrEF population. The investigators' objective is to complete the first open-label, randomized control trial of midodrine in the hypotensive HFrEF population to demonstrate feasibility in performing a trial in this patient population and to show efficacy in increasing blood pressure without associated harm. The results of this trial will be used as the foundation and rationale for future studies assessing the impact of midodrine use on GDMT utilization as well as hard cardiovascular outcomes in the hypotensive HFrEF population, including hospitalizations for heart failure and mortality.

Detailed description

This will be a pilot, open-label, randomized controlled trial with the intervention/treatment being midodrine in hospitalized patients with HFrEF. The comparator/control arm will be patients following standard of care, which is to undergo no further pharmacologic intervention directed at hypotension unless clinically indicated. Patients who meet inclusion criteria will be randomized (1:1) to either midodrine group or control group, which will occur at the time of recruitment. In the treatment group, patients will receive midodrine for a total planned duration of up to 5 days, or until hospital discharge, whichever comes first. The midodrine will initially be started at 2.5 mg po TID for 1 day, followed by 5.0 mg po TID x 1 day, 7.5 mg po TID x 1 day, and 10 mg po TID x 2 days. Side effects reported by patients and any adverse drug events will be documented. At the end of the inpatient study period, continuation of midodrine off-label will be at the treating clinician's discretion in the treatment arm. For patients discharged home less than 1 week from the exposure period, patients will be followed for 2 weeks with the Telehome monitoring program (THM), which is a virtual outpatient service intended to closely follow heart failure patients, to monitor blood pressure, heart rate, weight and adverse events or side effects. For patients discharged home between 1 to 2 weeks from the exposure period, they will be followed for 1 week with THM. For patients discharged after 2 or more weeks from the exposure period, no THM follow-up will occur. Frequency of THM follow-up, as well as inpatient monitoring parameters is as outlined in the "Data Capture" section. Key clinical measurements will be obtained in both treatment and control arms including blood pressure measurements (every 6 hours while awake, with each measurement in the treatment arm consisting of BP measured 1 hour after the administration of midodrine dose and in the supine position. For patients in the control arm, a similar frequency of blood pressures will be obtained at pre-specified times), NT-proBNP at the time of recruitment (Day 0, prior to administration of midodrine in treatment arm) and after 5 days (ie. Sample obtained at time of last dose at Day 4 or at Day 5) or hospital discharge (whichever comes first). Safety outcomes will be monitored for and assessed. The study will be open-label and neither the patient nor the treating physicians will be blinded in this study.

Conditions

• Heart Failure With Reduced Ejection Fraction
• Hypotension
• LV Dysfunction

Interventions

Type	Name	Description
DRUG	Midodrine Oral Tablet	Exposure to up to 5 days of midodrine (or until hospital discharge) in hospital at escalating doses with the following protocol: 2.5 mg po TID x 1 day, 5.0 mg po TID x 1 day, 7.5 mg po TID x 1 day, 10 mg po TID x 2 days.

Timeline

• Start date: 2024-08-01
• Primary completion: 2026-04-01
• Completion: 2026-07-01
• First posted: 2024-05-08
• Last updated: 2024-05-08