Renin-angiotensin-aldosterone System (RAAS), Inflammation, and Post-Operative Atrial Fibrillation

Official Title: “RAAS, Inflammation, and Post-operative AF”

AF is the most prevalent, sustained type of irregular heartbeat and affects over 2 million Americans. Post-operative AF, which leads to significant morbidity and a prolonged hospital stay, complicates 20% to 40% of CPB surgical procedures. While recent studies indicate that interruption of the renin-angiotensin-aldosterone system by either ACE inhibition or AT1 receptor antagonism decreases the incidence of AF following a heart attack or cardioversion (electric shock to the heart), its effect on the incidence of post-operative AF has not been throughly studied. Studies in both animals and humans suggest that inflammation-induced atrial remodeling plays an important role in the cause of AF. Recent studies also provide evidence that activation of the renin-angiotensin-aldosterone system induces inflammation, myocyte injury, proarrhythmic electrical remodeling, and fibrosis through aldosterone.

AF is the most prevalent, sustained type of irregular heartbeat and affects over 2 million Americans. Post-operative AF, which leads to significant morbidity and a prolonged hospital stay, complicates 20% to 40% of CPB surgical procedures. While recent studies indicate that interruption of the renin-angiotensin-aldosterone system by either ACE inhibition or AT1 receptor antagonism decreases the incidence of AF following a heart attack or cardioversion (electric shock to the heart), its effect on the incidence of post-operative AF has not been throughly studied. Studies in both animals and humans suggest that inflammation-induced atrial remodeling plays an important role in the cause of AF. Recent studies also provide evidence that activation of the renin-angiotensin-aldosterone system induces inflammation, myocyte injury, proarrhythmic electrical remodeling, and fibrosis through aldosterone.

This study will evaluate the effectiveness of ACE inhibition and aldosterone receptor antagonism at decreasing inflammation and AF following CPB surgery.

Intervention(s) in this Clinical Trial

• Drug: Placebo
  • Matching placebo taken once a day
• Drug: Ramipril
  • Taken orally, once a day
• Drug: Spironolactone
  • Taken orally, once a day

Arms, Groups and Cohorts in this Clinical Trial

• Placebo Comparator: 1
• Experimental: 2
  • ACE inhibitor
• Experimental: 3
  • MR antagonist

Primary Measures

• Occurrence of electrocardiographically confirmed AF or flutter at any time following neutralization of heparin at the end of CPB.
  • Time Frame: Measured at time of hospital discharge.
    Safety Issue?: No

Secondary Measures

• Intra-operative MAP
  • Time Frame: Measured during surgery
    Safety Issue?: Yes
• Intra-operative and post-operative requirements for pressors.
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: Yes
• Death
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: Yes
• Length of hospital stay
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: No
• Post-operative IL-6, PAI-1, t-PA and CRP concentrations and other biomarkers
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: No
• Serum potassium concentrations
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: Yes
• Creatinine concentrations(measured throughout the patient's hospital stay)
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: Yes
• Stroke
  • Time Frame: Measured until the time of hospital discharge
    Safety Issue?: Yes

Inclusion Criteria:

• 1. Undergoing elective valvular heart surgery, coronary artery bypass grafting
• 2. If female, must be postmenopausal for at least 1 year, status-post surgical sterilization, or if of childbearing potential, utilizing adequate birth control and willing to undergo urine beta-hcg testing prior to drug treatment and throughout the study

Exclusion Criteria

• 1. History of AF other than remote paroxysmal AF
• 2. Ejection fraction less than 30%
• 3. Evidence of coagulopathy (INR greater than 1.7 without warfarin therapy)
• 4. Emergency surgery
• 5. History of ACE inhibitor-induced angioedema
• 6. Low blood pressure (systolic blood pressure less than 100 mmHg and evidence of hypoperfusion)
• 7. Hyperkalemia (potassium level greater than 5.0 mEq/L at study entry)
• 8. Impaired kidney function (serum creatinine level greater than 1.6 mg/dl)
• 9. Any underlying or acute disease requiring regular medication that could possibly cause complications or make implementation of the study or interpretation of the study results difficult
• 10. Inability to discontinue current ACE inhibitor, AT1 receptor antagonist, or aldosterone receptor antagonist therapy
• 11. History of alcohol or drug abuse
• 12. Treatment with any investigational drug in the month prior to study entry
• 13. Mental condition that makes it impossible to understand the nature, scope and possible consequences of the study
• 14. Inability to comply with the study procedures (e.g., uncooperative attitude, inability to return for follow-up visits, and unlikelihood of completing the study)
• 15. Pregnant or breastfeeding

Gender Eligibility for this Clinical Trial: Both

Minimum Age for this Clinical Trial: 18 Years

Maximum Age for this Clinical Trial: 80 Years

Are Healthy Volunteers Accepted for this Clinical Trial?: No

Lead Investigator: Vanderbilt University Other

Overall Clinical Trial Officials and Contacts

Nancy J. Brown, M.D. Principal Investigator Vanderbilt University  

Information obtained from ClinicalTrials.gov on February 12, 2012

Link to the current ClinicalTrials.gov record. http://clinicaltrials.gov/show/NCT00141778

Study ID Number: 040385

ClinicalTrials.gov Identifier: NCT00141778

Health Authority: United States: Institutional Review Board