Prevention of Acute Myocardial Injury by Trimetazidine in Patients Hospitalized for COVID-19

NCT ID: NCT04760821

Last Updated: 2021-02-21

Basic Information

• Recruitment Status: UNKNOWN
• Clinical Phase: PHASE2
• Total Enrollment: 80 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2020-12-10
• Study Completion Date: 2021-04-30

Brief Summary

Acute myocardial injury has been a finding of variable frequency among patients diagnosed with COVID-19. It is now recognized that cTnI levels are strongly associated with increased mortality. The mechanisms underlying the myocardial injury remain unknown, and it is not clear whether they reflect local/systemic inflammatory process and/or cellular ischemia.

Both myocardial ischemia and ventricular dysfunction result in dramatic changes in mitochondrial oxidative metabolism. These changes involve an increase in the rate of cytoplasmic anaerobic glycolysis to compensate for the decrease in mitochondrial adenosine triphosphate (ATP) production. The rest of the mitochondrial oxidative metabolism originates mainly from the β-oxidation of free fatty acids, which occurs at the expense of glucose oxidation.

Trimetazidine is a competitive inhibitor of the enzyme 3-ketoacyl coenzyme A (CoA) long-chain thiolase (3-KAT), the last enzyme involved in the oxidation of fatty acids. Stimulation of glucose oxidation by trimetazidine results in a better coupling between glycolysis and glucose oxidation, with a consequent decrease in lactate production and intracellular acidosis, present in situations of myocardial ischemia or heart failure.

Thus, the PREMIER-COVID-19 study was designed to test the hypothesis that the use of trimetazidine associated with usual therapy in patients admitted with a diagnosis of moderate to severe acute respiratory syndrome by SARS-CoV2 infection reduces the extent of acute myocardial injury assessed by the peak release of ultra-sensitive troponin compared to usual therapy.

Detailed Description

Acute myocardial injury, defined by increased levels of high-sensitivity cardiac troponin I (cTnI), has been a finding of variable frequency among patients diagnosed with COVID-19. This myocardial impairment can occur in the form of acute myocarditis or an injury secondary to the imbalance between oxygen supply and demand (type 2 myocardial infarction). It is now recognized that cTnI levels are strongly associated with increased mortality. The mechanisms underlying the myocardial injury remain unknown, and it is not clear whether they reflect local/systemic inflammatory process and/or cellular ischemia.

Both myocardial ischemia and ventricular dysfunction result in dramatic changes in mitochondrial oxidative metabolism. These changes involve an increase in cytoplasmic anaerobic glycolysis rate to compensate for the decrease in mitochondrial ATP production. Unfortunately, the increase in glycolysis exceeds the subsequent mitochondrial oxidation capacity of pyruvate (glucose oxidation) derived from glycolysis, resulting in the intracellular accumulation of lactate and protons. The protons produced from this decoupling between glycolysis and glucose oxidation contribute to a rupture in ionic homeostasis and myocardial cells, resulting in lower cardiac efficiency. In both the ischemic heart and the insufficient heart, the rest of the mitochondrial oxidative metabolism originates mainly from the β-oxidation of free fatty acids, which occurs at the expense of glucose oxidation.

Trimetazidine is a competitive inhibitor of the enzyme 3-ketoacyl CoA long-chain thiolase (3-KAT), the last enzyme involved in the oxidation of fatty acids. Stimulation of glucose oxidation by trimetazidine results in a better coupling between glycolysis and glucose oxidation, with a consequent decrease in lactate production and intracellular acidosis present in situations of myocardial ischemia or heart failure.

Thus, the PREMIER-COVID-19 study (open and randomized) was designed to test the hypothesis that the use of trimetazidine associated with usual therapy in patients admitted with a diagnosis of moderate to severe acute respiratory syndrome by SARS-CoV2 infection reduces the extent of acute myocardial injury assessed by the peak release of ultra-sensitive troponin compared to usual therapy. Investigators will also assess, as secondary outcomes, the impact on clinical evolution to more severe forms (admission to the intensive care unit or the need for mechanical ventilatory support, length of stay in hospital and in-hospital mortality).

Conditions

Acute Respiratory Distress Syndrome; Covid19; Myocardial Injury

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

Usual Care

Patients ascribed to the Usual Care group will receive the standard of care for the management of patients admitted with moderate to severe acute respiratory distress syndrome due to SARS-CoV2. Usual Care means the clinical protocol approved by the enrolling center.

Group Type: NO_INTERVENTION

No interventions assigned to this group

Trimetazidine

Patients ascribed to the Usual Care group will receive the standard of care for the management of patients admitted with moderate to severe acute respiratory distress syndrome due to SARS-CoV2 plus trimetazidine.Usual Care means the clinical protocol approved by the enrolling center.

Group Type: EXPERIMENTAL

Trimetazidine

Intervention Type: DRUG

Trimetazidine 35mg bid in patients with GFR above 60mL/min. Trimetazidine 35mg od in patients with GFR between 30 and 60mL/min.

Interventions

Trimetazidine

Trimetazidine 35mg bid in patients with GFR above 60mL/min. Trimetazidine 35mg od in patients with GFR between 30 and 60mL/min.

Intervention Type: DRUG

Eligibility Criteria

Inclusion Criteria

1. Clinical diagnosis of moderate to severe acute respiratory syndrome due to SARS-CoV2 defined as:

1.1. Tachypnea: > 24 breaths per minute 1.2. Hypoxemia: arterial oxygen saturation <94% in room air by pulse oximetry 1.3. Presumptive (or confirmed) diagnosis of SARS-Cov2 infection by at least one of the following criteria:

1. Polymerase chain reaction assay (+) for SARS-CoV2

2. Serology (+) for SARS-CoV2

3. SARS-CoV2 antigen diagnostic tests (+)

4. Chest CT with findings suggestive of the diagnosis of COVID-19 in the presence of medical history or clinical signs compatible with the diagnosis of COVID-19

2. Signature of the Informed Consent Form

Exclusion Criteria

1. Chronic renal dysfunction stage 4 (GFR <30mL / min / 1.73m2 calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation

2. Patient on renal replacement therapy by dialysis

3. Pregnant and lactating women

4. Previous use of trimetazidine less than two weeks before hospital admission

5. Any clinical condition at the investigator´s discretion likely to be associated with elevation of baseline hs-troponin >99th percentile

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

InCor Heart Institute

OTHER

Sponsor Role: collaborator

Ministry of Health, Brazil

OTHER_GOV

Sponsor Role: lead

Responsible Party

Luis Henrique W Gowdak, MD, PhD

Clinical Scientist

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Luis Henrique Wolff Gowdak, MD, PhD

Role: STUDY_CHAIR

InCor (HC-FMUSP)

Felipe Gallego Lima, MD

Role: PRINCIPAL_INVESTIGATOR

InCor (HC-FMUSP)

Locations

Heart Institute (InCor-HCFMUSP)

São Paulo, São Paulo, Brazil

Site Status: RECRUITING

Countries

Brazil

Central Contacts

Luis Henrique Wolff Gowdak, MD, PhD

Role: CONTACT

luis.gowdak@gmail.com

+55-11-2661-5000 ext. 5929

Felipe Gallego Lima, MD

Role: CONTACT

felipeglima@yahoo.com.br

+55-11-2661-5000

Facility Contacts

Felipe Gallego Lima, MD

Role: primary

felipeglima@yahoo.com.br

+55-11-26615000 ext. 5810

Other Identifiers

SDC5100/20/129

Identifier Type: -

Identifier Source: org_study_id