Vericiguat: A Randomized, Phase Ib, Placebo-Controlled, Double-Blind, QTc Interval Study in Patients with Chronic Coronary Syndromes

BACKGROUND

Vericiguat is indicated for the treatment of symptomatic chronic heart failure in adult patients with reduced ejection fraction who are stabilized after a recent decompensation event.

OBJECTIVE

To investigate the effects of vericiguat on QT interval in patients with chronic coronary syndromes (CCS).

METHODS

This was a randomized, phase Ib, placebo-controlled, double-blind, double-dummy, multicenter study. Vericiguat once daily was up-titrated from 2.5 mg to 5 mg and then to 10 mg (treatments A, B, and C) at 14-day intervals. Positive control was moxifloxacin 400 mg (single dose on day 8 or day 50; placebo on other days [treatment D]). We evaluated the placebo-adjusted change from baseline of the Frederica-corrected QTc interval (QTcF), pharmacokinetics, safety, and tolerability of vericiguat.

RESULTS

In total, 74 patients with CCS, with mean (standard deviation) age 63.4 (8.0) years, were included and 72 patients completed the study. At each timepoint up to 7 h after administration, mean placebo-corrected change in QTcF from baseline was < 6 ms and the upper limit of the two-sided 90% confidence interval of the mean was below the 10-ms threshold for clinical relevance. Moxifloxacin confirmed the assay sensitivity. Median time of maximum concentration of vericiguat was 4.5 h post-dose. The adverse event profile of vericiguat was consistent with its mechanism of action, and the findings did not indicate any safety concerns.

CONCLUSIONS

As part of an integrative risk assessment, this study demonstrated no clinically relevant corrected QT prolongation with vericiguat 10 mg once daily at steady state.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov number, NCT03504982.

Vericiguat: a QTc interval study in patients with coronary artery disease

Background

Vericiguat is a soluble guanylate cyclase stimulator developed for the treatment of symptomatic chronic heart failure (HF) in adult patients with ejection fraction less than 45% who had a previous decompensation event. Guidelines on QT studies recommend evaluation of investigational drugs at supratherapeutic exposures in healthy volunteers. We anticipated that supratherapeutic doses of vericiguat would decrease blood pressure. We conducted an adjusted QT study using the therapeutic range of vericiguat in patients with coronary artery disease (CAD), who were expected to be more haemodynamically stable with fewer confounders (e.g., on the electrocardiogram) than a HF population.

Purpose

To assess the effect of vericiguat 10 mg once-daily on placebo-adjusted change from baseline of the Fridericia-corrected QT interval (QTcF) in patients with stable CAD.

Methods

This was a randomised, Phase Ib, placebo-controlled, double blind, double-dummy, multicentre study (NCT03504982). Test drug was vericiguat once-daily (up-titrated from 2.5 mg to 5 mg and then to 10 mg [treatments A, B, C] at 14-day intervals). The positive control was moxifloxacin 400 mg (single dose on Day 8 or Day 50 with placebo on other days [treatment D]; Figure). Patients were randomised to one of two sequences.

We evaluated QTcF interval prolongation potential of vericiguat at increasing doses up to 10 mg, steady state. We investigated the pharmacokinetics, safety and tolerability of vericiguat. A clinically meaningful effect was defined as a QTcF change from baseline &gt;10 ms relative to placebo. Assay sensitivity for moxifloxacin was confirmed by the lower limit of the 90% confidence interval (CI) of the time-matched, baseline-adjusted mean difference to placebo exceeding 5 ms at &gt;1 time point.

Results

A total of 74 patients (66 males and 8 females) with CAD, mean (standard deviation) age 63.4 (8.0) years, were included. Mean difference between vericiguat and placebo in QTcF change from baseline (≤7 h post-dose) was &lt;6 ms; no upper limit of the 90% CIs crossed the threshold of 10 ms. Lower limits of the two-sided 90% CI of the differences between moxifloxacin and placebo in QTcF change from baseline were &gt;5 ms at 3 of 4 time points (Table).

Peak plasma concentration (Cmax) of vericiguat following administration of vericiguat 10 mg was 322 μg/l and median time of maximum concentration (Tmax) was 4.5 h post-dose, in line with concentrations observed following administration of vericiguat 10 mg to patients with HF [1]. For moxifloxacin 400 mg, Cmax was 1960 μg/l and median Tmax was 3 h post-dose, in line with previously reported values [2]. Vericiguat up to 10 mg was generally safe and well tolerated.

Conclusion

This study supports the assessment that administration of vericiguat 10 mg is not associated with clinically meaningful QTc prolongation. These data contribute to the overall safety profile of vericiguat for the treatment of patients with HF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Funding was provided by Bayer AG, Berlin, Germany, and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA QTc study design

Growth after intrauterine laser coagulation for twin-twin transfusion syndrome

OBJECTIVE

The aim of this study was to investigate prenatal and postnatal growth of twins with twin-twin transfusion syndrome (TTTS) after intrauterine laser coagulation.

STUDY DESIGN

The weight and length of 54 sets of twins with severe TTTS surviving intrauterine laser coagulation at the intervention (median 20+4 weeks), at birth (median 34+3 weeks) and on the occasion of neurodevelopmental follow-up (median age 3 years 10 months) were investigated. All data were converted to Z scores, and groups were compared by two-tailed paired t test.

RESULTS

At all time points, donors are significantly lighter than recipients (p<0.001). After laser treatment the weight Z score of donors until birth remains unchanged (p=0.76), whereas recipients lose weight significantly (p<0.01). Postnatally, both donors and recipients show catch-up growth.

CONCLUSION

Intrauterine laser coagulation stops growth acceleration in recipients that leads to a decrease in intertwin discordance. After birth, significant catch-up growth was observed for the donor group (p<0.001).

Noise-induced annoyance and morbidity results from the pan-European LARES study

Traffic noise (road noise, railway noise, aircraft noise, noise of parking cars), is the most dominant source of annoyance in the living environment of many European countries. This is followed by neighbourhood noise (neighbouring apartments, staircase and noise within the apartment). The subjective experience of noise stress can, through central nervous processes, lead to an inadequate neuro-endocrine reaction and finally lead to regulatory diseases. Within the context of the LARES-survey (Large Analysis and Review of European housing and health Status), noise annoyance in the housing environment was collected and evaluated in connection with medically diagnosed illnesses. Adults who indicated chronically severe annoyance by neighbourhood noise were found to have an increased health risk for the cardiovascular system and the movement apparatus, as well as an increased risk of depression and migraine. Furthermore adults with chronically strong annoyance by traffic noise additionally showed an increased risk for respiratory health problems. With regards to older people both neighbourhood and traffic noise indicated in general a lower risk of noise annoyance induced illness than in adults. It can be assumed that the effect of noise-induced annoyance in older people is concealed by physical consequences of age (with a strong increase of illnesses). With children the effects of noise-induced annoyance from traffic, as well as neighbourhood noise, are evident in the respiratory system. The increased risk of illness in the respiratory system in children does not seem to be caused primarily by air pollutants, but rather, as the results for neighbourhood noise demonstrate, by emotional stress.

[Noise induced annoyance and morbidity. Results from the pan European LARES-survey]

Traffic noise (road, train and flight noise, and the noise of parking cars), is the dominant source of annoyance in the living environment of many European countries. This is followed by neighbourhood noise (neighbouring apartments, staircases and noise within the apartment). The subjective experience of noise stress can, through central nervous processes, lead to an inadequate neuro-endocrine reaction and finally to regulation diseases. Within the context of the LARES-survey, noise annoyance within the everyday living environment was collected and evaluated in connection with medically diagnosed illnesses. Adults who indicated chronically strong annoyance due to neighbourhood noise were found to have an increased health risk in the cardiovascular system, the movement apparatus as well as depression and migraine. For adults with chronically strong annoyance caused by traffic noise, the risks to the respiratory system also increased. In older people, both neighbourhood and traffic noise indicated, in general, a lower risk of noise annoyance induced illness than in adults. It can be assumed that the effects of noise induced annoyance in older people is concealed by the physical consequences of age (with a strong increase in illnesses). With children, the effects of noise induced annoyance from traffic as well as neighbourhood noise is evident in the respiratory system. The increased illness risks in the respiratory system in children do not seem to be caused primarily by air pollutants but rather, as with case of neighbourhood noise, though emotional stress.

Nocturnal awakenings due to aircraft noise. Do wake-up reactions begin at sound level 60 dB(A)?

Night-time wake-up thresholds at noise levels of 60 dB(A) are frequently employed in Germany to establish "noise polluted areas". The criterion is, however, based on an incorrect processing of statistical data gathered from an evaluation of literature performed by Griefahn et al. (1976). This finding has emerged from an extensive revision of the study. Using appropriate statistical methods, maximum levels of under 48 dB(A) are assessed as waking-up thresholds at ear level in sleeping persons, in contrast to maximum levels of 60 dB(A) calculated by Griefahn et al. in 1976. The linear dose-response relationship, which in the course of the revision could be derived from the early publications, agrees with the results of more recent literature evaluations. The present contribution is not intended to give rise to the question whether in the interest of medical prevention it is reasonable to develop night-time protective policies merely founded on noise levels marking the "statistical" onset of nocturnal wake-up reactions. In this context, emphasis is laid on the deformation of the biological rhythm of sleep.

Stress hormones and sleep disturbances - electrophysiological and hormonal aspects

In noise effect research often the awakening reaction is maintained to be the only important health related reaction. The main argument is that sleep represents a trophotropic phase ("energy storing"). In contrast to this awakening reactions or lying awake belong to the ergotropic phase ("energy consuming"). Frequent or long awakening reactions endanger therefore the necessary recovery in sleep and, in the long-run, health. Findings derived from arousal and stress hormone research make possible a new access to the noise induced nightly health risk. An arousal is a short change in sleeping condition, raising the organism from a lower level of excitation to a higher one. Arousals have the function to prevent life-threatening influences or events through activation of compensation mechanisms. Frequent occurrences of arousal triggered by nocturnal noise leads to a deformation of the circadian rhythm. Additionally, the deep sleep phases in the first part of the night are normally associated with a minimum of cortisol and a maximum of growth hormone concentrations. These circadian rhythms of sleep and neuroendocrine regulation are necessary for the physical as well as for the psychic recovery of the sleeper. Noise exposure during sleep which causes frequent arousal leads to decreased performance capacity, drowsiness and tiredness during the day. Long-term disturbances of the described circadian rhythms have a deteriorating effect on health, even when noise induced awakenings are avoided.

The influence of stressors on biochemical reactions--a review of present scientific findings with noise

For every faculty of perception there is, according to the degree of irritation, a biochemical or psychobiological activation. This is also true for the perception of sound or noise. Initially, these processes allow for the adjustment of the organism to a changed situation (eustress). Prolonged effects of stressors may ultimately lead to regulatory disturbances and induce pathological processes (distress). The pathogenetic concept that psychobiological stresses (e.g. noise) may be connected with the well-known risk factors of cardiovascular diseases, through excitation of the central nervous system, is based on the known stress models. The central connective factors are the activation hormones of the adrenal gland, also referred to as stress hormones. From blood and urine parameters recorded in epidemiological and experimental studies under the influence of acute or chronic noise, a simplified model of the pathogenetic mechanism has been developed. Fundamental conditions for future assessing the "stress hormones" have been derived, by means of which premorbid conditions can be determined on a population or group basis.

[Environmental noise and satisfaction with area of residence]

In the German National Health Interview and Examination Survey, more than one third, i.e. 36.2% of persons interviewed on the matter of noise nuisance in their homes attributed to outdoor noise confirmed the occurrence of noise. Regarding this result only small and statistically insignificant differences have been assessed in East and West Germany. The frequency of affirmative answers given by German women, ages 20-39, was significantly higher as compared to men in the same ages bracket. Regarding the dominant noise effects in their home, 87% of persons affected mentioned traffic noise as a source. In the second place neighbour noise has been reported by 32%. Aircraft and railway noises percepted by 20%, are in the third and fourth place. Particularly severe indoor noise effects, i.e. persisting noise during the night, are accompanied with clearly increased discontent regarding the home and living area.

[Peak sound pressure levels of gunshots from starter's pistols]

Starter's pistols are often bought for self-defense, but can also be used for criminal activities (e.g. assaults, etc.). When a starter's pistol is loaded with blank cartridges and is fired, a powerful shooting noise results. The level of the noise produced is high enough to cause acoustic trauma. For legal examinations and giving an expert opinion further information is needed about the power of such noise. We examined how high peak sound pressure levels were of the gunshots of blank cartridges and whether there existed any directional characteristics from the noise emissions. In all, 15 different models of starter's pistols of 8 different calibres were examined. In addition to blank cartridges, 8 mm tear gas cartridges were also examined. Four transducers were situated in the horizontal plane around the muzzle: 0 degree (shooting direction), 45 degrees, 90 degrees, and 180 degrees (towards the firer). The distances between the transducers and the muzzle were 25 cm, 50 cm, 100 cm, and 200 cm. At a distance of 1 m and in the 0 degree shooting direction the peak sound pressure levels of nearly all weapons tested exceeded 160 dB. At a shooting distance of 25 cm the peak sound pressure levels reached 181 dB. In addition, we observed a directional characteristic concerning the emission of noise: pistols produced higher peak sound pressure levels to the front than backwards towards the firer.

[Environmental medical action required on exposure to noise]

Basing on request for an expertise on the medical effects of noise on healthy adults, permissible values for mainly traffic noise were estimated from the literature. If the permissible values are exceeded, preventive medical action is necessary. Below these values the probability of noise-induced health hazards is essentially zero. The authors presume that noise levels above these permissible values, but below the limit of bearability, are an increasing danger to health. Preventive medical action must be weighed against the risk involved in persistent noise, depending on the situation and the need protection. The effect of noise as a health hazard is, apart from the mechanical damage to the inner ear, a psycho-physiological deregulation which can be either indirectly due to the annoyance or directly caused by stress of the vegetative-hormonal system. Therefore different permissible values for annoyance, the stress on the vegetative-hormonal system and for the loss of hearing are suggested, for both continual and maximum noise levels. In addition, de-regulation depends on the time of acoustic exposure because the sensitivity to noise follows a 24-hour cycle (circadian rhythm). It is therefore necessary to determine personal permissible limits for the nocturnal noise (sleep disorder). Permissible values for children are also suggested.