Angiotensin (1-7) Treatment to Improve Cognitive Functioning in Heart Failure Patients

In this non-randomized pilot study 16 heart failure patients will be enrolled. Adults (ages 55-75) with chronic HF will be recruited who do not have neurologic or psychiatric disorders expected to interfere with memory function. Patients must have been diagnosed with HF ≥ 90 days prior to enrollment, be clinically stable, and on stable medications. Participants have a medical history and examination, with documentation of evidence of HF, and screening to rule out dementia (Mini-Mental State Exam score less than 25), and depression (Geriatric Depression Scale score greater than 10. Participants will be treated for 12 weeks with a daily dose of subcutaneous Ang-(1-7) (100 mcg/kg/day). Half of the group will be given memory training in 2-hr sessions twice weekly for two weeks beginning at 6 weeks of drug treatment. Prior to drug treatment, baseline measures will include memory and neuropsychological tests and inflammatory markers. Memory and neuropsychological tests will be repeated at 3 weeks, 6 weeks and 12 weeks. Inflammatory biomarkers will be reassessed at 6 weeks and 12 weeks. Blood draws for pharmacokinetic (PK) measurements will be obtained at baseline and Day 7. MRI scans will be obtained from all participants who do not have an ICD, pacemaker or other contraindication to MRI at baseline with repeat scans at 12 weeks. Lastly Self-Care Efficacy testing will be obtained at 12 weeks from all participants.

Aim 1 Primary Outcome: Changes in performance on the Memory Intentions Test (MIST, a test of PM) between baseline and 12 weeks27 will be the primary endpoint to test effectiveness of PMT in the presence or absence of Ang-(1-7) treatment.MIST scores have been shown to predict medication adherence.

Aim 1 Secondary Outcomes:

Safety of the treatment will be assessed by careful collection of standard serious adverse events, and comparison of events across treatment arms. In addition, patients will be asked about difficulties associated with the therapy, and medication vials collected to assess compliance with therapy.
Self-care efficacy at 12 weeks will be measured using the SCHFI, a validated tool.
Other neuropsychological measures of memory, executive functions, and psychomotor speed will be assessed at baseline, 3 weeks, 6 weeks, and at the 12 week follow-up.
HF quality of life will be assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12 weeks.
Adjudicated HF hospitalizations, all-cause hospitalizations and death will be assessed by treatment arm.

Aim 2: Systemic Inflammation Assay: At baseline, and after 6 and 12 weeks of Ang-(1-7) treatment, blood will be collected for assessment of systemic inflammation. Blood will be placed in lavender-top EDTA tubes, centrifuged to obtain plasma, and rapidly frozen in liquid nitrogen.

Cytokines, chemokines, and additional circulating inflammatory analytes will be detected and quantified by multiplex immunoassay using a MAGPIX®. Each sample will be measured in duplicate. Data will be analyzed by ANOVA across all groups.

Aim 2 Primary Outcome: Immunosuppressive cytokines TGFα and IL-1 will be measured as they play an important role in the anti-inflammatory actions of Ang-(1-7) and are widely used as functional indicators of systemic inflammation. The more common clinical inflammatory marker of systemic inflammation C-reactive protein, will also be measured.