EntrestoTM (LCZ696) In Advanced Heart Failure (LIFE Study) (HFN-LIFE)

• ClinicalTrials.gov Identifier: NCT02816736
• Recruitment Status: Completed
• First Posted: June 29, 2016
• Results First Posted: December 3, 2021
• Last Update Posted: December 3, 2021
• Sponsor: Duke University
• Collaborator: National Heart, Lung, and Blood Institute (NHLBI)
• Information provided by (Responsible Party): Duke University

Study Description

Brief Summary:

The primary objective of the study is to determine whether, in patients with symptomatic, advanced heart failure due to left ventricular systolic dysfunction, treatment with LCZ696 for 24 weeks will improve Pro-B-type Natriuretic Peptide (NT-proBNP) levels, which reflect hemodynamic and clinical status, compared to treatment with valsartan.

Condition or disease	Intervention/treatment	Phase
Heart Failure	Drug: LCZ696; Drug: valsartan; Drug: LCZ696 placebo; Drug: valsartan placebo	Phase 4

Detailed Description:

Patients with advanced heart failure with reduced ejection fraction (HFrEF) have extremely high morbidity and mortality with 1 year outcomes of death and hospitalization of approximately 50%. For the most advanced heart failure patients, the evidence base for medical treatment is limited with consensus guidelines recommending consideration for either cardiac transplant or ventricular assist device, or palliative care.

The PARADIGM-HF trial showed that LCZ696, which consists of the neprilysin inhibitor sacubitril and the ARB valsartan, improved morbidity and mortality in patients with chronic HFrEF in comparison to enalapril. However, limited experience with advanced heart failure patients was gained from patients enrolled in the trial. Because the information on the effects of sacubitril/valsartan in patients with NYHA class IV heart failure is limited, the updated 2016 ACC/AHA/HFSA guidelines for the treatment of heart failure do not yet endorse the use of sacubitril/valsartan in patients with NYHA class IV heart failure. Accordingly, experience is needed on the use of, and outcomes with LCZ696 in patients unable to tolerate target doses of angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin receptor blocker (ARB).

This study will be a randomized, double-blinded trial of advanced heart failure subjects with 1:1 randomization to either LCZ696 (sacubitril and valsartan) or valsartan. Study drug will be administered in a double-dummy fashion, in which subjects take active (LCZ696 or valsartan) and placebo. Approximately 400 subjects will be randomized into the study.

Subjects will have an initial screening evaluation, including baseline laboratory tests as well as an assessment of left ventricular (LV) ejection fraction, at which time preliminary subject eligibility will be determined. The LV ejection fraction may have been obtained within the prior 12 months by 2-D echocardiogram, LV angiogram or radionuclide scintigraphy. Willing subjects meeting entry criteria will be consented. Those who meet all entry criteria and are interested in study participation will be enrolled.

Enrolled subjects will complete baseline assessments and undergo a run-in period of 3-7 days with LCZ696 50 mg (equivalent to Entresto™ 24/26 mg) po BID (taken by mouth twice a day) prior to randomization. For subjects taking an ACEI, the ACEI will be withheld for ≥ 36 hours prior to first dose of LCZ696.

Subjects who tolerate the run-in period with LCZ696 will be randomized 1:1 to LCZ696 or valsartan.

Study treatment will be titrated to the target dose of 200 mg LCZ696 (equivalent to Entresto™ 97/103 mg) as two 100 mg LCZ696 and 2 placebo tablets po BID or valsartan 160 mg (two 80 mg valsartan and 2 placebo tablets) po BID.*

Randomized subjects will receive the first dose of study drug as follows:

• For subjects not previously taking ACEI or ARB, previously taking ACEI or ARB at a low dose*, or subjects who have an eGFR < 30 mL/min/1.73m², the starting dose of valsartan will be 40 mg po BID and the starting dose of LCZ696 will be 50 mg po BID.
• For subjects taking an ARB at greater than low dose†, the starting dose of valsartan will be 80 mg po BID and the starting dose of LCZ696 will be 100 mg po BID.*

• For subjects taking an ACEI at greater than low dose†, the ACEI will be withheld for ≥ 36 hours prior to randomization. The starting dose of valsartan will be 80 mg po BID and the starting dose of LCZ696 will be 100 mg po BID.*

  • At Investigator discretion, study drug may be started at the low dose (LCZ696/placebo 50 mg po BID or valsartan/placebo 40 mg po BID) if there are any concerns regarding tolerability at the 100 mg / 80 mg dose.)

Per package insert, the valsartan compounded in Entresto™ is more bioavailable than the valsartan in other marketed formulations. The dose equivalence for valsartan compounded in Entresto™ compared to valsartan prepared alone (Entresto™ dose = marketed valsartan dose) is as follows: 26 mg=40 mg, 51 mg=80 mg, 103 mg=160 mg.

† Low dose is defined as 24 hour dose of ≤ 10 mg lisinopril, ≤ 5 mg ramipril, ≤ 50 mg losartan, ≤ 10 mg olmesartan, or other dose equivalent.

Dose adjustments will be performed every 2 weeks by doubling the dose of LCZ696 or valsartan up to the target maximum dose. The doses of LCZ696 are 50 mg (one 50 mg active and 1 placebo tablet), 100 mg (one 100 mg active and 1 placebo tablet) and 200 mg (two 100 mg active and 2 placebo tablets). These doses are equivalent to 24/26 mg, 49/51 mg, and 97/103 mg commercial Entresto™, respectively. The doses of valsartan are 40mg (one 40 mg active and 1 placebo tablet), 80 mg (one 80 mg active and 1 placebo tablet), and 160 mg (two 80 mg active and 2 placebo tablets). The criteria for doubling the dose will be based on systolic blood pressure (a SBP > 90 mmHg is required for up titration), changes in renal function (maximum serum creatinine of 2.0 mg/dL), and the absence of symptoms of hypotension. For those not tolerating the current dose of study drug, the dose will be down-titrated to the previous tolerated dose. Subjects will return to clinic for follow-up visits at 2, 4, 8, 12, and 24 weeks after randomization.

Assessments at the follow-up visits include some or all of the following: interim medical history, review of medications, physical examination with the New York Heart Association (NYHA) class assessment, Kansas City Cardiomyopathy Questionnaire (KCCQ) quality of life questionnaire, local laboratory testing (creatinine, Blood Urea Nitrogen (BUN), electrolytes), Core laboratory testing (Cystatin C, BNP, NT-proBNP), adherence and tolerance assessment, and adverse event monitoring.

Follow-up phone calls will be made at 10, 16, and 20, weeks after randomization to assess dosing compliance, record the occurrence of applicable adverse events and events of interest, and remind the subject of the date and time of their next in-person visit.

A final phone visit is conducted approximately 2 weeks after study visit 10 (26 weeks after randomization) to assess clinical stability and any applicable adverse events.

During the consent process, subjects will be asked if interested in donating samples and data for research purposes via a biorepository and/or genetic study. Based on site and IRB preference, this optional part of the study may be incorporated into the main consent or may be a separate consent and Institutional Review Board (IRB) application.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 365 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Triple (Participant, Care Provider, Investigator)
• Primary Purpose: Treatment
• Official Title: EntrestoTM (LCZ696) In Advanced Heart Failure (LIFE Study)
• Actual Study Start Date: March 2, 2017
• Actual Primary Completion Date: September 15, 2020
• Actual Study Completion Date: September 29, 2020

Arms and Interventions

Arm	Intervention/treatment
Active Comparator: LCZ696 (Entresto) + placebo; LCZ696 50 mg, 100 mg, or 200 mg orally twice daily for 24 weeks, plus valsartan placebo (to match 40 mg, 80 mg, or 160 mg) orally twice daily for 24 weeks	Drug: LCZ696; Subjects previously taking no or low-dose ACEI or ARB, or who have an eGFR < 30 mL/min/1.73m²: starting dose of LCZ696 = 50 mg po BID. Subjects taking an ARB at greater than low dose: starting dose of LCZ696 = 100 mg po BID. Subjects taking an ACEI at greater than low dose: starting dose of LCZ696 = 100 mg po BID. * At Investigator discretion, study drug may be started at the low dose if there are any concerns regarding tolerability. Dose adjustments will be performed every 2 weeks by doubling the dose of LCZ696 up to the target max dose of 200 mg po BID as tolerated. The doses of LCZ696 are 50mg (one low-dose (50mg) tablet), 100mg (one high-dose (100mg) tablet), and 200mg (two high-dose (100mg) tablets.) These doses are equivalent to 24/26 mg, 49/51 mg, and 97/103 mg commercial Entresto™, respectively.; Other Name: Entresto; Drug: valsartan placebo; Valsartan placebo tablets will be supplied to match the low-dose (40mg) and high-dose (80mg) active valsartan tablets. Dosing for valsartan placebo will mirror dosing for active LCZ696 (the same number of low or high-dose tablets will be given.)
Active Comparator: valsartan + placebo; valsartan 40 mg, 80 mg, or 160 mg orally twice daily for 24 weeks, plus LCZ696 placebo (to match 50 mg, 100 mg, or 200 mg) orally twice daily for 24 weeks	Drug: valsartan; Subjects previously taking no or low-dose ACEI or ARB, or who have an eGFR < 30 mL/min/1.73m²: the starting dose of valsartan = 40 mg po BID. Subjects taking an ARB at greater than low dose: starting dose of valsartan = 80 mg po BID. Subjects taking an ACEI at greater than low dose: starting dose of valsartan = 80 mg po BID. * At Investigator discretion, study drug may be started at the low dose if there are any concerns regarding tolerability. Dose adjustments will be performed every 2 weeks by doubling the dose of valsartan up to the target maximum dose of 160 mg po BID, as tolerated. The doses of valsartan are 40mg (one low-dose (40mg) tablet), 80mg (one high-dose (80mg) tablet), and 160mg (two high-dose (80mg) tablets).; Other Name: Diovan; Drug: LCZ696 placebo; LCZ696 placebo tablets will be supplied to match the low-dose (50mg) and high-dose (100mg) active LCZ696 tablets. Dosing for LCZ696 placebo will mirror dosing for active valsartan (the same number of low or high-dose tablets will be given.)

Outcome Measures

Primary Outcome Measures :

1. Change in NT-proBNP [ Time Frame: Baseline, 2, 4, 8, 12, and 24 weeks ]
   The proportional change from baseline in the AUC for NT-proBNP levels measured at 2, 4, 8, 12, and 24 weeks. AUC was normalized for time and divided by the baseline value of NTproBNP so it has no unitshas no units. With the log-scale, the value of 0 indicates, on average, no change in NTproBNP from baseline. A value > 0 indicates an increase in log NT Pro BNP relative to baseline and a value < 0 indicates a decrease in log NT Pro BNP relative to baseline.

Secondary Outcome Measures :

1. Composite Endpoint of the Effects of LCZ696 (Number of Days) [ Time Frame: Randomization through 24 weeks ]

   Composite endpoint of effects of LCZ696 compared to valsartan over 24 weeks will be compared based upon the number of days subjects are

   • alive and out of hospital
   • not listed for transplant (Status 1A, 1B or 1-4), or undergoing transplant
   • not implanted with an LVAD
   • not maintained or started on continuous inotropic therapy for ≥ 7 days
   • not hospitalized twice for HF (following the index admission) The days alive and out of hospital will end on the day of the second HF readmission, if applicable.
2. Tolerability - Target Dose [ Time Frame: Randomization through 24 weeks ]
   Tolerability as measured by number of subjects achieving a target dose of 0% (stopped study drug early or was never started on study drug), 25%, 50% or 100% of valsartan or LCZ696 (based on last dose of study drug taken prior to end of study)
3. Tolerability - Hypotension [ Time Frame: Randomization through 24 weeks ]
   Tolerability as measured by number of subjects developing hypotension (SBP ≤ 85 mmHg) with symptoms
4. Tolerability - Renal Function [ Time Frame: Randomization through 24 weeks ]
   Tolerability as measured by number of subjects developing worsening renal function (eGFR < 20 ml/min/1.73 m²)
5. Tolerability - Hyperkalemia [ Time Frame: Randomization through 24 weeks ]
   Tolerability as measured by number of subjects developing moderate (>/= 5.5 mmol/L-5.9 mmol/L) or severe (>/= 6 mmol/L) hyperkalemia

Other Outcome Measures:

1. Time to Death [ Time Frame: Randomization through 24 weeks ]
   Time to death through 24 weeks
2. Time to First Heart Failure (HF) Hospitalization [ Time Frame: Randomization through 24 weeks ]
   Time to first HF hospitalization through 24 weeks
3. Time to Death and First Heart Failure (HF) Hospitalization [ Time Frame: Randomization through 24 weeks ]
   Time to death and first HF hospitalization through 24 weeks
4. Total Number of Heart Failure (HF) Hospitalizations [ Time Frame: Randomization through 24 weeks ]
   Total number of HF hospitalization admissions through 24 weeks
5. Inotropic Therapy [ Time Frame: Randomization through 24 weeks ]
   Number of subjects on continuous inotropic therapy >/= 7 days after discharge from the index hospitalization through 24 weeks
6. Number of Subjects Listed for Transplant (Status 1A, 1B or 1-4), Transplanted or Implanted With an LVAD [ Time Frame: Randomization through 24 weeks ]
   Number of subjects listed for transplant (status 1A, 1B or 1-4), transplanted or implanted with an LVAD through 24 weeks.
7. Change in eGFR and Cystatin C Levels [ Time Frame: Randomization through 24 weeks ]
   Change in eGFR and cystatin C levels compared to baseline. Renal function will be assessed at baseline, 4, 8, 12, and 24 weeks
8. Unanticipated IV Diuretic Use [ Time Frame: Randomization through 24 weeks ]
   Number of subjects with unanticipated use of IV diuretics (outpatient, ER or inpatient) through 24 weeks.
9. Change in AUC in the Kansas City Cardiomyopathy Questionnaire (KCCQ) [ Time Frame: Randomization through 24 weeks ]
   Difference in AUC of the KCCQ at 4, 12 and 24 weeks
10. Change in AUC for the Ratio of NT-proBNP/BNP [ Time Frame: Randomization through 24 weeks ]
    The change in AUC for the ratio of NT-proBNP/BNP from baseline to weeks 2, 4, 8, 12 and 24 weeks

Eligibility Criteria

• Ages Eligible for Study: 18 Years to 85 Years (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Advanced HFrEF defined as including ALL

   1. LVEF≤ 35% documented during the preceding 12 months
   2. NYHA class IV symptomatology, defined as chronic dyspnea or fatigue at rest or on minimal exertion in the previous 3 months, or patients who require chronic inotropic therapy
   3. Minimum of 3 months GDMT for HF and/or intolerant to therapy
2. Systolic blood pressure ≥ 90 mmHg
3. Serum NT-proBNP ≥ 800 pg/mL OR BNP ≥ 250 pg/mL (most recent - less than 3 months old)

4. Any one or more of the following objective findings of advanced HF including:

   1. Current inotropic therapy or use of inotropes in the past 6 months
   2. ≥ 1 hospitalization for heart failure in the past 6 months (not including the index hospitalization for inpatient participants)
   3. LVEF ≤ 25% (within the past 12 months)
   4. Peak VO2 < 55% predicted or peak VO2 ≤ 16 for men or ≤ 14 for women (Respiratory Exchange Ratio (RER) ≥ 1.05) (within the past 12 months)
   5. 6 min walk test distance < 300 m (within the past 3 months)
5. Age ≥18 years and ≤ 85 years
6. Signed Informed Consent form

Exclusion Criteria:

1. Currently taking Entresto™
2. History of hypersensitivity or intolerance (unmodifiable) to Entresto™, an ACEI or ARB as well as known or suspected contraindications (including hereditary angioedema) to the study drugs.
3. Estimated glomerular filtration rate (eGFR) < 20 mL/min/1.73 m2 at baseline
4. Co-morbid conditions that may interfere with completing the study protocol (e.g. recent history of drug or alcohol abuse) or cause death within 1 year
5. Symptomatic hypotension at randomization or systolic blood pressure < 90 mmHg
6. Serum potassium > 5.5 mmol/L
7. Severe liver dysfunction (Childs-Pugh Class C)
8. Acute coronary syndrome within 4 weeks as defined by electrocardiographic (ECG) changes and biomarkers of myocardial necrosis (e.g. troponin) in an appropriate clinical setting (chest discomfort or anginal equivalent)
9. Planned or recent (≤ 4 weeks) PCI, coronary artery bypass grafting, or biventricular pacing
10. Currently hospitalized and listed status 1A, 1B or 1-4 for heart transplant
11. Current or scheduled for LVAD implantation within 30 days of study enrollment
12. Active infection (current use of oral or IV antimicrobial agents)
13. Primary hypertrophic or infiltrative cardiomyopathy, acute myocarditis, constrictive pericarditis or tamponade
14. Complex congenital heart disease
15. Concomitant use of aliskiren in patients with diabetes or renal impairment (eGFR <60 mL/min/1.73 m²)
16. Known pregnancy or anticipated pregnancy within the next 6 months or breastfeeding mothers
17. Enrollment in any other investigational clinical trial within 30 days prior to screening
18. Inability to comply with study procedures

Contacts and Locations

Locations

United States, California

Cedars-Sinai Heart Institute

Beverly Hills, California, United States, 90211

Sutter Health Mills-Peninsula Health Services

Sacramento, California, United States, 95816

San Diego Cardiac Center

San Diego, California, United States, 92123

United States, District of Columbia

MedStar Washington Hospital Center

Washington, District of Columbia, United States, 20010

United States, Georgia

Piedmont Heart Institute

Atlanta, Georgia, United States, 30309

Emory University School of Medicine

Atlanta, Georgia, United States, 30322

United States, Illinois

Advocate Christ Medical Center

Oak Lawn, Illinois, United States, 60453

United States, Indiana

St. Vincent Medical Group

Indianapolis, Indiana, United States, 46260

United States, Louisiana

Ochsner Clinic Foundation

New Orleans, Louisiana, United States, 70121

United States, Maryland

Johns Hopkins Hospital

Baltimore, Maryland, United States, 21287

United States, Massachusetts

Tufts Medical Center

Boston, Massachusetts, United States, 02111

Massachusetts General Hospital

Boston, Massachusetts, United States, 02114

Brigham and Women's Hospital

Boston, Massachusetts, United States, 02115

United States, Michigan

University of Michigan Health System

Ann Arbor, Michigan, United States, 48109

United States, Minnesota

Mayo Clinic

Rochester, Minnesota, United States, 55905

United States, Missouri

Washington University

Saint Louis, Missouri, United States, 63110

Saint Louis University Hospital

Saint Louis, Missouri, United States, 63117

United States, New York

Mount Sinai Hospital

New York, New York, United States, 10029

Stony Brook University Medical Center

Stony Brook, New York, United States, 11794

United States, North Carolina

Charlotte-Mecklenburg Hospital Authority

Charlotte, North Carolina, United States, 28203

Duke University Medical Center

Durham, North Carolina, United States, 27705

United States, Ohio

The Christ Hospital

Cincinnati, Ohio, United States, 45219

Case Western Medical Center

Cleveland, Ohio, United States, 44106

Metro Health System

Cleveland, Ohio, United States, 44109

Cleveland Clinic

Cleveland, Ohio, United States, 44195

The Ohio State University Medical Center

Columbus, Ohio, United States, 43210

United States, Oklahoma

Integris Baptist Medical Center

Oklahoma City, Oklahoma, United States, 73112

United States, Oregon

Oregon Health and Science University

Portland, Oregon, United States, 97239

United States, Pennsylvania

University of Pennsylvania

Philadelphia, Pennsylvania, United States, 19104

Thomas Jefferson University Hospital

Philadelphia, Pennsylvania, United States, 19107

Allegheny General Hospital

Pittsburgh, Pennsylvania, United States, 15212

Geisinger Medical Center

Wilkes-Barre, Pennsylvania, United States, 18711

United States, Tennessee

Vanderbilt University Medical Center

Nashville, Tennessee, United States, 37232

United States, Texas

Houston Methodist Research Institute

Houston, Texas, United States, 77030

United States, Utah

University of Utah School of Medicine

Salt Lake City, Utah, United States, 84132

United States, Virginia

Inova Heart and Vascular Insititute

Falls Church, Virginia, United States, 22042

Sentara Norfolk General Hospital

Norfolk, Virginia, United States, 23507

United States, Washington

University of Washington Medical Center

Seattle, Washington, United States, 98195

Sponsors and Collaborators

Duke University

National Heart, Lung, and Blood Institute (NHLBI)

Investigators

• Principal Investigator: Kevin Anstrom; Duke Health
• Study Chair: Eugene Braunwald, MD; Harvard University

  Study Documents (Full-Text)

Documents provided by Duke University:

Study Protocol  [PDF] February 20, 2019

Statistical Analysis Plan  [PDF] September 11, 2020

Informed Consent Form  [PDF] February 20, 2019

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Vader JM, Givertz MM, Starling RC, McNulty SE, Anstrom KJ, Desvigne-Nickens P, Hernandez AF, Braunwald E, Mann DL; LIFE Investigators. Tolerability of Sacubitril/Valsartan in Patients With Advanced Heart Failure: Analysis of the LIFE Trial Run-In. JACC Heart Fail. 2022 Jul;10(7):449-456. doi: 10.1016/j.jchf.2022.04.013.

Mann DL, Givertz MM, Vader JM, Starling RC, Shah P, McNulty SE, Anstrom KJ, Margulies KB, Kiernan MS, Mahr C, Gupta D, Redfield MM, Lala A, Lewis GD, DeVore AD, Desvigne-Nickens P, Hernandez AF, Braunwald E; LIFE Investigators. Effect of Treatment With Sacubitril/Valsartan in Patients With Advanced Heart Failure and Reduced Ejection Fraction: A Randomized Clinical Trial. JAMA Cardiol. 2022 Jan 1;7(1):17-25. doi: 10.1001/jamacardio.2021.4567.

Mann DL, Greene SJ, Givertz MM, Vader JM, Starling RC, Ambrosy AP, Shah P, McNulty SE, Mahr C, Gupta D, Redfield MM, Lala A, Lewis GD, Mohammed SF, Gilotra NA, DeVore AD, Gorodeski EZ, Desvigne-Nickens P, Hernandez AF, Braunwald E; LIFE Investigators. Sacubitril/Valsartan in Advanced Heart Failure With Reduced Ejection Fraction: Rationale and Design of the LIFE Trial. JACC Heart Fail. 2020 Oct;8(10):789-799. doi: 10.1016/j.jchf.2020.05.005. Epub 2020 Jun 10. Erratum In: JACC Heart Fail. 2020 Dec;8(12):1059.

• Responsible Party: Duke University
• ClinicalTrials.gov Identifier: NCT02816736
• Other Study ID Numbers: Pro00071722; 5U01HL084904 ( U.S. NIH Grant/Contract )
• First Posted: June 29, 2016
• Results First Posted: December 3, 2021
• Last Update Posted: December 3, 2021
• Last Verified: December 2021

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Duke University:

Heart Failure; Heart Diseases; Cardiovascular Diseases; Valsartan; Entresto

Additional relevant MeSH terms:

Heart Failure; Heart Diseases; Cardiovascular Diseases; Valsartan; Sacubitril and valsartan sodium hydrate drug combination; Antihypertensive Agents; Angiotensin II Type 1 Receptor Blockers; Angiotensin Receptor Antagonists; Molecular Mechanisms of Pharmacological Action