Coronary Artery Disease Clinical Trial
Official title:
An 8-week, Open-Label Clinical Trial of the Efficacy and Safety of Vortioxetine in Patients With Major Depressive Disorder and Coronary Artery Disease
This is a preliminary, open-label, clinical trial designed to assess the efficacy, safety, and tolerability of vortioxetine for the treatment of major depressive disorder in patients with coronary artery disease. In addition, the study will assess the effects of vortioxetine on heart rate variability in these patients.
Comorbid Major Depressive Disorder (MDD) and Coronary Artery Disease (CAD) are common:
Major depressive disorder is a highly prevalent disorder that is serious, and in some cases
life-threatening, condition. The 12-month prevalence of major depressive disorder in the
United States is 6.6% (Kessler et al., 2003). Coronary artery disease (CAD) is also a large
and growing problem in the United States. According to the 2014 American Heart Association
(AHA) report on heart disease and stroke statistics, an estimated 15.4 million Americans ≥20
years of age have coronary artery disease. The total prevalence of coronary artery disease
in this population is estimated to be 6.4%, with a prevalence of 7.9% in men and 5.1% in
women. By the year 2030, the prevalence of coronary artery disease is projected to increase
approximately 18% from 2013 estimates (Go et al., 2014). Thus, patients with major
depressive disorder and comorbid CAD represent a large population of patients.
Depression in patients with CAD is clinically important:
Depression frequently accompanies coronary artery disease and has been linked more somatic
symptoms, hospitalizations, increased financial burden, and poorer quality of life, as well
as being a predictor of worse outcomes of cardiac disease. Reduction of cardiac risk factors
is less likely to be successful in depressed patients. Depression may also interfere with
medication adherence, as depressed patients are three times as likely to be noncompliant
with their medication regimens. In addition, depression is associated with decreased rates
of participation in cardiac rehabilitation, higher healthcare utilization and costs, and
greatly reduced quality of life (Lichtman et al., 2009). Due to these effects of depression
on coronary artery disease, there is increasing recognition that depression should be
formally considered a risk factor for adverse medical outcomes in patients with acute
coronary syndrome (Lichtman et al., 2014).
Thus, there is a great, unmet clinical need to treat patients with major depressive disorder
and coronary artery disease.
In addition to the older tricyclic antidepressants, the newer serotonin-norepinephrine
reuptake inhibitors are also associated with cardiovascular risks like hypertension,
orthostatic hypotension, and perhaps QTc prolongation (Mago et al., 2014). Vortioxetine is a
newly approved antidepressant thought to work by combining modulation of 5-HT receptor
subtypes and inhibition of the serotonin transporter (Citrome, 2014). Early data suggests
that this multimodal mechanism of action results in increased brain levels of serotonin,
dopamine, and noradrenaline in the prefrontal cortex (Pehrson et al., 2013). Clinical trials
of vortioxetine for major depressive disorder have not shown any cardiovascular adverse
effects (Mago et al., 2014).
Heart Rate Variability (HRV) Heart Rate Variability is a measure is based on the changes in
the interval between consecutive heart beats and between consecutive instantaneous heart
rates. It has become the conventionally accepted term to describe variations of both
instantaneous heart rate and RR intervals. Long term reduced heart rate variability can lead
to immune dysfunction and inflammation, cardiovascular disease and mortality (Newhouse,
2014). Several studies in depressive patients have shown reduced heart rate variability that
suggests an increased sympathetic activity and/or reduced vagal activity (Carney et al.,
2009). Thus, treating depression effectively may reduce heart rate variability, which is a
surrogate marker for better cardiovascular outcomes.
The proposed study has been planned as a pilot, open-label study of the use, for the first
time, of vortioxetine in patients with documented coronary disease. Therefore, the sample
size is not based on a formal sample size calculation but on feasibility of a small study
that, if positive, can lead to a future larger, adequately powered study. A sample size of
25 patients is appropriate for the present purpose. The results of this proposed study would
inform sample size calculation for a future, larger study.
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Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment
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