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Design and rationale of a multicentre, randomized, double blind, placebo-controlled clinical trial to evaluate the effect of vitamin D on ventricular remodeling in patients with anterior myocardial infarction: The VITamin D in Acute Myocardial Infarction (VITDAMI) For peer reviewtrial only
Journal: BMJ Open
Manuscript ID bmjopen-2016-011287
Article Type: Protocol
Date Submitted by the Author: 27-Jan-2016
Complete List of Authors: Tuñón, José; Fundación Jiménez Díaz, Cardiology; Universidad Autonoma de Madrid, Medicine González-Hernández, Ignacio; Fundacion Jimenez Diaz, Cardiology Llanos-Jiménez, Lucía; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Research Unit Alonso-Martín, Joaquín; Hospital Universitario de Getafe, Cardiology; Universidad Rey Juan Carlos, Medicine Escudier-Villa, Juan; Hospital Universitario Puerta del Hierro Majadahonda, Cardiology http://bmjopen.bmj.com/ Tarín, Nieves; Hospital Universitario de Mostoles, Cardiology Cristóbal, Carmen; Hospital de Fuenlabrada, Cardiology; Universidad Rey Juan Carlos, Medicine Sanz, Petra; Hospital Rey Juan Carlos, Cardiology; Universidad Rey Juan Carlos, Medicine Pello, Ana ; Fundacion Jimenez Diaz, Cardiology Aceña, Álvaro; Fundacion Jimenez Diaz, Cardiology Carda, Rocío; Fundacion Jimenez Diaz, Cardiology Orejas, Miguel; Fundacion Jimenez Diaz, Cardiology Tomás, Marta; Fundacion Jimenez Diaz, Radiology on September 23, 2021 by guest. Protected copyright. Beltrán, Paula; Fundacion Jimenez Diaz, Cardiology Calero-Rueda, María José; Hospital Rey Juan Carlos, Cardiology Marcos, Esther; Hospital Universitario de Mostoles, Cardiology Serrano-Antolín, José María; Hospital de Fuenlabrada, Cardiology Gutierrez-Landaluce, Carlos; Hospital de Fuenlabrada, Cardiology Jiménez, Rosa; Hospital de Fuenlabrada, Cardiology Cabezudo, Jorge; Hospital de Fuenlabrada, Cardiology Curcio, Alejandro; Hospital de Fuenlabrada, Cardiology Peces-Barba, Germán; Fundacion Jimenez Diaz, Neumology; Universidad Autonoma de Madrid, Medicine González-Parra, Emilio; Fundacion Jimenez Diaz, Nephrology; Universidad Autonoma de Madrid, Medicine Muñoz-Siscart, Raquel; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Research Unit González-Casaus, María Luisa; Hospital Gomez-Ulla, Laboratory of Renal Function Lorenzo, Antonio; Hospital Universitario de Mostoles, Cardiology
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1 2 3 4 Huelmos, Ana; Hospital Universitario Fundacion Alcorcon, Cardiology 5 Goicolea, Javier; Hospital Universitario Puerta del Hierro Majadahonda, Cardiology 6 Ibáñez, Borja; Fundacion Jimenez Diaz, Cardiology; Fundacion Centro 7 Nacional de Investigaciones Cardiovasculares Carlos III 8 Hernández, Gonzalo; FAES FARMA 9 Alonso-Pulpón, Luis; Hospital Universitario Puerta del Hierro Majadahonda, 10 Cardiology; Universidad Autonoma de Madrid, Medicine 11 Farré, Jerónimo; Fundacion Jimenez Diaz, Cardiology; Universidad 12 Autonoma de Madrid, Medicine 13 Lorenzo, Óscar; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Vascular Research Laboratory; Universidad Autonoma de 14 Madrid, Medicine 15 For peerMahíllo-Fernández, review Ignacio; Instituto deonly Investigacion Sanitaria de la 16 Fundacion Jimenez Diaz, Research Unit 17 Egido, Jesus; Fundacion Jimenez Diaz, Nephrology; Universidad Autonoma 18 de Madrid, Medicine 19 Primary Subject 20 Cardiovascular medicine Heading: 21 22 Secondary Subject Heading: Cardiovascular medicine, Renal medicine 23 Vitamin D, acute myocardial infarction, calcifediol, remodeling, cardiac 24 Keywords: 25 magnetic resonance imaging 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from
1 2 3 Design and rationale of a multicentre, randomized, double blind, placebo- 4 controlled clinical trial to evaluate the effect of vitamin D on ventricular 5 6 remodeling in patients with anterior myocardial infarction: 7 The VITamin D in Acute Myocardial Infarction (VITDAMI) trial 8 9 José Tuñón, MD, PhD,a,b,c Ignacio González-Hernández, MD,a Lucía Llanos-Jiménez, MD,d 10 e,f g h 11 Joaquín Alonso-Martín, MD, PhD, Juan M. Escudier-Villa, MD, Nieves Tarín, MD, PhD, 12 Carmen Cristóbal, MD, PhD,f,i Petra Sanz, MD,f,i Ana M. Pello, MD,a Álvaro Aceña, MD,a 13 14 Rocío Carda, MD,a Miguel Orejas, MD,a Marta Tomás, MD,k Paula Beltrán, MD,PhD,a María 15 José Calero-Rueda,For MD, peerj Esther Marcos, review MD,h José María Serrano-Antolín,only MD,i Carlos 16 17 Gutiérrez-Landaluce, MD,i Rosa Jiménez, MD,i Jorge Cabezudo, MD,i Alejandro Curcio, MD,i 18 Germán Peces-Barba, MD, PhD,b,l Emilio González-Parra, MD, PhD,b,m Raquel Muñoz-Siscart, 19 20 BSc,d María Luisa González-Casaus, MD,n Antonio Lorenzo, MD,h Ana Huelmos, MD, PhD,o 21 g a,p q 22 Javier Goicolea, MD, PhD, Borja Ibáñez, MD, PhD, Gonzalo Hernández, MD, Luis M 23 Alonso-Pulpón, MD, PhD,b,g Jerónimo Farré, MD, PhD,a,b Óscar Lorenzo, PhD,b,c Ignacio 24 d b,c,r 25 Mahíllo-Fernández, PhD, Jesús Egido, MD, PhD 26 27 28 aDepartment of Cardiology, Fundación Jiménez Díaz, Madrid, Spain 29 bDepartment of Medicine, Autónoma University, Madrid, Spain, 30 cVascular Research Laboratory, IIS-Fundación Jiménez Díaz, Madrid, Spain 31 dResearch Unit, IIS-Fundación Jiménez Díaz, Madrid, Spain, 32 eDepartment of Cardiology, University Hospital of Getafe, Madrid, Spain, 33 f Department of Medicine, Rey Juan Carlos University, Alcorcón, Spain http://bmjopen.bmj.com/ 34 gDepartment of Cardiology, University Hospital Puerta de Hierro, Madrid, Spain, 35 hDepartment of Cardiology, University Hospital of Móstoles, Móstoles, Spain, 36 iDepartment of Cardiology, Hospital de Fuenlabrada, Madrid, Spain 37 j Department of Cardiology, Hospital Rey Juan Carlos, Móstoles, Madrid, Spain 38 k Department of Radiology, Fundación Jiménez Díaz, Madrid, Spain 39 lDepartment of Neumology, Fundación Jiménez Díaz, Madrid, Spain 40 mDepartment of Nephrology, Fundación Jiménez Díaz, Madrid, Spain 41 n Laboratory of Renal Function, Hospital Gómez-Ulla, Madrid, Spain on September 23, 2021 by guest. Protected copyright. 42 oDepartment of Cardiology, Fundación Hospital Alcorcón, Madrid, Spain 43 p 44 Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain qFAES FARMA S.A. laboratories, Vizcaya, Spain 45 r 46 CIBERDEM, Madrid, Spain 47 48 Word Count: 4,887 49 Corresponding author: José Tuñón, MD, PhD, Department of Cardiology, IIS-Fundación 50 51 Jiménez Díaz, Avenida Reyes Católicos 2, 28040 Madrid (Spain), Phone 00-34-915504800 52 Ext: 3701, email [email protected] 53 54 55 Key words: Vitamin D; calcifediol; acute myocardial infarction; remodeling; cardiac magnetic 56 resonance imaging 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml1 Page 3 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from
1 2 3 ABSTRACT 4 Introduction: Decreased plasma vitamin D (VD) levels are linked to cardiovascular 5 damage. However, clinical trials have failed to demonstrate a benefit of VD 6 supplements on left ventricular (LV) remodeling. Anterior ST-elevation acute 7 myocardial infarction (STEMI) is the best human model to study the effect of 8 treatments on LV remodeling. We present a proof-of-concept study that aims to 9 10 investigate whether VD treatment improves LV remodeling in patients with anterior 11 STEMI. 12 13 Methods and Analysis: The VITDAMI (VITamin D in Acute Myocardial Infarction) 14 trial is a multicenter, randomized, double-blind, placebo-controlled trial. One hundred 15 forty-fourFor patients diagnosedpeer with review anterior STEMI will only be assigned to receive 16 calcifediol 0.266 mg capsules (Hidroferol® SGC)/15 days or placebo on a 2:1 basis 17 during 12 months. Primary objective: to evaluate the effect of calcifediol on LV 18 remodeling defined as an increase in LV end-diastolic volume ≥10% (magnetic 19 resonance imaging). Secondary objectives include change in LV end-diastolic and end- 20 21 systolic volumes, ejection fraction, LV mass, diastolic function, sphericity index, and 22 size of fibrotic area; endothelial function; plasma levels of aminoterminal fragment of 23 B-type natriuretic peptide, galectin-3, and monocyte chemoattractant protein-1; levels of 24 calcidiol (VD metabolite) and other components of mineral metabolism (fibroblast 25 growth factor-23 [FGF-23], the soluble form of its receptor klotho, parathormone, and 26 phosphate). Differences in the effect of VD will be investigated according to plasma 27 levels of FGF-23 and klotho. Treatment safety and tolerability will be assessed. To our 28 knowledge, this is the first study to evaluate this outcome in patients with STEMI and 29 the possible influence of FGF-23 and klotho on this benefit. 30 31 32 Ethics and dissemination: This trial has been approved by the Madrid Regional Ethics 33 Committee, and by the Ethics Committees of all participating institutions. It is http://bmjopen.bmj.com/ 34 registered in ClinicalTrials.gov 35 (https://www.clinicaltrials.gov/ct2/show/NCT02548364?term=VITDAMI&rank=1). 36 The results will be submitted to indexed medical journals and presented at national and 37 international meetings. 38 39 40 41 on September 23, 2021 by guest. Protected copyright. 42 STRENGTHS AND LIMITATIONS OF THIS STUDY 43 44 45 • This study will assess the effect of vitamin D (VD) supplements on the 46 myocardium after an acute myocardial infarction, which is probably the best 47 model to study left ventricular remodeling. 48 49 • In addition to calcidiol plasma levels, other components of mineral metabolism 50 such as fibroblast growth factor 23 (FGF23) and its soluble receptor, klotho, will 51 be taken into account. 52 53 • As a limitation, this study is not powered to study if a potential benefit of VD on 54 myocardial remodeling translates into a clinical benefit. In case of a positive 55 result, a larger study would be necessary to investigate this issue. 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml2 BMJ Open Page 4 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from
1 2 3 4 INTRODUCTION 5 6 Traditionally, changes in plasma levels of the components of mineral 7 metabolism [vitamin D (VD), fibroblast growth factor-23 (FGF-23), parathyroid 8 hormone (PTH), and phosphate (P)] have been associated with renal disease. When 9 slight decreases in glomerular filtration rate appear, the excretion of P is reduced. 10 Compensatory responses are then activated to maintain P homeostasis, including an 11 increase in the levels of FGF-23 and a subsequent rise in those of PTH[1]. FGF-23 12 promotes phosphaturia and decreases levels of plasma VD, both by downregulating 13 synthesis and by increasing degradation[1]. 14 15 AlthoughFor high peerP levels are associated review with an increase only in cardiovascular events 16 and mortality[2], the aforementioned adaptive mechanisms prevent an increase of serum 17 18 P levels in the early stages of chronic kidney disease. However, these compensatory 19 mechanisms themselves are also related to cardiovascular damage[3, 4]. Thus, high 20 FGF-23 plasma levels are independently associated with endothelial dysfunction, 21 arterial stiffness, atherosclerosis burden, vascular calcification, left ventricular (LV) 22 hypertrophy, progression of renal disease, and incidence of mortality and cardiovascular 23 events in the general population as well as in patients with coronary artery disease, even 24 after adjusting for renal glomerular filtration[3-9]. Similarly, increased PTH plasma 25 levels are related to LV hypertrophy, hypertension, and increased cardiovascular 26 events[10-15]. Finally, VD deficiency has been associated with endothelial dysfunction, 27 28 inflammation, and vascular smooth muscle cell proliferation, vascular calcification, 29 activation of the renin-angiotensin system, hypertension, myocardial infarction, and 30 stroke[16-21]. However, low VD plasma levels are not only associated to vascular 31 damage, but they also play an important role in the state of the myocardium. In this 32 regard, VD deficiency is associated with rat LV hypertrophy and systolic dysfunction, 33 biatrial enlargement, metabolic changes, inflammation, fibrosis, and apoptosis[22]. http://bmjopen.bmj.com/ 34 35 Of interest, abnormalities of mineral metabolism are not restricted to patients 36 with overt renal disease, as in more than 50% of patients with coronary artery disease 37 we have observed a deficiency of VD. However, only 20% of them had an estimated 38 glomerular filtration rate <60 mL/min/1.73 m2[9]. Moreover, abnormalities of mineral 39 metabolism were evident even at glomerular filtration rates >90 ml/min/1.73 m2[23]. In 40 addition, the inverse relationship between VD levels and risk of coronary heart disease 41
has also been seen in the general population[19, 24]. on September 23, 2021 by guest. Protected copyright. 42 43 Despite the negative association between VD deficiency and cardiovascular 44 disease described in multiple studies[9, 19, 25-34], clinical trials have failed to 45 convincingly demonstrate a benefit of VD supplements on CV health. One such study 46 was the PRIMO trial, which showed no improvement in ventricular mass index or any 47 other remodeling parameters by administering paricalcitol, a selective activator of VD 48 receptors, to patients with chronic renal failure[35]. However, experiments performed in 49 50 vitro and in several animal models of LV pressure overload show that VD supplements 51 attenuate LV hypertrophy, reduce cardiac fibrosis, and decrease the expression of 52 collagen, fibronectin, and transforming growth factor-β (TGF-β), along with an 53 improvement of the systolic and diastolic function[36-39]. The negative results of the 54 PRIMO trial may have several causes. The main cause could be that the population 55 selected was not ideal for the purpose of linking VD supplements and ameliorated CV 56 health. Second, hypertension leads to myocardial remodeling over the years, and it 57 seems difficult to modify this process in only 48 weeks of therapy. Another potential 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml3 Page 5 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from
1 2 3 reason is that FGF-23 plasma levels were not taken into account. Indeed, it has recently 4 been observed that low levels of VD were associated with increasing mass and diameter 5 when coexisting with high levels of FGF-23[40]. In accordance with this, we have 6 recently reported that low levels of VD were predictors of poor outcome in coronary 7 patients with FGF-23 plasma levels that were higher than the median value of 70 8 RU/ml, but they were not effective predictors if FGF-23 plasma levels were below the 9 10 median[9]. Other authors have shown similar data for the progression of chronic kidney 11 disease[41]. With regard to LV remodeling, FGF-23 is associated with more severe 12 hypertrophy when plasma VD levels are low than when they are normal[40]. These data 13 provide support for the notion that, in addition to being an independent marker of 14 cardiovascular risk, FGF-23 plasma levels influence the effect of low VD levels. 15 Finally, klothoFor plasma peer levels were not review taken into account. Thisonly protein is a co-receptor 16 for FGF-23, whose extracellular portion can be released and act as an endocrine 17 substance with multiple functions. Low levels of klotho are related to kidney damage, 18 but also to vascular calcification and cardiac hypertrophy and fibrosis, causing klotho to 19 20 be considered an anti-aging protein[42]. Thus, it is possible that in people without 21 reduced glomerular filtrate, klotho levels are normal and could interfere with the 22 hypertrophic effect of FGF-23. The fact that VD may increase klotho levels reinforces 23 the possibility that this compound may have a protective cardiovascular effect. 24 In summary, there is substantial evidence demonstrating the negative effects of VD 25 26 deficiency on the cardiovascular system, including the development of LV hypertrophy. 27 Despite the negative results of VD supplements in previous clinical trials, the convincing 28 evidence obtained in animal models in which it is shown that VD may protect the heart 29 supports the need for a new clinical trial designed to take into account the most recent 30 discoveries in the field. The VITDAMI trial has been designed as a proof-of-concept 31 study to test the effect of VD supplements in patients with anterior ST-elevation 32 myocardial infarction (STEMI). The reason is that a great part of the remodeling process 33 following a large STEMI may be concentrated in the months following the acute event, http://bmjopen.bmj.com/ 34 making these patients probably the best human model for studying therapeutic 35 36 interventions on ventricular remodeling. Moreover, when STEMI affects the anterior wall 37 of the LV, it tends to be larger than in other locations, and remodeling is thus especially 38 intensive in these cases. In this regard, in the METOCARD trial comparing early versus 39 delayed beta-blockade in patients with anterior STEMI[43, 44], the control group showed 40 an increase of 11.5% in mean LV end-diastolic volume and a decrease of 22.8% in mean 41 LV mass at 6 months, along with a minimal increase of 2.2% in the ejection fraction. In on September 23, 2021 by guest. Protected copyright. 42 addition, we will see if this effect occurs only in those patients with FGF-23 above the 43 median or in all the study subjects. Similarly, we will assess possible differences in the 44 45 effect of VD in patients with klotho plasma levels above and below the median. Based on 46 the ideas developed above, it is possible that benefits could be present only in patients 47 with elevated levels of FGF-23, where klotho levels are below the median, or in both 48 situations. 49 50 51 METHODS 52 53 Study aim 54 To compare the effect of one year treatment with Calcifediol 0.266 mg 55 (equivalent to 15,960 units) soft gelatin capsules versus placebo treatment on LV 56 remodeling in patients with anterior STEMI. 57 58 Primary Hypothesis 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml4 BMJ Open Page 6 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from
1 2 3 The oral administration of one Calcifediol 0. 266 mg soft gelatin capsule every 4 15 days to patients with anterior STEMI will reduce the presence of LV remodeling 5 assessed by cardiac magnetic resonance imaging (MRI), and defined as an increase in 6 LV end-diastolic volume of ≥10%, at one year as compared with the baseline 7 assessment. 8 9 Secondary Hypotheses 10 11 1. Patients receiving calcifediol will show, as compared to those receiving placebo: 12 13 • Less increase in end-diastolic and end-systolic volumes. 14 • More increase in ejection fraction. 15 For peer review only 16 • Less decrease in diastolic sphericity index, defined as the ratio of long- to short- 17 axis dimension of the left ventricular cavity at end-diastole[45]. 18 • Less increase in the area of fibrosis. 19 • Better diastolic function. 20 • Better endothelial function. 21 • A significant reduction in plasma levels of one or more of these biomarkers: NT- 22 23 proBNP (N-terminal brain natriuretic peptide) and galectin-3, as related to heart 24 failure and adverse prognosis; and monocyte chemoattractant protein-1 (MCP- 25 1), related to inflammation and acute ischemic events[46]. 26 • Higher plasma levels of calcidiol (25OH VD) and/or klotho, and lower levels of 27 FGF-23 and/or PTH. 28 29 2. The results of the previous hypotheses will be more evident or even restricted to 30 those patients with FGF-23>median and/or klotho medication due to other reasons will be excluded form the analysis. The reason is that on September 23, 2021 by guest. Protected copyright. 42 this is just a proof-of-concept study, where we try to demonstrate for the first time in 43 human beings that taking VD supplements to reach normal calcidiol levels may 44 45 decrease LV remodeling after a STEMI. On the other hand, we do not intend to show 46 that anterior STEMI must be treated with VD, as a large clinical trial demonstrating 47 reduction of clinical events would be necessary for this purpose. 48 49 Trial Population 50 51 Patients between 40 and 85 years of age admitted at the hospital due to an anterior 52 STEMI, that have received complete revascularization, that are expected to be 53 discharged alive, and who accept to participate and sign the Informed Consent are 54 eligible for randomization. STEMI is defined by suggestive symptoms, such as chest 55 discomfort irradiated to the arms or jaw, or just compatible symptoms as sweating, 56 nausea, vomiting or ill-defined malaise lasting more than 20 min, in association with 57 persistent electrocardiographic ST elevation and subsequent release of biomarkers of 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml5 Page 7 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 myocardial necrosis with standard curve[47]. Diagnostic anterior ST elevation in 4 absence of LV hypertrophy or left bundle-branch block is defined according to current 5 guidelines as new ST elevation at the J point in at least 2 contiguous leads of ≥2 mm in 6 V1-6 in men; in women ≥1.5 mm in V2–V3 and/or ≥1 mm in the remaining anterior 7 leads will be accepted[48]. Exclusion criteria are listed in Table 1. Recruitment will be 8 competitive. 9 10 11 Table 1. Exclusion Criteria 12 ______13 -Death or complications compromising patient survival (i.e: cardiogenic shock) during the 14 index event 15 -Indication of cardiac transplant For peer review1 only 16 -Impossibility to perform the desirable revascularization 17 -Revascularization pending at the moment of discharge 18 -Previous myocardial infarction 19 -Valve prosthesis 20 -Aortic stenosis with mean gradient>25 mm Hg (Doppler) and stenosis of any other valve 21 -Moderate to severe valve regurgitation 22 -Cardiomyopathy (Dilated, Hypertrophic or Restrictive) 23 -Severe left ventricle hypertrophy (wall thickness ≥17 mm in men and ≥16 mm in women) 24 -Conditions limiting survival 25 -Inflammatory or immune disease 26 -Estimated Glomerular Filtration Rate <45 ml/min/1.73 m2 27 -Intolerance to vitamin D supplements 28 -Indication or patient’s decision to take vitamin D or calcium 29 -Therapy with drugs that can interfere absorption, distribution, metabolism or excretion of 30 Vitamin D: 31 Anti-epileptic (Phenitoine, Phenobarbital, Primidone, other enzymatic inducers) 32 Cholestiramine, cholestipol, Orlistat 33 Penicillins http://bmjopen.bmj.com/ 34 Laxatives as paraphine and mineral oil 35 Digitalis 36 Magnesium salts 37 Verapamil 38 Steroids 39 -Disorders that can interfere the pharmacokinetics or pharmacodynamics of Vitamin D: 40 Hepatic insufficiency, inflammatory bowel disease, sarchoidosis, Tuberculosis, or other 41 granulomatous disorders. on September 23, 2021 by guest. Protected copyright. 42 -Plasma Calcium levels >10.5 mg/dl, history of hypercalciuria or calcium litiasis. 43 -Contraindications for Magnetic Resonance Imaging: claustrophoby, pacemaker, 44 defibrillators, resynchronization devices, or high probability that they need them during the 45 study (among them, patients with ejection fraction<30% at discharge) 46 -Impossibility to follow the patients 47 -Difficult compliance of the therapy as estimated by the investigator 48 -Patient rejects to participate and/or does not sign the informed consent 49 -Pregnancy or lactation period 50 1 51 Severe stenoses are allowed only in secondary vessels considered not relevant by the investigator 52 53 Trial Design 54 55 The VITDAMI trial is a randomized, multicentre, double-blind, placebo- 56 controlled trial in patients with anterior STEMI comparing the effect of VD 57 supplements (cacifediol) with placebo during one year on LV remodeling. 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml6 BMJ Open Page 8 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 The protocol (version 2.1, July 1, 2015) has been approved by the corresponding 4 Institutional Review Board and the Spanish Drug Agency. One-hundred forty four 5 patients with anterior STEMI, will be included at the Departments of Cardiology at 6 eight sites in Madrid, Spain, that have been chosen because they have the equipment 7 and programs needed to care for patients with STEMI, along with the facility for cardiac 8 magnetic resonance. After signing the informed consent they will undergo cardiac 9 10 examination by MRI and Echocardiography, blood extraction for plasma storage, 11 electrocardiogram, and non-invasive endothelial function test (only in patients admitted 12 to Fundación Jiménez Díaz) (Figure 1) as soon as possible and no later than 5 days after 13 admission. Immediately after completing these tests, patients will receive on a 2:1 14 randomized, double-blind basis an oral dose of 0.266 mg of calcifediol or placebo every 15 15 days duringFor one year.peer In addition review to study treatment, only patients will be managed 16 according to standard clinical practice based in European guidelines for STEMI[48]. 17 Given that it may be heterogeneity in calcidiol plasma levels due to different baseline 18 levels, a 2:1 instead of 1:1 randomization has been chosen in order to allow comparing 19 20 the outcomes across different ranges of calcidiol levels. 21 Forty-five days after inclusion, blood will be extracted to perform a safety 22 determination of calcidiol and calcium plasma levels, to adjust the dose of study 23 medication according to the results. By phone contact, dose adjustment will be 24 communicated to the patient and potential adverse effects will be investigated. At 25 months 3 and 9 patients will go to hospital pharmacy to get the study medication and 26 compliance and adverse effects will be checked by phone call. At month 6, patients will 27 be seen by the investigator to rule out adverse effects and to collect empty blisters to 28 confirm compliance of study medication, performing also a new blood extraction for 29 30 study plasma determinations. Finally, on month 12, all the examinations performed at 31 inclusion will be repeated, the study drug will be discontinued and the study will be 32 finished. Table 2 summarizes the visit schedule. 33 Patient recruitment started in November 2015 and the trial is expected to http://bmjopen.bmj.com/ 34 conclude in December 2017. 35 36 37 Table 2. Visit Schedule 38 39 40 V0 V1 V2 V2 V4 V5 41 42 0 m 1.5 m 3 m 6 m 9 m 12 m on September 23, 2021 by guest. Protected copyright. 43 44 Inclusion/exclusion Criteria X 45 46 Informed consent X 47 48 Clinical History X X X 49 50 Concomitant medication X X X 51 Physical Exam X X X 52 53 Heart rate and Blood Pressure X X X 54 55 Hemogram and biochemistry X X X 56 57 Chest roentgengram X X 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml7 Page 9 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 Electrocardiogram X X X 4 5 Safety determination of plasma X 6 calcidiol and calcium 7 8 Blood extraction for study X X X 9 determinations 10 11 Cardiac Magnetic Resonance Imaging X X 12 13 Echocardiogram X X 14 Endothelial function1 X X 15 For peer review only 16 Dispense study medication X X X X X 17 18 Compliance Check X X X X X 19 20 Adverse Events X X X X X 21 22 23 24 Randomization and blinding 25 Patients will be randomly assigned to receive 1 Calcifediol 0.266 mg soft gelatine 26 capsule (Hidroferol® SGC), or 1 soft capsule, containing placebo, every 15 days. 27 Allocation ratio will be 2:1 and randomization scheme will be computer-generated by 28 29 the statistician at the coordinating centre and block-balanced. Closed envelops with the 30 randomization code will be prepared and distributed to the participating centers. 31 Treatment allocation will be blind for patients and the research team. Unblinding will be 32 allowed in case a patient develops serious adverse event if the attending medical team 33 estimates that it is necessary to preserve patient’s health. http://bmjopen.bmj.com/ 34 35 36 Study Medication 37 ® 38 Hidroferol SGC will be used for this trial. This is a new formulation containing 39 0.266 mg of Calcifediol (15,960 UI of VD) that improves bioavailability (22%) with 40 respect to the liquid Calcifediol immediate release oral formulation, due to its SEDDS 41 pharmaceutical technology (Self-Emulsifying Drug Delivery Systems). 42 on September 23, 2021 by guest. Protected copyright. 43 Calcifediol and placebo capsules will be provided and labeled by FAES FARMA 44 S.A. Laboratories to ensure the blindness of the study. The Department oh Pharmacy at 45 each centre will receive the study medication, and will have a registry of the medication 46 received, dispensed and stored. The medication will be stored in appropriate conditions 47 and kept locked under restricted access. Any non-used study medication and all the 48 empty recipients will be stored until the end of the study and then will be sent to the 49 promoter. 50 51 Adherence to study medication will be evaluated using a diary that the patient 52 must fill including the forgotten doses. In addition, the registry of pharmacy will be 53 used to confirm adherence to the treatment. 54 55 56 Safety Issues 57 58 At 1.5 months a safety assessment of plasma calcidiol and calcium levels will be 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml8 BMJ Open Page 10 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 performed, as by this time calcidiol is expected to reach its peak concentration. The 4 study therapy will be adjusted following these rules: 5 6 • Calcidiol > 70 ng/ml or calcium >10.5 mg/dl: Therapy will be stopped and 7 the patient will continue being followed. 8 9 • Calcidiol 30-70 ng/ml and calcium ≤10.5 mg/dl. The dose of study drug will 10 be reduced to one capsule every month as a maintenance dose. 11 12 • Calcidiol <30 ng/ml and calcium ≤10.5 mg/dl: The dose of the study drug will 13 be kept at 1 capsule every 15 days. 14 15 Of interest,For no baselinepeer calcidiol review measurement is performed, only as this is deemed 16 unnecessary due to different reasons. 1) In a previous study from our group in 704 17 18 patients with coronary artery disease[9, 23], maximal calcidiol levels were 51 ng/ml, far 19 from the upper normal limit of 70 ng/ml. 2) The dose chosen is well below the tolerable 20 upper intake level of 4,000 UI/d[49,50]. 3) In the large VITAL clinical trial, in primary 21 prevention, a dose of 2,000 UI/d VD is being used for 5 years without assessing basal 22 levels and performing only one safety determination of calcidiol levels in a small 23 subgroup of patients[51]. 24 25 Criteria for Study Withdrawal 26 27 • Violation of Inclusion/Exclusion criteria. 28 • Patient will: According to the Declaration of Helsinki, patients may give up the 29 study at any moment and by any reason they consider. 30 • Patient who does not collaborate properly with the investigators. 31 32 • Unexpected serious adverse events. 33 • New myocardial infarction during follow-up, as it may influence LV remodeling http://bmjopen.bmj.com/ 34 • Placement of devices that are not compatible with the performance of cardiac 35 MRI, such as pacemakers, automated implantable cardioverter defibrillators or 36 resynchronization devices. 37 • Heart transplantation. 38 39 40 Trial Procedures 41 Cardiac MRI on September 23, 2021 by guest. Protected copyright. 42 43 Comprehensive cardiac MRI will be carried out to study cardiac function, LV 44 mass, myocardial edema and myocardial fibrosis/necrosis. Scans will be performed with 45 1.5 Tesla equipments at each participating centre. For assessment of global and 46 segmental left and right ventricular function, and LV mass, balanced steady-state free 47 precession with sensitivity encoding fast parallel imaging technique (True FISP, SSFP) 48 sequence will be used for cine imaging. Images will be obtained at short axis (8 mm 49 slices from the apex to the base of the left ventricle), 4-chamber, 2-chamber, and 3- 50 51 chamber. Myocardial edema will be assessed matching the slice position of the cine 52 images, using a T2-weighted triple IR turbo spin echo (STIR) sequence. For study of 53 fibrosis/myocardial necrosis, gadolinium based contrast agent will be intravenously 54 administered. Delayed enhancement imaging to assess necrotic myocardium will be 55 performed using IR Turbo-FLASH (3D-IR-GRE, 2D-IR-GRE, and PSIR sequences). 56 MRI studies will be analyzed blinded to treatment allocation at a central core laboratory 57 located at the Centro Nacional de Investigaciones Cardiovasculares Carlos III with the 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml9 Page 11 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 QMass system (7.6) by two independent observers. 4 The necrotic/fibrotic area is defined as area with delayed gadolinium up-take 5 6 (high-intensity STIR signals) and myocardium at risk as area with edema. Salvaged 7 myocardium is assessed as the difference between myocardial at risk and the necrotic 8 area. Myocardium at risk, the necrotic size and the salvaged myocardium will be 9 expressed as percentage of the total left ventricular mass. In addition, the necrotic area 10 will be also expressed in grams. All the results will be given in absolute numbers and 11 normalized by Body Surface Area. LV end-diastolic and end-systolic volumes, as well 12 as the ejection fraction and the LV sphericity index (maximal long-axis/short axis of LV 13 cavity at end-diastole) will be assessed[45]. Finally, microvascular obstruction, a 14 parameter related to cardiac remodeling[52] will be assessed at the initial MRI 15 For peer review only 16 exploration. Cardiac MRI evaluation will be performed by two independent observers, 17 and differences will be resolved by consensus. An inter-observer concordance analysis 18 will be carried out. 19 20 21 Doppler-Echocardiography 22 This technique will be performed and interpreted at the centre where the patient 23 is included. Apical four-chamber and two-chamber views as well as long- and short-axis 24 parasternal views will be used. Bidimensional and M-mode echocardiography will be 25 used to analyze diastolic and systolic diameters of the LV, septal and posterior wall 26 27 thickness, ejection fraction (Simpson method), segmental contractility using a 17- 28 segment model and registering areas of akinesia, dyskinesia and hypokinesia. Diastolic 29 function will be assessed by analyzing the Deceleration Time (ms), peak E and A waves 30 (cm/s), E/A ratio, and the isovolumetric relaxation time (ms) by pulsed Doppler, and E’ 31 (cm/s) and A’ (cm/s) waves by Tissue Doppler Imaging. 32 33 http://bmjopen.bmj.com/ 34 Endothelial Function Test 35 36 The ENDOPAT technology will be used, measuring changes of finger arterial 37 pulsatile volume (reactive hyperemia plethysmographic biosensors). This test will be 38 carried out in the subgroup of patients at the Fundación Jiménez Díaz. Given that this 39 group will have a small sample size, subgroup analysis will not be performed and only 40 comparisons between both groups of therapy will be carried out. 41 42 on September 23, 2021 by guest. Protected copyright. 43 Blood Extractions and Assessments 44 45 At blood withdrawal, 26 ml will be obtained, from which 18 ml will be placed in 46 EDTA tubes and 8 ml in tubes without EDTA. Blood will undergo centrifugation for 10 47 minutes at 2,500 G and the obtained plasma will be stored in 2 ml criovials at -80ºC. 48 Half of these samples will be stored at Instituto de Investigación Sanitaria Fundación 49 Jiménez Díaz and the other half at the Móstoles University Hospital to limit the 50 51 probabilities of damaging the samples in case of failure of the freezer. Nevertheless, 52 both freezers have a CO2 release system and telephonic alarm for cases of malfunction 53 of the system. The study of mineral metabolism will be performed at the Laboratory of 54 Renal Function at Gómez-Ulla hospital, and the remaining determinations will be 55 carried out at the Laboratories of Biochemistry and Vascular Pathology at Fundación 56 Jiménez Díaz. Calcidiol levels will be quantified using chemiluminescent immunoassay 57 (CLIA) with LIAISON ®XLanalyzer (total VD Assay DiaSorin, Saluggia, Italy). FGF- 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml10 BMJ Open Page 12 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 23 will be assessed by an ELISA that recognizes epitopes in the terminal portion 4 carboxyl terminus of FGF-23 (Human FGF-23, C-Term, Immutopics Inc, San 5 Clemente, CA), klotho will be studied by ELISA (soluble alpha-klotho ELISA, IBL 6 International, Hamburg, Germany), intact PTH by an automated chemiluminescent 7 method of second generation (2010 platform Elecsys, Roche Diagnostics, Mannheim, 8 Germany), and P will be assessed by enzymatic method (Integra 400 analyzer, Roche 9 10 Diagnostics, Mannheim, Germany). NT-proBNP levels will be determined by 11 immunoassay (VITROS, Orthoclinical Diagnostics, USA), high-sensitivity C-reactive 12 proteins by immunoturbidimetric latex and determinations of lipids, glucose and 13 creatinine will be carried out by standard methods (ADVIA 2400 Chemistry System, 14 Siemens, Germany). Plasma levels of MCP-1 and galectin-3 will be determined in 15 duplicate Forusing commercially peer available review ELISA kits (BMS279/2, only Bender MedSystems, 16 Burlingame, California; and DCP00, R&D Systems, Minneapolis, Minnesota). Albumin 17 and calcium will be assessed by standard methods (ADVIA 2400 Chemistry System, 18 Siemens, Germany). 19 20 Finally, if patient consents, the remaining plasma samples will be stored in a 21 registered collection (Instituto de Salud Carlos III, C.0003386) for future determinations 22 of plasma levels of other molecules that may be potentially related with the other 23 variables assessed, such as mineral metabolism or LV remodeling. 24 25 26 27 Trial Outcomes and variables to assess 28 • Main outcome: Development of LV remodeling defined as an increase of 10% 29 or more in the end-diastolic volume by cardiac MRI at the end of the study as 30 compared with the baseline assessment. 31 32 • Secondary Outcomes 33 -% change in LV End-diastolic volume. http://bmjopen.bmj.com/ 34 35 -% change in LV End-systolic volume. 36 -% change in Ejection fraction. 37 -% change in Sphericity index. 38 -% change in size of the necrotic/fibrotic area, defined as delayed 39 gadolinium up-take (high-intensity STIR signals). 40 -% change in LV mass. 41 -% change in endothelial Function at 12 months. on September 23, 2021 by guest. Protected copyright. 42 -% change in diastolic function as assessed by Flow and Tissue Doppler. 43 -Also, the levels of these biomarkers in plasma will be measured both at 6 44 and 12 months: 45 46 NT-proBNP, galectin-3, MCP-1, and hs-C reactive protein 47 Calcidiol, FGF-23, PTH, P, and klotho 48 49 • Other outcomes 50 -To assess if the main and secondary outcomes differ in patients with 51 FGF-23 plasma levels above and below the median. 52 Klotho plasma levels above and below the median. 53 54 Different tertiles of calcidiol plasma levels. 55 -Adverse event description. 56 -Compliance rate. 57 -Safety and tolerance of calcifediol supplements. 58 -Incidence of heart failure, death or any acute coronary syndrome (STEMI 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml11 Page 13 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 or non-ST-elevation acute coronary syndrome). 4 5 Statistical considerations 6 7 Sample size 8 As there are no published data on the effect of VD on LV remodeling in patients 9 with STEMI, a formal sample size calculation based on the expected effect for the 10 11 primary end-point has not been performed. From this point of view, the trial can be 12 considered exploratory for the primary outcome. In the METOCARD study[43], 13 comparing early versus delayed beta-blockade in a similar population, 52% of patients 14 from the group of conventional beta-blockade developed this outcome at six months. 15 Given thatFor we expect peerthis number to bereview higher at one year, onlywe believe that a reduction 16 of 24% in the number of patients is a reasonable target if VD really has a positive effect. 17 With these numbers we estimate that 120 patients are needed to have a power of 80% 18 (1-β=0.8) using a two-sided test with a level of significance α=0.05, assuming that the 19 LV end-diastolic volume measured by MRI is normally distributed. 20 21 To have 120 cases suitable for analysis we have estimated that it is necessary to 22 include a total of 144 patients. With this sample size, considering that mortality the first 23 year after a STEMI may be up to 5%[53], and taking into account that we have 24 observed a 2.6% of incidence of recurrent non-fatal myocardial infarctions during this 25 period in our patients (unpublished data), we will have 11 patients not completing the 26 27 trial, leaving 133 patients. In addition, we estimate that up to 10% of these patients 28 could give up the study for other reasons, then leading 120 patients for analysis. 29 Endothelial function will be assessed only in one center. However, information 30 regarding endothelial function is available from one previous study by Tarcin et al[54]. 31 32 The authors describe that flow-mediated vasodilation increases significantly from 33 7.0±3.2% to 10.4±3.3% after treatment with VD. Assuming that similar differences will http://bmjopen.bmj.com/ 34 be observed in our study, 33 subjects would be enough to have a power of 80% with a 35 two-sided level of significance α=0.05. 36 37 38 Statistical Analysis 39 40 Analyses of treatment effect will be performed per protocol. No interim analyses 41 will be performed, given the short duration and the limited sample used in this proof-of- 42 concept study. A descriptive analysis of baseline characteristics of patients included in on September 23, 2021 by guest. Protected copyright. 43 both groups will be performed, to ensure that they are comparable. Qualitative variables 44 will be described as absolute numbers and percentages. Quantitative variables with 45 normal distribution (tested by Kolmogorov-Smirnov test) will be reported as mean 46 (standard deviation), and those that do not follow a normal distribution will be 47 described as median (interquartile range). 48 49 To compare quantitative variables between the VD and the placebo groups, the 50 Student t-test will be used in case data are normally distributed. In case distribution is 51 not normal, the Mann-Whitney test will be performed. For the comparison of baseline 52 versus variables at the end of treatment the paired t-test will be used for normally 53 distributed data and the Wilcoxon test will be carried out if normal distribution cannot 54 55 be demonstrated. For qualitative variables, chi-squared test will be performed. 56 Also, differences in the same parameters will be assessed among the groups 57 defined by plasma calcidiol tertiles. For quantitative data, one-way analysis of variance 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml12 BMJ Open Page 14 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 (ANOVA) followed by post-hoc tests will be used in cases of normal distribution. The 4 Kruskal-Wallis test followed by Mann-Witney tests will be performed if the distribution 5 is not normal. Qualitative analyses will be performed by Chi2 test. 6 7 Interobserver variability will be assessed by the estimation of intraclass 8 correlation coefficients. Analyses will be considered significant when “p”<0.05 (two- 9 tailed). Analyses will be performed with SPSS 19.0 statistical package. 10 11 12 ETHICS AND DISSEMINATION 13 14 This trial has been already approved by the Regional Ethics Committee of the 15 CommunityFor of Madrid peer and by the Ethics review Committees of all participatingonly institutions. 16 We have contracted liability insurance to cover the patients from potential adverse 17 consequences secondary to their participation in the trial. 18 All patients will sign an informed consent before participating, and will have the 19 20 possibility to ask questions about the trial to the investigators. The trial is registered in 21 ClinicalTrials.gov 22 (https://www.clinicaltrials.gov/ct2/show/NCT02548364?term=VITDAMI&rank=1) 23 The participating centers will be monitored by SCReN (Spanish Clinical research 24 Network) an independent agency, every six months, reviewing Case Report Forms and 25 confirming that they include solely data that exist at the hospital clinical records of the 26 patients. 27 The results will be submitted to indexed medical journals and presented at national and 28 international meetings. 29 30 31 CONCLUSIONS 32 33 The VITDAMI trial is the first exploratory trial to evaluate the effect of VD http://bmjopen.bmj.com/ 34 treatment on myocardial remodeling in patients with anterior STEMI and preserved 35 renal function. Furthermore, it will be the first to analyze the influence of other 36 components of mineral metabolism, such as FGF-23 and klotho levels, on the effect of 37 VD. The results, expected by December 2017, will likely contribute to our 38 understanding of the complex role of VD and other components of mineral metabolism 39 in cardiovascular diseases. If the trial is successful, a large-scale study should be 40 41 performed to see if the improvement in cardiac remodeling translates into clinical 42 benefits. on September 23, 2021 by guest. Protected copyright. 43 44 45 Ackowledgements 46 We are indebted to Oliver Shaw (IIS-Fundación Jiménez Díaz, Madrid, Spain) for 47 48 his assistance in editing this work. 49 50 Funding 51 52 The VITDAMI trial is an investigator initiated study, promoted by the Instituto de 53 Investigación Sanitaria-Fundación Jiménez Díaz. Funding has been obtained from 54 Fondo de Investigaciones Sanitarias (PI14/01567) (http://www.isciii.es/) and Spanish 55 Society of Cardiology (http://secardiologia.es/). In addition, the study medication has 56 been provided freely by the pharmaceutical Company FAES FARMA S.A. (Leioa, 57 Vizcaya, Spain) (http://faesfarma.com/). This company was the only funder who 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml13 Page 15 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 collaborated in study design (G Hernández). No funders will have a role in collection, 4 management, analysis, interpretation of data; writing the report; and the decision to 5 submit the report for publication. 6 7 8 Contributors 9 10 José Tuñón, Emilio González-Parra, and Jesús Egido conceived the study 11 All authors participated in the development of the protocol 12 13 José Tuñón, Ignacio Hernández-González and Lucía Llanos-Jiménez raised the 14 manuscript. All other authors revised the manuscript for relevant scientific content 15 For peer review only 16 All authors approved the final version of the manuscript. 17 18 19 Competing Interests 20 21 Professor Egido has been lecturer for Abbott Spain. There are no other potential 22 conflicts of interest. 23 24 25 Committees and organization of the trial 26 Coordinating Centre: Instituto de Investigación Sanitaria Fundación Jiménez Díaz. It 27 holds the missions of acquiring and preparing the material for the trial and organizes the 28 investigator meetings. 29 30 Steering Committee: Designed the protocol, obtained funding, management of 31 32 economical resources, creates all policy related to the project, and resolves the obstacles 33 that may arise. It is composed by: José Tuñón, Joaquín Alonso, Juan Escudier-Villa, http://bmjopen.bmj.com/ 34 Nieves Tarín, Petra Sanz, Carmen Cristóbal, Jesús Egido, Emilio Rodríguez-Parra, 35 Miguel Orejas. 36 37 End Point adjudication Committee: It will be in charge of analyzing the appearance of 38 cardiovascular and non-cardiovascular adverse events. It will be composed by: José 39 Tuñón, Lucía Llanos-Jiménez, Ana M. Pello, Álvaro Aceña, Rocío Carda, Emilio 40 Rodríguez-Parra, Germán Peces-Barba, and Jesús Egido. 41 42 on September 23, 2021 by guest. Protected copyright. 43 Data Management Team: This Committee will guarantee that the data are kept safe and 44 anonymous, and that statistical analyses will be conducted properly. Composition: José 45 Tuñón, Lucía Llanos-Jiménez, Raquel Muñoz-Siscart, and Ignacio Mahíllo-Fernández. 46 These are the only investigators that will have full-access to the final trial dataset. 47 48 Writting Committee: This Committee will be composed by: José Tuñón, Lucía Llanos- 49 Jiménez, Joaquín Alonso, Miguel Orejas, Jesús Egido. There will be no professional 50 writers but the text will be checked by an English-native speaker. 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml14 BMJ Open Page 16 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 REFERENCES 4 5 1. Wolf M. Forging forward with 10 burning questions on FGF23 in kidney disease. J Am Soc 6 Nephrol 2010;21:1427-35. 7 2. Gonzalez-Parra E, Tuñón J, Egido J, et al. Phosphate: a stealthier killer than previously 8 thought? Cardiovasc Pathol 2012;21:372-81. 9 10 3. Faul C, Amaral AP, Oskouei B, et al. 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ESC Guidelines for 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml17 Page 19 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 the management of acute myocardial infarction in patients presenting with ST-segment 4 elevation. Eur Heart J 2012;33:2569-619. 5 6 49. Ross AC, Manson JE, Abrams SA, et al. The 2011 Report on Dietary Reference Intakes for 7 Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. The 8 Journal of Clinical Endocrinology and Metabolism 2011;96:53-58. 9 10 50. Hathcock JN, Shao A, Vieth R, et al. Risk assessment for vitamin D. Am J Clin Nutr 11 2007;85:6–18. 12 51. Manson JE, Bassuk SS, Lee IM, et al. The VD and OmegA-3 TriaL (VITAL): rationale and 13 design of a large randomized controlled trial of VD and marine omega-3 fatty acid supplements 14 for the primary prevention of cancer and cardiovascular disease. Contemp Clin Trials 15 2012;33:159-71.For peer review only 16 17 52. Romero J, Lupercio F, Díaz JC, et al. Microvascular obstruction detected by cardiac MRI 18 after AMI for the prediction of LV remodeling and MACE: A meta-analysis of prospective 19 Int J Cardiol 20 trials. 2015;202:344-8. 21 22 53. López-Sendón JL, González-Juanatey JR, Pinto F, et al. Quality markers in cardiology: 23 measures of outcomes and clinical practice-a perspective of the Spanish Society of Cardiology 24 and of Thoracic and Cardiovascular Surgery. Eur Heart J 2015 Oct 21. pii: ehv527. [Epub 25 ahead of print] Review. PubMed PMID: 26491106. 26 27 54. Tarcin O, Yavuz DG, Ozben B, et al. Effect of VD deficiency and replacement on 28 endothelial function in asymptomatic subjects. J Clin Endocrinol Metab 2009;94:4023–30. 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml18 BMJ Open Page 20 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 FIGURE LEGEND 5 Figure 1. Flow chart of the VITDAMI Trial. ECG: Electrocardiogram; MRI: Magnetic 6 Resonance Imaging; STEMI: ST-elevation myocardial infarction; VITDAMI: VITamin D in 7 Acute Myocardial Infarction. 8 (1) Only at Fundación Jiménez Díaz 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml19 Page 21 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Figure 1. Flow chart of the VITDAMI Trial. ECG: Electrocardiogram; MRI: Magnetic Resonance Imaging; 33 STEMI: ST-elevation myocardial infarction; VITDAMI: VITamin D in Acute Myocardial Infarction. http://bmjopen.bmj.com/ 34 (1) Only at Fundación Jiménez Díaz 35 36 352x264mm (72 x 72 DPI) 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 5 6 7 SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and 8 9 related documents* 10 Section/item Item Description 11 No 12 13 Administrative information 14 15 Title For1 peer Descriptive title review identifying the study only design, population, interventions, 16 and, if applicable, trial acronym 17 18 Trial registration 2a Trial identifier and registry name. If not yet registered, name of 19 20 intended registry 21 2b All items from the World Health Organization Trial Registration Data 22 23 Set 24 25 Protocol version 3 Date and version identifier 26 Funding 4 Sources and types of financial, material, and other support 27 28 Roles and 5a Names, affiliations, and roles of protocol contributors 29 responsibilities 30 5b Name and contact information for the trial sponsor 31 32 5c Role of study sponsor and funders, if any, in study design; collection, 33 management, analysis, and interpretation of data; writing of the report; http://bmjopen.bmj.com/ 34 35 and the decision to submit the report for publication, including whether 36 they will have ultimate authority over any of these activities 37 38 5d Composition, roles, and responsibilities of the coordinating centre, 39 steering committee, endpoint adjudication committee, data 40 management team, and other individuals or groups overseeing the 41 trial, if applicable (see Item 21a for data monitoring committee) on September 23, 2021 by guest. Protected copyright. 42 43 44 Introduction 45 Background and 6a Description of research question and justification for undertaking the 46 47 rationale trial, including summary of relevant studies (published and 48 unpublished) examining benefits and harms for each intervention 49 50 6b Explanation for choice of comparators 51 52 Objectives 7 Specific objectives or hypotheses 53 54 Trial design 8 Description of trial design including type of trial (eg, parallel group, 55 crossover, factorial, single group), allocation ratio, and framework (eg, 56 superiority, equivalence, noninferiority, exploratory) 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 1 Page 23 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 Methods: Participants, interventions, and outcomes 3 4 Study setting 9 Description of study settings (eg, community clinic, academic hospital) 5 and list of countries where data will be collected. Reference to where 6 list of study sites can be obtained 7 8 Eligibility criteria 10 Inclusion and exclusion criteria for participants. If applicable, eligibility 9 criteria for study centres and individuals who will perform the 10 11 interventions (eg, surgeons, psychotherapists) 12 Interventions 11a Interventions for each group with sufficient detail to allow replication, 13 14 including how and when they will be administered 15 For peer review only 16 11b Criteria for discontinuing or modifying allocated interventions for a 17 given trial participant (eg, drug dose change in response to harms, 18 participant request, or improving/worsening disease) 19 20 11c Strategies to improve adherence to intervention protocols, and any 21 procedures for monitoring adherence (eg, drug tablet return, 22 laboratory tests) 23 24 11d Relevant concomitant care and interventions that are permitted or 25 prohibited during the trial 26 27 Outcomes 12 Primary, secondary, and other outcomes, including the specific 28 measurement variable (eg, systolic blood pressure), analysis metric 29 30 (eg, change from baseline, final value, time to event), method of 31 aggregation (eg, median, proportion), and time point for each 32 outcome. Explanation of the clinical relevance of chosen efficacy and 33 harm outcomes is strongly recommended http://bmjopen.bmj.com/ 34 35 Participant 13 Time schedule of enrolment, interventions (including any run-ins and 36 timeline washouts), assessments, and visits for participants. A schematic 37 38 diagram is highly recommended (see Figure) 39 40 Sample size 14 Estimated number of participants needed to achieve study objectives 41 and how it was determined, including clinical and statistical 42 assumptions supporting any sample size calculations on September 23, 2021 by guest. Protected copyright. 43 44 Recruitment 15 Strategies for achieving adequate participant enrolment to reach 45 target sample size 46 47 Methods: Assignment of interventions (for controlled trials) 48 49 Allocation: 50 51 Sequence 16a Method of generating the allocation sequence (eg, computer- 52 generation generated random numbers), and list of any factors for stratification. 53 To reduce predictability of a random sequence, details of any planned 54 restriction (eg, blocking) should be provided in a separate document 55 56 that is unavailable to those who enrol participants or assign 57 interventions 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 2 BMJ Open Page 24 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 Allocation 16b Mechanism of implementing the allocation sequence (eg, central 3 concealment telephone; sequentially numbered, opaque, sealed envelopes), 4 mechanism describing any steps to conceal the sequence until interventions are 5 assigned 6 7 Implementation 16c Who will generate the allocation sequence, who will enrol participants, 8 and who will assign participants to interventions 9 10 Blinding 17a Who will be blinded after assignment to interventions (eg, trial 11 (masking) participants, care providers, outcome assessors, data analysts), and 12 13 how 14 15 For17b peerIf blinded, circumstances review under which only unblinding is permissible, and 16 procedure for revealing a participant’s allocated intervention during 17 the trial 18 19 Methods: Data collection, management, and analysis 20 21 Data collection 18a Plans for assessment and collection of outcome, baseline, and other 22 methods trial data, including any related processes to promote data quality (eg, 23 duplicate measurements, training of assessors) and a description of 24 study instruments (eg, questionnaires, laboratory tests) along with 25 26 their reliability and validity, if known. Reference to where data 27 collection forms can be found, if not in the protocol 28 29 18b Plans to promote participant retention and complete follow-up, 30 including list of any outcome data to be collected for participants who 31 discontinue or deviate from intervention protocols 32 33 Data 19 Plans for data entry, coding, security, and storage, including any http://bmjopen.bmj.com/ 34 management related processes to promote data quality (eg, double data entry; 35 range checks for data values). Reference to where details of data 36 37 management procedures can be found, if not in the protocol 38 39 Statistical 20a Statistical methods for analysing primary and secondary outcomes. 40 methods Reference to where other details of the statistical analysis plan can be 41 found, if not in the protocol 42 on September 23, 2021 by guest. Protected copyright. 43 20b Methods for any additional analyses (eg, subgroup and adjusted 44 analyses) 45 46 20c Definition of analysis population relating to protocol non-adherence 47 (eg, as randomised analysis), and any statistical methods to handle 48 missing data (eg, multiple imputation) 49 50 Methods: Monitoring 51 52 Data monitoring 21a Composition of data monitoring committee (DMC); summary of its role 53 and reporting structure; statement of whether it is independent from 54 55 the sponsor and competing interests; and reference to where further 56 details about its charter can be found, if not in the protocol. 57 Alternatively, an explanation of why a DMC is not needed 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 3 Page 25 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 21b Description of any interim analyses and stopping guidelines, including 3 who will have access to these interim results and make the final 4 decision to terminate the trial 5 6 Harms 22 Plans for collecting, assessing, reporting, and managing solicited and 7 spontaneously reported adverse events and other unintended effects 8 of trial interventions or trial conduct 9 10 Auditing 23 Frequency and procedures for auditing trial conduct, if any, and 11 whether the process will be independent from investigators and the 12 13 sponsor 14 15 Ethics and disseminationFor peer review only 16 17 Research ethics 24 Plans for seeking research ethics committee/institutional review board 18 approval (REC/IRB) approval 19 20 Protocol 25 Plans for communicating important protocol modifications (eg, 21 amendments changes to eligibility criteria, outcomes, analyses) to relevant parties 22 (eg, investigators, REC/IRBs, trial participants, trial registries, journals, 23 regulators) 24 25 Consent or assent 26a Who will obtain informed consent or assent from potential trial 26 27 participants or authorised surrogates, and how (see Item 32) 28 26b Additional consent provisions for collection and use of participant data 29 30 and biological specimens in ancillary studies, if applicable 31 32 Confidentiality 27 How personal information about potential and enrolled participants will 33 be collected, shared, and maintained in order to protect confidentiality http://bmjopen.bmj.com/ 34 before, during, and after the trial 35 36 Declaration of 28 Financial and other competing interests for principal investigators for 37 interests the overall trial and each study site 38 39 Access to data 29 Statement of who will have access to the final trial dataset, and 40 disclosure of contractual agreements that limit such access for 41 investigators on September 23, 2021 by guest. Protected copyright. 42 43 Ancillary and 30 Provisions, if any, for ancillary and post-trial care, and for 44 45 post-trial care compensation to those who suffer harm from trial participation 46 Dissemination 31a Plans for investigators and sponsor to communicate trial results to 47 48 policy participants, healthcare professionals, the public, and other relevant 49 groups (eg, via publication, reporting in results databases, or other 50 data sharing arrangements), including any publication restrictions 51 52 31b Authorship eligibility guidelines and any intended use of professional 53 writers 54 55 31c Plans, if any, for granting public access to the full protocol, participant- 56 level dataset, and statistical code 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 4 BMJ Open Page 26 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 Appendices 3 4 Informed consent 32 Model consent form and other related documentation given to 5 materials participants and authorised surrogates 6 7 Biological 33 Plans for collection, laboratory evaluation, and storage of biological 8 specimens specimens for genetic or molecular analysis in the current trial and for 9 future use in ancillary studies, if applicable 10 11 *It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013 12 Explanation & Elaboration for important clarification on the items. Amendments to the 13 protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT 14 15 Group underFor the Creative peer Commons “Attribution-NonCommercial-NoDerivs review only 3.0 Unported” 16 license. 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 5 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from Design and rationale of a multicentre, randomized, double blind, placebo-controlled clinical trial to evaluate the effect of vitamin D on ventricular remodeling in patients with anterior myocardial infarction: The VITamin D in Acute Myocardial Infarction (VITDAMI) For peer reviewtrial only Journal: BMJ Open Manuscript ID bmjopen-2016-011287.R1 Article Type: Protocol Date Submitted by the Author: 13-Apr-2016 Complete List of Authors: Tuñón, José; Fundación Jiménez Díaz, Cardiology; Universidad Autonoma de Madrid, Medicine González-Hernández, Ignacio; Fundacion Jimenez Diaz, Cardiology Llanos-Jiménez, Lucía; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Research Unit Alonso-Martín, Joaquín; Hospital Universitario de Getafe, Cardiology; Universidad Rey Juan Carlos, Medicine Escudier-Villa, Juan; Hospital Universitario Puerta del Hierro Majadahonda, Cardiology http://bmjopen.bmj.com/ Tarín, Nieves; Hospital Universitario de Mostoles, Cardiology Cristóbal, Carmen; Hospital de Fuenlabrada, Cardiology; Universidad Rey Juan Carlos, Medicine Sanz, Petra; Hospital Rey Juan Carlos, Cardiology; Universidad Rey Juan Carlos, Medicine Pello, Ana ; Fundacion Jimenez Diaz, Cardiology Aceña, Álvaro; Fundacion Jimenez Diaz, Cardiology Carda, Rocío; Fundacion Jimenez Diaz, Cardiology Orejas, Miguel; Fundacion Jimenez Diaz, Cardiology Tomás, Marta; Fundacion Jimenez Diaz, Radiology on September 23, 2021 by guest. Protected copyright. Beltrán, Paula; Fundacion Jimenez Diaz, Cardiology Calero-Rueda, María José; Hospital Rey Juan Carlos, Cardiology Marcos, Esther; Hospital Universitario de Mostoles, Cardiology Serrano-Antolín, José María; Hospital de Fuenlabrada, Cardiology Gutierrez-Landaluce, Carlos; Hospital de Fuenlabrada, Cardiology Jiménez, Rosa; Hospital de Fuenlabrada, Cardiology Cabezudo, Jorge; Hospital de Fuenlabrada, Cardiology Curcio, Alejandro; Hospital de Fuenlabrada, Cardiology Peces-Barba, Germán; Fundacion Jimenez Diaz, Neumology; Universidad Autonoma de Madrid, Medicine González-Parra, Emilio; Fundacion Jimenez Diaz, Nephrology; Universidad Autonoma de Madrid, Medicine Muñoz-Siscart, Raquel; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Research Unit González-Casaus, María Luisa; Hospital Gomez-Ulla, Laboratory of Renal Function Lorenzo, Antonio; Hospital Universitario de Mostoles, Cardiology For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 Huelmos, Ana; Hospital Universitario Fundacion Alcorcon, Cardiology 5 Goicolea, Javier; Hospital Universitario Puerta del Hierro Majadahonda, Cardiology 6 Ibáñez, Borja; Fundacion Jimenez Diaz, Cardiology; Fundacion Centro 7 Nacional de Investigaciones Cardiovasculares Carlos III 8 Hernández, Gonzalo; FAES FARMA 9 Alonso-Pulpón, Luis; Hospital Universitario Puerta del Hierro Majadahonda, 10 Cardiology; Universidad Autonoma de Madrid, Medicine 11 Farré, Jerónimo; Fundacion Jimenez Diaz, Cardiology; Universidad 12 Autonoma de Madrid, Medicine 13 Lorenzo, Óscar; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Vascular Research Laboratory; Universidad Autonoma de 14 Madrid, Medicine 15 For peerMahíllo-Fernández, review Ignacio; Instituto deonly Investigacion Sanitaria de la 16 Fundacion Jimenez Diaz, Research Unit 17 Egido, Jesus; Fundacion Jimenez Diaz, Nephrology; Universidad Autonoma 18 de Madrid, Medicine 19 Primary Subject 20 Cardiovascular medicine Heading: 21 22 Secondary Subject Heading: Cardiovascular medicine, Renal medicine 23 Vitamin D, acute myocardial infarction, calcifediol, remodeling, cardiac 24 Keywords: 25 magnetic resonance imaging 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 Design and rationale of a multicentre, randomized, double blind, placebo 4 controlled clinical trial to evaluate the effect of vitamin D on ventricular 5 6 remodeling in patients with anterior myocardial infarction: 7 The VITamin D in Acute Myocardial Infarction (VITDAMI) trial 8 9 José Tuñón, MD, PhD,a,b,c Ignacio González Hernández, MD,a Lucía Llanos Jiménez, MD, 10 d e,f g 11 PhD, Joaquín Alonso Martín, MD, PhD, Juan M. Escudier Villa, MD, Nieves Tarín, MD, 12 PhD,h Carmen Cristóbal, MD, PhD,f,i Petra Sanz, MD,f,i Ana M. Pello, MD,a Álvaro Aceña, 13 14 MD,a Rocío Carda, MD,a Miguel Orejas, MD,a Marta Tomás, MD,k Paula Beltrán, MD,PhD,a 15 María JoséFor Calero Rueda, peer MD,j Esther Marcos,review MD,h José María onlySerrano Antolín, MD,i Carlos 16 17 Gutiérrez Landaluce, MD,i Rosa Jiménez, MD,i Jorge Cabezudo, MD,i Alejandro Curcio, MD,i 18 Germán Peces Barba, MD, PhD,b,l Emilio González Parra, MD, PhD,b,m Raquel Muñoz Siscart, 19 20 BSc,d María Luisa González Casaus, MD,n Antonio Lorenzo, MD,h Ana Huelmos, MD, PhD,o 21 g a,p q 22 Javier Goicolea, MD, PhD, Borja Ibáñez, MD, PhD, Gonzalo Hernández, MD, Luis M 23 Alonso Pulpón, MD, PhD,b,g Jerónimo Farré, MD, PhD,a,b Óscar Lorenzo, PhD,b,c Ignacio 24 d b,c,r 25 Mahíllo Fernández, PhD, Jesús Egido, MD, PhD 26 27 28 aDepartment of Cardiology, Fundación Jiménez Díaz, Madrid, Spain 29 bDepartment of Medicine, Autónoma University, Madrid, Spain, 30 cVascular Research Laboratory, IIS Fundación Jiménez Díaz, Madrid, Spain 31 dResearch Unit, IIS Fundación Jiménez Díaz, Madrid, Spain, 32 eDepartment of Cardiology, University Hospital of Getafe, Madrid, Spain, 33 f Department of Medicine, Rey Juan Carlos University, Alcorcón, Spain http://bmjopen.bmj.com/ 34 gDepartment of Cardiology, University Hospital Puerta de Hierro, Madrid, Spain, 35 hDepartment of Cardiology, University Hospital of Móstoles, Móstoles, Spain, 36 iDepartment of Cardiology, Hospital de Fuenlabrada, Madrid, Spain 37 jDepartment of Cardiology, Hospital Rey Juan Carlos, Móstoles, Madrid, Spain 38 k Department of Radiology, Fundación Jiménez Díaz, Madrid, Spain 39 lDepartment of Neumology, Fundación Jiménez Díaz, Madrid, Spain 40 mDepartment of Nephrology, Fundación Jiménez Díaz, Madrid, Spain 41 n Laboratory of Renal Function, Hospital Gómez Ulla, Madrid, Spain on September 23, 2021 by guest. Protected copyright. 42 oDepartment of Cardiology, Fundación Hospital Alcorcón, Madrid, Spain 43 pCentro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain 44 qFAES FARMA S.A. laboratories, Vizcaya, Spain 45 r 46 CIBERDEM, Madrid, Spain 47 48 Word Count: 5,116 49 Corresponding author: José Tuñón, MD, PhD, Department of Cardiology, IIS Fundación 50 51 Jiménez Díaz, Avenida Reyes Católicos 2, 28040 Madrid (Spain), Phone 00-34-915504800 52 Ext: 3701, email [email protected] 53 54 55 Key words: Vitamin D; calcifediol; acute myocardial infarction; remodeling; cardiac magnetic 56 resonance imaging 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml1 Page 3 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 ABSTRACT 4 Introduction: Decreased plasma vitamin D (VD) levels are linked to cardiovascular 5 damage. However, clinical trials have not demonstrated a benefit of VD supplements on 6 left ventricular (LV) remodeling. Anterior ST elevation acute myocardial infarction 7 (STEMI) is the best human model to study the effect of treatments on LV remodeling. 8 We present a proof of concept study that aims to investigate whether VD improves LV 9 10 remodeling in patients with anterior STEMI. 11 12 Methods and Analysis: The VITDAMI (VITamin D in Acute Myocardial Infarction) 13 trial is a multicenter, randomized, double blind, placebo controlled trial. One hundred 14 forty four patients with anterior STEMI will be assigned to receive calcifediol 0.266 15 mg capsulesFor (Hidroferol peer® SGC)/15 daysreview or placebo on a 2:1only basis during 12 months. 16 Primary objective: to evaluate the effect of calcifediol on LV remodeling defined as 17 an increase in LV end-diastolic volume≥10% (magnetic resonance imaging). 18 19 Secondary objectives: change in LV end-diastolic and end-systolic volumes, 20 ejection fraction, LV mass, diastolic function, sphericity index, and size of fibrotic 21 area; endothelial function; plasma levels of aminoterminal fragment of B-type 22 natriuretic peptide, galectin-3, and monocyte chemoattractant protein-1; levels of 23 calcidiol (VD metabolite) and other components of mineral metabolism (fibroblast 24 growth factor 23 [FGF 23], the soluble form of its receptor klotho, parathormone, and 25 phosphate). Differences in the effect of VD will be investigated according to plasma 26 levels of FGF 23 and klotho. Treatment safety and tolerability will be assessed. This 27 28 is the first study to evaluate the effect of VD on cardiac remodeling in patients with 29 STEMI. 30 31 Ethics and dissemination: This trial has been approved by the corresponding 32 Institutional Review Board and National Competent Authority (AEMPS). It will be 33 conducted in accordance to Good clinical practice (ICH GCP) requirements, ethical http://bmjopen.bmj.com/ 34 principles of Declaration of Helsinki and national laws. Trial registration number: 35 NCT02548364.The results will be submitted to indexed medical journals and presented 36 at national and international meetings. 37 38 39 40 41 STRENGTHS AND LIMITATIONS OF THIS STUDY on September 23, 2021 by guest. Protected copyright. 42 43 44 • This study will assess the effect of vitamin D (VD) supplements on the 45 myocardium after an acute myocardial infarction, which is probably the best 46 model to study left ventricular remodeling. 47 48 • In addition to calcidiol plasma levels, other components of mineral metabolism 49 such as fibroblast growth factor 23 (FGF23) and its soluble receptor, klotho, will 50 be taken into account. 51 52 • As a limitation, this study is not powered to study if a potential benefit of VD on 53 myocardial remodeling translates into a clinical benefit. In case of a positive 54 result, a larger study would be necessary to investigate this issue. 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml2 BMJ Open Page 4 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 INTRODUCTION 4 Traditionally, changes in plasma levels of the components of mineral 5 6 metabolism [vitamin D (VD), fibroblast growth factor 23 (FGF 23), parathyroid 7 hormone (PTH), and phosphate (P)] have been associated with renal disease[1 3]. When 8 slight decreases in glomerular filtration rate appear, the excretion of P is reduced. 9 Compensatory responses are then activated to maintain P homeostasis, including an 10 increase in the levels of FGF 23 and a subsequent rise in those of PTH[1]. FGF 23 11 promotes phosphaturia and decreases levels of plasma VD, both by downregulating 12 synthesis and by increasing degradation[1]. 13 14 Although high P levels are associated with an increase in cardiovascular events 15 and mortality[2],For the aforementionedpeer adaptivereview mechanisms preventonly an increase of serum 16 P levels in the early stages of chronic kidney disease[1 3]. However, these 17 18 compensatory mechanisms themselves are also related to cardiovascular damage[4, 5]. 19 Thus, high FGF 23 plasma levels are independently associated with endothelial 20 dysfunction, arterial stiffness, atherosclerosis burden, vascular calcification, left 21 ventricular (LV) hypertrophy, progression of renal disease, and incidence of mortality 22 and cardiovascular events in the general population as well as in patients with coronary 23 artery disease, even after adjusting for renal glomerular filtration[4 10]. Similarly, 24 increased PTH plasma levels are related to LV hypertrophy, hypertension, and increased 25 cardiovascular events[11 16]. Finally, VD deficiency has been associated with 26 endothelial dysfunction, inflammation, and vascular smooth muscle cell proliferation, 27 28 vascular calcification, activation of the renin angiotensin system, hypertension, 29 myocardial infarction, and stroke[17 22]. However, low VD plasma levels are not only 30 associated to vascular damage, but they also play an important role in the state of the 31 myocardium. In this regard, VD deficiency is associated with rat LV hypertrophy and 32 systolic dysfunction, biatrial enlargement, metabolic changes, inflammation, fibrosis, 33 and apoptosis[23]. http://bmjopen.bmj.com/ 34 35 Of interest, abnormalities of mineral metabolism are not restricted to patients 36 with overt renal disease, as in more than 50% of patients with coronary artery disease 37 we have observed a deficiency of VD. However, only 20% of them had an estimated 38 glomerular filtration rate <60 mL/min/1.73 m2[10]. Moreover, abnormalities of mineral 39 metabolism were evident even at glomerular filtration rates >90 ml/min/1.73 m2[24]. In 40 addition, the inverse relationship between VD levels and risk of coronary heart disease 41 has also been seen in the general population[20, 25]. on September 23, 2021 by guest. Protected copyright. 42 43 Despite the negative association between VD deficiency and cardiovascular 44 disease described in multiple studies[10, 20, 26 35], clinical trials have failed to 45 convincingly demonstrate a benefit of VD supplements on CV health. One such study 46 was the PRIMO trial, which showed no improvement in ventricular mass index or any 47 other remodeling parameters by administering paricalcitol, a selective activator of VD 48 receptors, to patients with chronic renal failure[36]. However, experiments performed in 49 50 vitro and in several animal models of LV pressure overload show that VD supplements 51 attenuate LV hypertrophy, reduce cardiac fibrosis, and decrease the expression of 52 collagen, fibronectin, and transforming growth factor β (TGF β), along with an 53 improvement of the systolic and diastolic function[37 40]. The negative results of the 54 PRIMO trial may have several causes. The main cause could be that the population 55 selected was not ideal for the purpose of linking VD supplements and ameliorated CV 56 health. Second, hypertension leads to myocardial remodeling over the years, and it 57 seems difficult to modify this process in only 48 weeks of therapy. Another potential 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml3 Page 5 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 reason is that FGF 23 plasma levels were not taken into account. Indeed, it has recently 4 been observed that low levels of VD were associated with increasing mass and diameter 5 when coexisting with high levels of FGF 23[41]. In accordance with this, we have 6 recently reported that low levels of VD were predictors of poor outcome in coronary 7 patients with FGF 23 plasma levels that were higher than the median value of 70 8 RU/ml, but they were not effective predictors if FGF 23 plasma levels were below the 9 10 median[10]. Other authors have shown similar data for the progression of chronic 11 kidney disease[42]. These data provide support for the notion that, in addition to being 12 an independent marker of cardiovascular risk, FGF 23 plasma levels influence the effect 13 of low VD levels. Finally, klotho plasma levels were not taken into account. This 14 protein is a co receptor for FGF 23, whose extracellular portion can be released and act 15 as an endocrineFor substance peer with multiple review functions. Low levels only of klotho are related to 16 kidney damage, but also to vascular calcification and cardiac hypertrophy and fibrosis, 17 causing klotho to be considered an anti aging protein[43]. Thus, it is possible that in 18 people without reduced glomerular filtrate, klotho levels are normal and could interfere 19 20 with the hypertrophic effect of FGF 23. The fact that VD may increase klotho levels 21 reinforces the possibility that this compound may have a protective cardiovascular 22 effect. 23 In summary, there is substantial evidence demonstrating the negative effects of VD 24 deficiency on the cardiovascular system, including the development of LV hypertrophy. 25 26 Despite the negative results of VD supplements in previous clinical trials, the convincing 27 evidence obtained in animal models in which it is shown that VD may protect the heart 28 supports the need for a new clinical trial designed to take into account the most recent 29 discoveries in the field. The VITDAMI trial has been designed as a proof of concept 30 study to test the effect of VD supplements in patients with anterior ST elevation 31 myocardial infarction (STEMI). The reason is that a great part of the remodeling process 32 following a large STEMI may be concentrated in the months following the acute event, 33 making these patients probably the best human model for studying therapeutic http://bmjopen.bmj.com/ 34 interventions on ventricular remodeling. Moreover, when STEMI affects the anterior wall 35 36 of the LV, it tends to be larger than in other locations, and remodeling is thus especially 37 intensive in these cases. In this regard, in the METOCARD trial comparing early versus 38 delayed beta blockade in patients with anterior STEMI[44, 45], the control group showed 39 an increase of 11.5% in mean LV end diastolic volume and a decrease of 22.8% in mean 40 LV mass at 6 months, along with a minimal increase of 2.2% in the ejection fraction. In 41 addition, we will see if this effect occurs only in those patients with FGF 23 above the on September 23, 2021 by guest. Protected copyright. 42 median or in all the study subjects. Similarly, we will assess possible differences in the 43 effect of VD in patients with klotho plasma levels above and below the median. Based on 44 45 the ideas developed above, it is possible that benefits could be present only in patients 46 with elevated levels of FGF 23, in those with klotho levels below the median, or in both 47 situations. 48 49 50 METHODS 51 52 Study aim 53 To compare the effect of one year treatment with Calcifediol 0.266 mg 54 (equivalent to 15,960 units) soft gelatin capsules versus placebo treatment on LV 55 remodeling in patients with anterior STEMI. 56 57 Primary Hypothesis 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml4 BMJ Open Page 6 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 The oral administration of one Calcifediol 0. 266 mg soft gelatin capsule every 4 15 days to patients with anterior STEMI will reduce the presence of LV remodeling 5 assessed by cardiac magnetic resonance imaging (MRI), and defined as an increase in 6 LV end diastolic volume of ≥10%, at one year as compared with the baseline 7 assessment. 8 9 Secondary Hypotheses 10 11 1. Patients receiving calcifediol will show, as compared to those receiving placebo: 12 13 • Less increase in end diastolic and end systolic volumes. 14 • More increase in ejection fraction. 15 For peer review only 16 • Less decrease in diastolic sphericity index, defined as the ratio of long to short 17 axis dimension of the left ventricular cavity at end-diastole[46]. 18 • Less increase in the area of fibrosis. 19 • Better diastolic function. 20 • Better endothelial function. 21 • A significant reduction in plasma levels of one or more of these biomarkers: NT 22 23 proBNP (N terminal brain natriuretic peptide) and galectin 3, as related to heart 24 failure and adverse prognosis; and monocyte chemoattractant protein 1 (MCP 25 1), related to inflammation and acute ischemic events[47]. 26 • Higher plasma levels of calcidiol (25OH VD) and/or klotho, and lower levels of 27 FGF 23 and/or PTH. 28 29 2. The results of the previous hypotheses will be more evident or even restricted to 30 those patients with FGF 23>median and/or klotho medication due to other reasons will be excluded from the analysis. The reason is that on September 23, 2021 by guest. Protected copyright. 42 this is just a proof of concept study, where we try to demonstrate for the first time in 43 human beings that taking VD supplements to reach normal calcidiol levels may 44 45 decrease LV remodeling after a STEMI. On the other hand, we do not intend to show 46 that anterior STEMI must be treated with VD, as a large clinical trial demonstrating 47 reduction of clinical events would be necessary for this purpose. 48 49 Trial Population 50 51 Patients between 40 and 85 years of age admitted at the hospital due to an anterior 52 STEMI, that have received primary angioplasty, that are expected to be discharged 53 alive, and who accept to participate and sign the Informed Consent are eligible for 54 randomization. STEMI is defined by suggestive symptoms, such as chest discomfort 55 irradiated to the arms or jaw, or just compatible symptoms as sweating, nausea, 56 vomiting or ill defined malaise lasting more than 20 min, in association with persistent 57 electrocardiographic ST elevation and subsequent release of biomarkers of myocardial 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml5 Page 7 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 necrosis with standard curve[48]. Diagnostic anterior ST elevation in absence of LV 4 hypertrophy or left bundle branch block is defined according to current guidelines as 5 new ST elevation at the J point in at least 2 contiguous leads of ≥2 mm in V1 6 in men; 6 in women ≥1.5 mm in V2–V3 and/or ≥1 mm in the remaining anterior leads will be 7 accepted[49]. Exclusion criteria are listed in Table 1. Recruitment will be competitive. 8 9 Table 1. Exclusion Criteria 10 11 ______12 Death or complications compromising patient survival (i.e: cardiogenic shock) during the 13 index event No primary angioplasty 14 1 15 ImpossibilityFor to perform peer the desirable review revascularization only 16 Indication of cardiac transplant 17 Surgical coronary revascularization during the index event 18 Revascularization pending at the moment of discharge 19 Complications that extend patient´s stay at the hospital for more than 7 days 20 Absence of akinetic area in the anterior wall of the left ventricle 21 Previous myocardial infarction 22 Valve prosthesis 23 Aortic stenosis with mean gradient>25 mm Hg (Doppler) and stenosis of any other valve 24 Moderate to severe valve regurgitation 25 Cardiomyopathy (Dilated, Hypertrophic or Restrictive) 26 Severe left ventricle hypertrophy (wall thickness ≥17 mm in men and ≥16 mm in women) 27 Conditions limiting survival 28 Inflammatory or immune disease 29 Estimated Glomerular Filtration Rate <40 ml/min/1.73 m2 30 Intolerance to vitamin D supplements 31 Indication or patient’s decision to take vitamin D or calcium 32 Therapy with drugs that can interfere absorption, distribution, metabolism or excretion of 33 Vitamin D: http://bmjopen.bmj.com/ 34 Anti epileptic (Phenitoine, Phenobarbital, Primidone, other enzymatic inducers) 35 Cholestiramine, cholestipol, Orlistat 36 Penicillins 37 Laxatives as paraphine and mineral oil 38 Digitalis 39 Magnesium salts 40 Verapamil 41 Steroids on September 23, 2021 by guest. Protected copyright. 42 Disorders that can interfere the pharmacokinetics or pharmacodynamics of Vitamin D: 43 Hepatic insufficiency, inflammatory bowel disease, sarchoidosis, Tuberculosis, or other 44 granulomatous disorders. 45 Plasma Calcium levels >10.5 mg/dl, history of hypercalciuria or calcium litiasis. 46 Contraindications for Magnetic Resonance Imaging: claustrophoby, pacemaker, 47 defibrillators, resynchronization devices, or high probability that they need them during the 48 study (among them, patients with ejection fraction<30% at discharge) 49 Impossibility to follow the patients 50 Difficult compliance of the therapy as estimated by the investigator 51 Patient rejects to participate and/or does not sign the informed consent 52 Pregnancy or lactation period 53 Patients participating in another clinical trial 54 1Severe stenoses (angiographic severity>70% or borderline with a positive intracoronary adenosine test) are 55 allowed only in secondary vessels considered either not relevant by the investigator because of small vessel diameter, 56 distal lesion, or technically unfeasible due to vessel calcification or tortuosity. 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml6 BMJ Open Page 8 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 Trial Design 5 6 The VITDAMI trial is a randomized, multicentre, double blind, placebo 7 controlled trial in patients with anterior STEMI comparing the effect of VD 8 supplements (cacifediol) with placebo during one year on LV remodeling. 9 The protocol (version 2.1, July 1, 2015) has been approved by the corresponding 10 Institutional Review Board and the Spanish Drug Agency. One hundred forty four 11 patients with anterior STEMI, will be included at the Departments of Cardiology at 12 eight sites in Madrid, Spain, that have been chosen because they have the equipment 13 and programs needed to care for patients with STEMI, along with the facility for cardiac 14 magnetic resonance. After signing the informed consent they will undergo cardiac 15 For peer review only 16 examination by MRI and Echocardiography, blood extraction for plasma storage, 17 electrocardiogram, and non invasive endothelial function test (only in patients admitted 18 to Fundación Jiménez Díaz) (Figure 1) as soon as possible and no later than 7 days after 19 admission. Immediately after completing these tests, patients will receive on a 2:1 20 randomized, double blind basis an oral dose of 0.266 mg of calcifediol or placebo every 21 15 days (±1 day) during one year. In addition to study treatment, patients will be 22 managed according to standard clinical practice based in European guidelines for 23 STEMI[48]. Given that it may be heterogeneity in calcidiol plasma levels due to 24 different baseline levels, a 2:1 instead of 1:1 randomization has been chosen in order to 25 26 allow comparing the outcomes across different ranges of calcidiol levels. 27 Forty five days after inclusion, blood will be extracted to perform a safety 28 determination of calcidiol and calcium plasma levels, to adjust the dose of study 29 medication according to the results. By phone contact, dose adjustment will be 30 communicated to the patient and potential adverse effects will be investigated. At 31 months 3 and 9 adverse effects will be checked by phone call. At month 6, patients will 32 be seen by the investigator to rule out adverse effects and to collect empty blisters to 33 confirm compliance of study medication, performing also a new blood extraction for http://bmjopen.bmj.com/ 34 study plasma determinations. At this time they will be provided study medication for 35 36 the last six months of the study. Finally, on month 12, all the examinations performed at 37 inclusion will be repeated, the study drug will be discontinued. One month after the last 38 dose, a follow up visit will be performed by phone contact to register any possible 39 adverse events, and the study will be finished. Table 2 summarizes the visit schedule. 40 Patient recruitment started in November 2015 and the trial is expected to 41 conclude in December 2017. 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml7 Page 9 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 Table 2. Visit Schedule 5 6 7 V0 V1 V2 V2 V4 V5 V6 8 9 0 m 1.5 m 3 m 6 m 9 m 12 m 13m 10 11 Inclusion/exclusion Criteria X 12 Informed consent X 13 14 Clinical History X X X X X 15 For peer review only 16 Concomitant medication X X X 17 18 Physical Exam X X X 19 20 Heart rate and Blood Pressure X X X 21 22 Hemogram and biochemistry X X X 23 24 Chest roentgengram X X 25 26 Electrocardiogram X X X 27 28 Safety determination of plasma X 29 calcidiol and calcium 30 Blood extraction for study X X X 31 determinations 32 33 Cardiac Magnetic Resonance X X http://bmjopen.bmj.com/ 34 Imaging 35 36 Echocardiogram X X 37 38 Endothelial function1 X X 39 40 Dispense study medication/Collect X X X 41 empty blisters 42 on September 23, 2021 by guest. Protected copyright. 43 Compliance Check X X X X X 44 45 Adverse Events X X X X X X 46 47 48 Randomization and blinding 49 50 Patients will be randomly assigned to receive 1 Calcifediol 0.266 mg soft gelatine 51 capsule (Hidroferol® SGC), or 1 soft capsule, containing placebo, every 15 days. 52 Allocation ratio will be 2:1 and randomization scheme will be computer generated by 53 the statistician at the coordinating centre and block balanced. Closed envelops with the 54 randomization sequence will be prepared and distributed to the participating centers. 55 56 Treatment allocation will be blind for patients and the research team. Unblinding will be 57 allowed in case a patient develops serious adverse event if the attending medical team 58 estimates that it is necessary to preserve patient’s health. 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml8 BMJ Open Page 10 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 5 Study Medication 6 Hidroferol® SGC will be used for this trial. This is a new formulation containing 7 0.266 mg of Calcifediol (15,960 UI of VD) that improves bioavailability (22%) with 8 respect to the liquid Calcifediol immediate release oral formulation, due to its SEDDS 9 pharmaceutical technology (Self Emulsifying Drug Delivery Systems). 10 11 Calcifediol and placebo capsules will be provided and labeled by FAES FARMA 12 S.A. Laboratories to ensure the blindness of the study. The Department oh Pharmacy at 13 each centre will receive the study medication, and will have a registry of the medication 14 received, dispensed and stored. The medication will be stored in appropriate conditions 15 and kept For locked under peer restricted access. review Any non used studyonly medication and all the 16 17 empty recipients will be stored until the end of the study and then will be sent to the 18 promoter. 19 Adherence to study medication will be evaluated by direct questions to the patient 20 in each visit on how many doses he/she has omitted. In addition, this information will 21 be checked wiht pharmacy registry to obtain the final adherence percentage. 22 23 24 Safety Issues 25 26 At 1.5 months a safety assessment of plasma calcidiol and calcium levels will be 27 performed after the intake of the first three doses as by this time calcidiol is expected 28 to reach its peak concentration. The study therapy will be adjusted following these 29 rules: 30 31 • Calcidiol > 70 ng/ml or calcium >10.5 mg/dl: Therapy will be stopped and 32 the patient will continue being followed. 33 http://bmjopen.bmj.com/ 34 • Calcidiol 30-70 ng/ml and calcium ≤10.5 mg/dl. The dose of study drug will 35 36 be reduced to one capsule every month as a maintenance dose. 37 38 • Calcidiol <30 ng/ml and calcium ≤10.5 mg/dl: The dose of the study drug will 39 be kept at 1 capsule every 15 days. 40 41 Of interest, no baseline calcidiol measurement is performed, as this is deemed 42 unnecessary due to different reasons. 1) In a previous study from our group in 704 on September 23, 2021 by guest. Protected copyright. 43 patients with coronary artery disease[10, 24], maximal calcidiol levels were 51 ng/ml, 44 far from the upper normal limit of 70 ng/ml. 2) The dose chosen is well below the 45 tolerable upper intake level of 4,000 UI/d[50,51]. 3) In the large VITAL clinical trial, in 46 primary prevention, a dose of 2,000 UI/d VD is being used for 5 years without assessing 47 basal levels and performing only one safety determination of calcidiol levels in a small 48 subgroup of patients[52]. 49 50 Criteria for Study Withdrawal 51 52 • Violation of Inclusion/Exclusion criteria. 53 • Patient will: according to the Declaration of Helsinki, patients may give up the 54 55 study at any moment and by any reason they consider. 56 • Patient who does not collaborate properly with the investigators. 57 • Unexpected serious adverse events. 58 • New myocardial infarction during follow up, as it may influence LV remodeling 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml9 Page 11 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 • Placement of devices that are not compatible with the performance of cardiac 4 MRI, such as pacemakers, automated implantable cardioverter defibrillators or 5 resynchronization devices. 6 • Heart transplantation. 7 8 9 Trial Procedures 10 Cardiac MRI 11 12 Comprehensive cardiac MRI will be carried out to study cardiac function, LV 13 mass, myocardial edema and myocardial fibrosis/necrosis. Scans will be performed with 14 1.5 Tesla equipments at each participating centre. For assessment of global and 15 segmentalFor left and right peer ventricular function,review and LV mass, only balanced steady state free 16 precession with sensitivity encoding fast parallel imaging technique (True FISP, SSFP) 17 sequence will be used for cine imaging. Images will be obtained at short axis (8 mm 18 slices from the apex to the base of the left ventricle), 4 chamber, 2 chamber, and 3 19 20 chamber. Myocardial edema will be assessed matching the slice position of the cine 21 images, using a T2 weighted triple IR turbo spin echo (STIR) sequence. For study of 22 fibrosis/myocardial necrosis, gadolinium based contrast agent will be intravenously 23 administered. Delayed enhancement imaging to assess necrotic myocardium will be 24 performed using IR Turbo FLASH (3D IR GRE, 2D IR GRE, and PSIR sequences). 25 26 The necrotic/fibrotic area is defined as area with delayed gadolinium up take 27 (high intensity STIR signals) and myocardium at risk as area with edema. Salvaged 28 myocardium is assessed as the difference between myocardial at risk and the necrotic 29 area. Myocardium at risk, the necrotic size and the salvaged myocardium will be 30 expressed as percentage of the total left ventricular mass. In addition, the necrotic area 31 will be also expressed in grams. All the results will be given in absolute numbers and 32 normalized by Body Surface Area. LV end diastolic and end systolic volumes, as well 33 as the ejection fraction and the LV sphericity index (maximal long axis/short axis of LV http://bmjopen.bmj.com/ 34 cavity at end diastole) will be assessed[46]. Finally, microvascular obstruction, a 35 36 parameter related to cardiac remodeling[53] will be assessed at the initial MRI 37 exploration. MRI studies will be analyzed blinded to treatment allocation at a central 38 core laboratory located at the Centro Nacional de Investigaciones Cardiovasculares 39 Carlos III with the QMass system (7.6). Fifteen percent of the MRI studies will be 40 chosen at random to perform inter and intraobserver variability. 41 42 on September 23, 2021 by guest. Protected copyright. 43 Doppler Echocardiography 44 This technique will be performed and interpreted at the centre where the patient 45 is included. Apical four chamber and two chamber views as well as long and short axis 46 47 parasternal views will be used. Bidimensional and M mode echocardiography will be 48 used to analyze diastolic and systolic diameters of the LV, septal and posterior wall 49 thickness, ejection fraction (Simpson method), segmental contractility using a 17 50 segment model and registering areas of akinesia, dyskinesia and hypokinesia. Diastolic 51 function will be assessed by analyzing the Deceleration Time (ms), peak E and A waves 52 (cm/s), E/A ratio, and the isovolumetric relaxation time (ms) by pulsed Doppler, and E’ 53 (cm/s) and A’ (cm/s) waves by Tissue Doppler Imaging. 54 55 56 Endothelial Function Test 57 58 The ENDOPAT technology will be used, measuring changes of finger arterial 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml10 BMJ Open Page 12 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 pulsatile volume (reactive hyperemia plethysmographic biosensors). This test will be 4 carried out in the subgroup of patients at the Fundación Jiménez Díaz. Given that this 5 group will have a small sample size, subgroup analysis will not be performed and only 6 comparisons between both groups of therapy will be carried out. 7 8 9 Blood Extractions and Assessments 10 11 At blood withdrawal, 26 ml will be obtained, from which 18 ml will be placed in 12 EDTA tubes and 8 ml in tubes without EDTA. Blood will undergo centrifugation for 10 13 minutes at 2,500 G and the obtained plasma will be stored in 2 ml criovials at 80ºC. 14 Half of these samples will be stored at Instituto de Investigación Sanitaria Fundación 15 Jiménez DíazFor and thepeer other half atreview the Móstoles University only Hospital to limit the 16 17 probabilities of damaging the samples in case of failure of the freezer. Nevertheless, 18 both freezers have a CO2 release system and telephonic alarm for cases of malfunction 19 of the system. The study of mineral metabolism will be performed at the Laboratory of 20 Renal Function at Gómez Ulla hospital, and the remaining determinations will be 21 carried out at the Laboratories of Biochemistry and Vascular Pathology at Fundación 22 Jiménez Díaz. Calcidiol levels will be quantified using chemiluminescent immunoassay 23 (CLIA) with LIAISON ®XLanalyzer (total VD Assay DiaSorin, Saluggia, Italy). FGF 24 23 will be assessed by an ELISA that recognizes epitopes in the terminal portion 25 carboxyl terminus of FGF 23 (Human FGF 23, C Term, Immutopics Inc, San 26 27 Clemente, CA), klotho will be studied by ELISA (soluble alpha klotho ELISA, IBL 28 International, Hamburg, Germany), intact PTH by an automated chemiluminescent 29 method of second generation (2010 platform Elecsys, Roche Diagnostics, Mannheim, 30 Germany), and P will be assessed by enzymatic method (Integra 400 analyzer, Roche 31 Diagnostics, Mannheim, Germany). NT proBNP levels will be determined by 32 immunoassay (VITROS, Orthoclinical Diagnostics, USA), high sensitivity C reactive 33 proteins by immunoturbidimetric latex and determinations of lipids, glucose and http://bmjopen.bmj.com/ 34 creatinine will be carried out by standard methods (ADVIA 2400 Chemistry System, 35 Siemens, Germany). Plasma levels of MCP 1 and galectin 3 will be determined in 36 37 duplicate using commercially available ELISA kits (BMS279/2, Bender MedSystems, 38 Burlingame, California; and DCP00, R&D Systems, Minneapolis, Minnesota). Albumin 39 and calcium will be assessed by standard methods (ADVIA 2400 Chemistry System, 40 Siemens, Germany). 41 42 Finally, if patient consents, the remaining plasma samples will be stored in a on September 23, 2021 by guest. Protected copyright. 43 registered collection (Instituto de Salud Carlos III, C.0003386) for future determinations 44 of plasma levels of other molecules that may be potentially related with the other 45 variables assessed, such as mineral metabolism or LV remodeling. 46 47 48 Trial Outcomes 49 • Main outcome: Proportion of patients in each treatment group that develop LV 50 remodeling defined as an increase of ≥10% in the end diastolic volume measured 51 by cardiac MRI at the end of the study as compared with the baseline assessment. 52 53 54 • Secondary Outcomes: 55 % change in LV End diastolic volume. 56 % change in LV End systolic volume. 57 % change in Ejection fraction. 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml11 Page 13 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 % change in Sphericity index. 4 % change in size of the necrotic/fibrotic area, defined as delayed 5 gadolinium up take (high intensity STIR signals). 6 % change in LV mass. 7 % change in endothelial function 8 % change in diastolic function as assessed by Flow and Tissue 9 10 Doppler. 11 Adverse Events rate and description 12 Compliance rate 13 Incidence of heart failure, death or any acute coronary syndrome 14 (STEMI or non ST elevation acute coronary syndrome). 15 For Levelspeer of the following review biomarkers in onlyplasma will be measured 16 both at 6 and 12 months: 17 NT proBNP, galectin 3, MCP 1, and hs C reactive protein 18 Calcidiol, FGF 23, PTH, P, and klotho 19 20 21 In addition to comparing the changes in the final versus the baseline 22 assessment of all the mentioned variables, we will compare also the results 23 obtained in the final visit between both treatment groups. 24 25 26 27 Also, assessment of main and secondary outcomes will be performed in the following 28 subgroup of patients: 29 30 FGF 23 plasma levels above and below the median. 31 Klotho plasma levels above and below the median. 2 32 eGFR above and below 60 ml/min/1.73 m 33 Different tertiles of calcidiol plasma levels. Also, pre specified http://bmjopen.bmj.com/ 34 cut off levels will be set 10, 15, and 20 ng/ml plasma levels. 35 Different degrees of microvascular obstruction at baseline MRI. 36 With/ without thrombectomy at primary angioplasty 37 In patients that achieve TIMI III flow at primary angioplasty 38 39 40 Statistical considerations 41 Sample size 42 on September 23, 2021 by guest. Protected copyright. 43 As there are no published data on the effect of VD on LV remodeling in patients 44 with STEMI, a formal sample size calculation based on the expected effect for the 45 primary end point has not been performed. From this point of view, the trial can be 46 considered exploratory for the primary outcome. First, we defined as remodeling an 47 increase in 10% of LV end diastolic volume, given that according to previous studies 48 this value is above the observed intra and interobserver variability for this parameter in 49 cardiac MRI[54]. Then, the probability that a variation higher than 10% in the final 50 51 study as compared to the baseline is due to observational variability is very low. Then, 52 we reviewed data from the METOCARD study[44], comparing early versus delayed 53 beta blockade in a similar population, and observed that 52% of patients from the group 54 of conventional beta blockade developed this outcome at six months. Given that we 55 expect this number to be higher at one year, we believe that a reduction of 24% in the 56 number of patients is a reasonable target if VD really has a positive effect. With these 57 numbers we estimate that 120 patients are needed to have a power of 80% (1 β=0.8) 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml12 BMJ Open Page 14 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 using a two sided test with a level of significance α=0.05, assuming that the LV end 4 diastolic volume measured by MRI is normally distributed. 5 6 To have 120 cases suitable for analysis we have estimated that it is necessary to 7 include a total of 144 patients. With this sample size, considering that mortality the first 8 year after a STEMI may be up to 5%[55], and taking into account that we have 9 observed a 2.6% of incidence of recurrent non fatal myocardial infarctions during this 10 period in our patients (unpublished data), we will have 11 patients not completing the 11 trial, leaving 133 patients. In addition, we estimate that up to 10% of these patients 12 could give up the study for other reasons, then leading 120 patients for analysis. 13 14 Endothelial function will be assessed only in one center. However, information 15 regarding Forendothelial peerfunction is available review from one previous only study by Tarcin et al[56]. 16 The authors describe that flow mediated vasodilation increases significantly from 17 7.0±3.2% to 10.4±3.3% after treatment with VD. Assuming that similar differences will 18 be observed in our study, 33 subjects would be enough to have a power of 80% with a 19 two sided level of significance α=0.05. 20 21 22 23 Statistical Analysis 24 Analyses of treatment effect will be performed per protocol. No interim analyses 25 will be performed, given the short duration and the limited sample used in this proof of 26 concept study. A descriptive analysis of baseline characteristics of patients included in 27 28 both groups will be performed, to ensure that they are comparable. Qualitative variables 29 will be described as absolute numbers and percentages. Quantitative variables with 30 normal distribution (tested by Kolmogorov Smirnov test) will be reported as mean 31 (standard deviation), and those that do not follow a normal distribution will be 32 described as median (interquartile range). 33 http://bmjopen.bmj.com/ 34 To compare quantitative variables between the VD and the placebo groups, the 35 Student t test will be used in case data are normally distributed. In case distribution is 36 not normal, the Mann Whitney test will be performed. For the comparison of baseline 37 versus variables at the end of treatment the paired t test will be used for normally 38 distributed data and the Wilcoxon test will be carried out if normal distribution cannot 39 be demonstrated. For qualitative variables, chi squared test will be performed. 40 41 Also, differences in the same parameters will be assessed among the groups 42 defined by plasma calcidiol tertiles. For quantitative data, one way analysis of variance on September 23, 2021 by guest. Protected copyright. 43 (ANOVA) followed by post hoc tests will be used in cases of normal distribution. The 44 Kruskal Wallis test followed by Mann Witney tests will be performed if the distribution 45 is not normal. Qualitative analyses will be performed by Chi2 test. 46 47 Interobserver variability will be assessed by the estimation of intraclass 48 correlation coefficients. Analyses will be considered significant when “p”<0.05 (two 49 tailed). Analyses will be performed with SPSS 19.0 statistical package. 50 51 52 ETHICS AND DISSEMINATION 53 54 This trial has been already approved by the Regional Ethics Committee of the 55 Community of Madrid and by the Ethics Committees of all participating institutions. 56 We have contracted liability insurance to cover the patients from potential adverse 57 consequences secondary to their participation in the trial. 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml13 Page 15 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 All patients will sign an informed consent before participating, and will have the 4 possibility to ask questions about the trial to the investigators. The trial is registered in 5 ClinicalTrials.gov (NCT02548364). Clinical Trial Pharmacovigilance and Monitoring 6 will be performed by SCReN (Spanish Clinical Research Network) an independent 7 agency, every six months, reviewing Case Report Forms and confirming that they 8 include solely data that exist at the hospital clinical records of the patients. 9 10 The results will be submitted to indexed medical journals and presented at national and 11 international meetings. 12 13 CONCLUSIONS 14 15 TheFor VITDAMI peer trial is the firstreview exploratory trial toonly evaluate the effect of VD 16 treatment on myocardial remodeling in patients with anterior STEMI and preserved 17 renal function. Furthermore, it will be the first to analyze the influence of other 18 components of mineral metabolism, such as FGF 23 and klotho levels, on the effect of 19 VD. The results, expected by December 2017, will likely contribute to our 20 21 understanding of the complex role of VD and other components of mineral metabolism 22 in cardiovascular diseases. If the trial is successful, a large scale study should be 23 performed to see if the improvement in cardiac remodeling translates into clinical 24 benefits. 25 26 27 Ackowledgements 28 29 We are indebted to Oliver Shaw (IIS Fundación Jiménez Díaz, Madrid, Spain) for 30 his assistance in editing this work. 31 32 Funding 33 http://bmjopen.bmj.com/ 34 The VITDAMI trial is an investigator initiated study, promoted by the Instituto de 35 Investigación Sanitaria Fundación Jiménez Díaz. Funding has been obtained from 36 Fondo de Investigaciones Sanitarias (PI14/01567) (http://www.isciii.es/) and Spanish 37 Society of Cardiology (http://secardiologia.es/). In addition, the study medication has 38 39 been provided freely by the pharmaceutical Company FAES FARMA S.A. (Leioa, 40 Vizcaya, Spain) (http://faesfarma.com/). This company was the only funder who 41 collaborated in study design (G Hernández). No funders will have a role in collection, 42 management, analysis, interpretation of data; writing the report; and the decision to on September 23, 2021 by guest. Protected copyright. 43 submit the report for publication. 44 45 46 Contributors 47 48 José Tuñón, Emilio González Parra, and Jesús Egido conceived the study 49 All authors participated in the development of the protocol 50 51 José Tuñón, Ignacio Hernández González and Lucía Llanos Jiménez raised the 52 manuscript. All other authors revised the manuscript for relevant scientific content 53 54 All authors approved the final version of the manuscript. 55 56 57 Competing Interests 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml14 BMJ Open Page 16 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 Professor Egido has been lecturer for Abbott Spain. There are no other potential 4 conflicts of interest. 5 6 7 Committees and organization of the trial 8 Coordinating Centre: Instituto de Investigación Sanitaria Fundación Jiménez Díaz. It 9 holds the missions of acquiring and preparing the material for the trial and organizes the 10 11 investigator meetings. 12 13 Steering Committee: Designed the protocol, obtained funding, management of 14 economical resources, creates all policy related to the project, and resolves the obstacles 15 that may Forarise. It is composedpeer by: Joséreview Tuñón, Joaquín Alonso,only Juan Escudier Villa, 16 Nieves Tarín, Petra Sanz, Carmen Cristóbal, Jesús Egido, Emilio Rodríguez Parra, 17 Miguel Orejas. 18 19 End Point adjudication Committee: It will be in charge of analyzing the appearance of 20 21 cardiovascular and non cardiovascular adverse events. It will be composed by: José 22 Tuñón, Lucía Llanos Jiménez, Ana M. Pello, Álvaro Aceña, Rocío Carda, Emilio 23 Rodríguez Parra, Germán Peces Barba, and Jesús Egido. 24 25 Data Management Team: This Committee will guarantee that the data are kept safe and 26 anonymous, and that statistical analyses will be conducted properly. Composition: José 27 Tuñón, Lucía Llanos Jiménez, Raquel Muñoz Siscart, and Ignacio Mahíllo Fernández. 28 These are the only investigators that will have full access to the final trial dataset. 29 30 31 Writting Committee: This Committee will be composed by: José Tuñón, Lucía Llanos 32 Jiménez, Joaquín Alonso, Miguel Orejas, Jesús Egido. There will be no professional 33 writers but the text will be checked by an English native speaker. http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml15 Page 17 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 REFERENCES 4 5 1. Wolf M. Forging forward with 10 burning questions on FGF23 in kidney disease. J Am Soc 6 Nephrol 2010;21:1427 35. 7 2. Gonzalez Parra E, Tuñón J, Egido J, et al. Phosphate: a stealthier killer than previously 8 thought? Cardiovasc Pathol 2012;21:372 81. 9 10 3. Larsson T, Nisbeth U, Ljunggren O¨ et al. Circulating concentration of FGF 23 increases as 11 renal function declines in patients with chronic kidney disease, but does not change in response 12 to variation in phosphate intake in healthy volunteers. Kidney Int 2003; 64: 2272–9. 13 14 4. Faul C, Amaral AP, Oskouei B, et al. FGF23 induces left ventricular hypertrophy. J Clin 15 Invest 2011;121:4393 408.For peer review only 16 17 5. Parker BD, Schurgers LJ, Brandenburg VM, et al. The associations of fibroblast growth 18 factor 23 and uncarboxylated matrix Gla protein with mortality in coronary artery disease: the 19 Heart and Soul Study. Ann Intern Med 2010;152:640 8. 20 21 6. Mirza MA, Larsson A, Lind L, et al. Circulating fibroblast growth factor 23 is associated 22 with vascular dysfunction in the community. Atherosclerosis 2009;205:385 90. 23 24 25 7. Mirza MA, Hansen T, Johansson L, et al. Relationship between circulating FGF23 and total 26 body atherosclerosis in the community. Nephrol Dial Transplant 2009;24:3125 31. 27 28 8. Masai H, Joki N, Sugi K, et al. A preliminary study of the potential role of FGF 23 in 29 coronary calcification in patients with suspected coronary artery disease. Atherosclerosis 30 2013;226:228 33. 31 32 9. Ärnlöv J, Carlsson AC, Sundström J, et al. Higher fibroblast growth factor 23 increases the 33 risk of all cause and cardiovascular mortality in the community. Kidney Int 2013;83:160 6. http://bmjopen.bmj.com/ 34 35 10. Tuñón J, Cristóbal C, Tarín N, et al. Coexistence of low VD and high fibroblast growth 36 factor 23 plasma levels predicts an adverse outcome in patients with coronary artery disease. 37 PLOS ONE 2014;9:e95402. 38 39 11. Kestenbaum B, Katz R, de Boer I, et al. Vitamin D, parathyroid hormone, and 40 cardiovascular events among older adults. J Am Coll Cardiol 2011;58:1433 41. 41 42 12. Taylor EN, Curhan GC, Forman JP. Parathyroid hormone and the risk of incident on September 23, 2021 by guest. Protected copyright. 43 hypertension. J Hypertens 2008;26:1390 4. 44 45 13. Anderson JL, Vanwoerkom RC, Horne BD, et al. Parathyroid hormone, vitamin D, renal 46 dysfunction, and cardiovascular disease: dependent or independent risk factors? Am Heart J 47 2011;162:331 9. 48 49 14. Saleh FN, Schirmer H, Sundsfjord J, et al. Parathyroid hormone and left ventricular 50 hypertrophy. Eur Heart J 2003;24:2054–60. 51 52 15. Aceña A, Pello AM, Carda R, et al. Parathormone levels are independently associated with 53 the presence of left ventricular hypertrophy in patients with coronary artery disease. The 54 Journal of Nutrition Health and Aging 2015; in press 55 56 16. Hagström E, Hellman P, Larsson TE, et al. Plasma parathyroid hormone and the risk of 57 cardiovascular mortality in the community. Circulation 2009;119:2765 71. 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml16 BMJ Open Page 18 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 17. Gonzalez Parra E, Rojas Rivera J, Tuñón J, et al. VD receptor activation and cardiovascular 4 disease. Nephrol Dial Transplant 2012;27(Suppl 4):17 21. 5 6 18. Watson KE, Abrolat ML, Malone LL, et al. Active serum vitamin D levels are inversely 7 correlated with coronary calcification. Circulation 1997;96:1755 60. 8 9 19. Syal SK, Kapoor A, Bhatia E, et al. Vitamin D deficiency, coronary artery disease, and 10 endothelial dysfunction: observations from a coronary angiographic study in Indian patients. J 11 Invasive Cardiol 2012;24:385 9. 12 13 20. Scragg R, Jackson R, Holdaway IM, et al. Myocardial infarction is inversely associated with 14 plasma 25 hydroxyvitamin D3 levels: a community based study. Int J Epidemiol 1990;19:559 15 63. For peer review only 16 17 21. Lavie CJ, Lee JH, Milani RV. Vitamin D and cardiovascular disease will it live up to its 18 hype? J Am Coll Cardiol 2011;58:1547 56. 19 20 22. De Borst MH, Vervloet MG, ter Wee PM, et al. Cross talk between the renin angiotensin 21 aldosterone system and VD FGF 23 klotho in chronic kidney disease. J Am Soc Nephrol 22 2011;22:1603 9. 23 24 23. Assalin HB, Rafacho BP, dos Santos PP, et al. Impact of the length of vitamin D deficiency 25 on cardiac remodeling. Circ Heart Fail 2013;6:809 16. 26 27 24. González Parra E, Aceña A, Lorenzo O, et al. Important abnormalities of bone mineral 28 metabolism are present in patients with coronary artery disease with a mild decrease of the 29 estimated glomerular filtration rate. J Bone Min Metabolism 2105; Aug 23. [Epub ahead of 30 print] PMID: 26298279 31 32 25. Karakas M, Thorand B, Zierer A, et al. Low levels of serum 25 hydroxyvitamin D are 33 associated with increased risk of myocardial infarction, especially in women: results from the http://bmjopen.bmj.com/ 34 MONICA/KORA Augsburg case cohort study. J Clin Endocrinol Metab 2013;98:272 80. 35 36 26. Joergensen C, Gall MA, Schmedes A, et al. VD levels and mortality in type 2 diabetes. 37 Diabetes Care 2010;33:2238 43. 38 39 27. Melamed ML, Muntner P, Michos ED, et al. Serum 25 hydroxyVD levels and the 40 prevalence of peripheral arterial disease: results from NHANES 2001 to 2004. Arterioscler 41 Thromb Vasc Biol 2008;28:1179 85. on September 23, 2021 by guest. Protected copyright. 42 28. Wang TJ, Pencina MJ, Booth SL, et al. VD deficiency and risk of cardiovascular disease. 43 Circulation 2008;117:503 11. 44 45 29. Giovannucci E, Liu Y, Hollis BW, et al. 25 hydroxyVD and risk of myocardial infarction in 46 men: a prospective study. Arch Intern Med 2008;168:1174–80. 47 30. Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25 hydroxyVD 48 and 1,25 dihydroxy VD levels with all cause and cardiovascular mortality. Arch Intern Med 49 2008;168:1340–9. 50 51 31. Pilz S, Dobnig H, Nijpels G, et al. VD and mortality in older men and women. Clin 52 Endocrinol (Oxf) 2009;71:666–72. 53 32. Poole KE, Loveridge N, Barker PJ, et al. Reduced VD in acute stroke. Stroke 2006;37:243– 54 5. 55 56 33. Wang L, Song Y, Manson JE, et al. Circulating 25 hydroxy vitamin D and risk of 57 cardiovascular disease: a meta analysis of prospective studies. Circ Cardiovasc Qual Outcomes 58 2012;5:819 29. 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml17 Page 19 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 34. Grandi NC, Breitling LP, Brenner H. Vitamin D and cardiovascular disease: systematic 5 review and meta analysis of prospective studies. Prev Med 2010;51:228 33 6 7 35. Brøndum Jacobsen P, Benn M, Jensen GB, et al. 25 hydroxyvitamin d levels and risk of 8 ischemic heart disease, myocardial infarction, and early death: population based study and 9 meta analyses of 18 and 17 studies. Arterioscler Thromb Vasc Biol 2012;32:2794 802. 10 11 36. Thadhani R, Appelbaum E, Pritchett Y, et al. Vitamin D therapy and cardiac structure and 12 function in patients with chronic kidney disease: the PRIMO randomized controlled trial. JAMA 13 2012;307:674 84. 14 15 37. Wu J, ForGarami M, Chengpeer T, et al. 1,25(OH)2 review VD3, and retinoic only acid antagonize endothelin 16 stimulated hypertrophy of neonatal rat cardiac myocytes. J Clin Invest 1996;97: 1577 88. 17 18 38. Bodyak N, Ayus JC, Achinger S, et al. Activated vitamin D attenuates left ventricular 19 abnormalities induced by dietary sodium in Dahl salt sensitive animals. Proc Natl Acad Sci U S 20 A 2007;104:16810 5. 21 22 39. Meems LM, Cannon MV, Mahmud H, et al. The vitamin D receptor activator paricalcitol 23 prevents fibrosis and diastolic dysfunction in a murine model of pressure overload. J Steroid 24 Biochem Mol Biol 2012;132:282 9. 25 26 40. Koleganova N, Piecha G, Ritz E, et al. Calcitriol ameliorates capillary deficit and fibrosis of 27 the heart in subtotally nephrectomized rats. Nephrol Dial Transplant 2009;24:778 87. 28 29 41. Ky B, Shults J, Keane MG, et al; CRIC Study Investigators. FGF23 modifies the 30 relationship between vitamin D and cardiac remodeling. Circ Heart Fail 2013;6:817 24. 31 32 42. Nakano C, Hamano T, Fujii N, et al. Combined use of vitamin D status and FGF23 for risk 33 stratification of renal outcome. Clin J Am Soc Nephrol 2012;7:810 9. http://bmjopen.bmj.com/ 34 35 43. Hu MC, Kuro o M, Moe OW. Renal and extrarenal actions of Klotho. Semin Nephrol 36 2013;33:118 29. 37 38 44. Pizarro G, Fernández Friera L, Fuster V, et al. Long term benefit of early pre reperfusion 39 metoprolol administration in patients with acute myocardial infarction: results from the 40 METOCARD CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute 41 Myocardial Infarction). J Am Coll Cardiol 2014;63:2356 62. on September 23, 2021 by guest. Protected copyright. 42 43 45. Ibáñez B, Macaya C, Sánchez Brunete V, et al. Effect of early metoprolol on infarct size in 44 ST segment elevation myocardial infarction patients undergoing primary percutaneous coronary 45 intervention: the Effect of Metoprolol in Cardioprotection During an Acute Myocardial 46 Infarction (METOCARD CNIC) trial. Circulation 2013;128:1495 503. 47 48 46. van Dalen BM, Kauer F, Vletter WB, et al. Influence of cardiac shape on left ventricular 49 twist. J Appl Physiol 2010;108:146 51. 50 51 47. Tuñón J, Blanco Colio L, Cristóbal C, et al. Usefulness of a combination of monocyte 52 chemoattractant protein 1, galectin 3, and N terminal probrain natriuretic peptide to predict 53 cardiovascular events in patients with coronary artery disease. Am J Cardiol 2014;113:434 40. 54 55 48. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. 56 Circulation 2012;126:2020 35. 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml18 BMJ Open Page 20 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 49. Task Force on the management of ST segment elevation acute myocardial infarction of the 4 European Society of Cardiology (ESC), Steg PG, James SK, Atar D, et al. ESC Guidelines for 5 the management of acute myocardial infarction in patients presenting with ST segment 6 elevation. Eur Heart J 2012;33:2569 619. 7 8 50. Ross AC, Manson JE, Abrams SA, et al. The 2011 Report on Dietary Reference Intakes for 9 Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. The 10 Journal of Clinical Endocrinology and Metabolism 2011;96:53 58. 11 12 51. Hathcock JN, Shao A, Vieth R, et al. Risk assessment for vitamin D. Am J Clin Nutr 13 2007;85:6–18. 14 52. Manson JE, Bassuk SS, Lee IM, et al. The VD and OmegA 3 TriaL (VITAL): rationale and 15 design of aFor large randomized peer controlled trialreview of VD and marine omega 3only fatty acid supplements 16 for the primary prevention of cancer and cardiovascular disease. Contemp Clin Trials 17 2012;33:159 71. 18 19 20 53. Romero J, Lupercio F, Díaz JC, et al. Microvascular obstruction detected by cardiac MRI 21 after AMI for the prediction of LV remodeling and MACE: A meta analysis of prospective 22 trials. Int J Cardiol 2015;202:344 8. 23 24 54. Luijnenburg SE, Robbers Visser D, Moelker A, et al. Intra observer and interobserver 25 variability of biventricular function, volumes and mass in patients with congenital heart disease 26 measured by CMR imaging. Int J Cardiovasc Imaging 2010 Jan;26:57 64. 27 28 55. López Sendón JL, González Juanatey JR, Pinto F, et al. Quality markers in cardiology: 29 measures of outcomes and clinical practice a perspective of the Spanish Society of Cardiology 30 and of Thoracic and Cardiovascular Surgery. Eur Heart J 2015 Oct 21. pii: ehv527. [Epub 31 ahead of print] Review. PubMed PMID: 26491106. 32 33 56. Tarcin O, Yavuz DG, Ozben B, et al. Effect of VD deficiency and replacement on http://bmjopen.bmj.com/ 34 endothelial function in asymptomatic subjects. J Clin Endocrinol Metab 2009;94:4023–30. 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml19 Page 21 of 27 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 FIGURE LEGEND 5 Figure 1. Flow chart of the VITDAMI Trial. ECG: Electrocardiogram; MRI: Magnetic 6 Resonance Imaging; STEMI: ST elevation myocardial infarction; VITDAMI: VITamin D in 7 Acute Myocardial Infarction. 8 (1) Only at Fundación Jiménez Díaz 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml20 BMJ Open Page 22 of 27 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Figure 1. Flow chart of the VITDAMI Trial. ECG: Electrocardiogram; MRI: Magnetic Resonance Imaging; 33 STEMI: ST-elevation myocardial infarction; VITDAMI: VITamin D in Acute Myocardial Infarction. http://bmjopen.bmj.com/ 34 (1) Only at Fundación Jiménez Díaz 35 352x264mm (72 x 72 DPI) 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 Page 2 2 Page 1, 14 1, 15 14, 14, 15 14, Addressed on on Addressed number page Page 7 7 Page Page 15 15 Page 15 1, N/A N/A BMJ Open http://bmjopen.bmj.com/ on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only interpretation of data; writing of the report; and the decision to submit the report for publication, including including publication, for report the submit to decision the and report; of the writing ofdata; interpretation activities any ofthese over authority ultimate have will they whether adjudication committee, data management team, and other individuals or groups overseeing the trial, if trial, the overseeing groups or individuals other and managementteam, data committee, adjudication committee) monitoring data for 21a (seeItem applicable Description Description 5c 5c and analysis, management, collection, design; study in ifany, funders, sponsorand study of Role 5d 5d endpoint committee, steering centre, coordinating of the responsibilities and roles, Composition, 1 1 acronym trial if applicable, and, interventions, population, design, study the identifying title Descriptive 1 Page 2b 2b Set Data Registration Trial Organization WorldHealth fromthe items All 5b sponsor trial forthe information contact and Name 5a 5a contributors protocol of roles and affiliations, Names, No No 4 4 support other and material, financial, of types and Sources Protocol version version Protocol Funding 3 identifier version and Date Roles and and Roles responsibilities Title Title Trial registration registration Trial 2a registry intended of name registered, yet Ifname. not registry and identifier Trial Administrative information Administrative documents* related and protocol trial clinical a in address to items Recommended Checklist: 2013 SPIRIT Section/item Item Page 23 of 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 2 Page 24 of 27 Pages 6-9 6-9 Pages Page 11, 12 12 11, Page Page 7, 8 8 7, Page N/A N/A Page 9, 10 10 9, Page Pages 8-9 8-9 Pages Pages 5, 6 6 5, Pages Page 7 7 Page Page 7 7 Page Pages 3, 4 4 3, Pages protocol the In 5 Page and visits for visits and BMJ Open http://bmjopen.bmj.com/ on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only be collected. Reference to where list of study sites can be obtained obtained be can sites ofstudy list where to Reference collected. be allocation ratio, and framework (eg, superiority, equivalence, noninferiority, exploratory) exploratory) noninferiority, equivalence, superiority, (eg, framework and ratio, allocation participants. A schematic diagram is highly recommended (see Figure) Figure) (see recommended highly is diagram schematic A participants. Time schedule of enrolment, interventions (including any run-ins and washouts), assessments, assessments, washouts), and run-ins any (including interventions enrolment, of schedule Time efficacy and harm outcomes is strongly recommended recommended strongly is andharm outcomes efficacy median, proportion), and time point for each outcome. Explanation of the clinical relevance of chosen chosen of relevance clinical of the Explanation foroutcome. each point timeand proportion), median, pressure), analysis metric (eg, change from baseline, final value, time to event), method of aggregation (eg, aggregation methodof event), to time value, final baseline, from change (eg, metric analysis pressure), Primary, secondary, and other outcomes, including the specific measurement variable (eg, systolic blood blood (eg,systolic variable measurement specific the including outcomes, other and secondary, Primary, Relevant concomitant care and interventions that are permitted or prohibited during the trial trial the during prohibited or permitted are that interventions and care concomitant Relevant (eg, drug tablet return, laboratory tests) tests) laboratory return, tablet drug (eg, Strategies to improve adherence to intervention protocols, and any procedures for monitoring adherence adherence monitoring for procedures any and protocols, intervention to adherence improve to Strategies change in response to harms, participant request, or improving/worsening disease) disease) improving/worsening or request, participant harms, to response in change Criteria for discontinuing or modifying allocated interventions for a given trial participant (eg, drug dose drug (eg, participant trial given for a interventions allocated modifying or fordiscontinuing Criteria administered administered Interventions for each group with sufficient detail to allow replication, including how and when they will be be they will and when how including replication, allow to detail sufficient with group each for Interventions individuals who will perform the interventions (eg, surgeons, psychotherapists) psychotherapists) surgeons, (eg, interventions the perform will who individuals Inclusion and exclusion criteria for participants. If applicable, eligibility criteria for study centres and centres and criteriastudy for eligibility applicable, If for participants. criteria exclusion and Inclusion studies (published and unpublished) examining benefits and harms for each intervention intervention each for harms and benefits examining unpublished) and (published studies 13 13 12 12 11d 11d 11c 11c 11b 11b 11a 11a 10 10 6a 6a of relevant summary including trial, the forundertaking justification and question of research Description Participant timeline timeline Participant Outcomes Outcomes Interventions Interventions Eligibility criteria criteria Eligibility Study setting Study 9 will data where ofcountries list and hospital) clinic,academic community (eg, settings of study Description Methods: Participants, interventions, and outcomes outcomes and interventions, Participants, Methods: Introduction Introduction Background and Background rationale Objectives design Trial 7 8 hypotheses or 6b objectives Specific group), single factorial, crossover, group, parallel (eg, oftrial type including design of trial Description comparators of forchoice Explanation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. 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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only Reference to where data collection forms can be found, if not in the protocol protocol inthe ifnot found, be can forms collection data where to Reference study instruments (eg, questionnaires, laboratory tests) along with their reliability and validity, if known. if known. validity, and reliability their with along tests) laboratory questionnaires, (eg, instruments study processes to promote data quality (eg, duplicate measurements, training of assessors) and a description of description a and assessors) of training measurements, duplicate (eg, quality data promote to processes Plans for assessment and collection of outcome, baseline, and other trial data, including any related related any including data, other trial and baseline, ofoutcome, collection and forassessment Plans allocated intervention during the the trial during intervention allocated If blinded, circumstances under which unblinding is permissible, and procedure for revealing a participant’s participant’s a forrevealing procedure and is permissible, unblinding which under circumstances blinded, If assessors, data analysts), and how how and analysts), data assessors, Who will be blinded after assignment to interventions (eg, trial participants, care providers, outcome outcome careproviders, participants, trial (eg, interventions to afterassignment blinded be will Who interventions interventions Who will generate the allocation sequence, who will enrol participants, and who will assign participants to to participants assign will andwho participants, enrol will who sequence, allocation the generate will Who opaque, sealed envelopes), describing any steps to conceal the sequence until interventions are assigned assigned are interventions until sequence the conceal to steps any describing envelopes), sealed opaque, Mechanism of implementing the allocation sequence (eg, central telephone; sequentially numbered, numbered, sequentially telephone; central (eg, sequence allocation the implementing of Mechanism or assign interventions interventions assign or (eg, blocking) should be provided in a separate document that is unavailable to those who enrol participants participants enrol who those to unavailable is that document separate a in provided be should blocking) (eg, factors for stratification. To reduce predictability of a random sequence, details of any planned restriction restriction planned ofany details sequence, random a of predictability reduce To forstratification. factors Method of generating the allocation sequence (eg, computer-generated random numbers), and list of any of list any and numbers), random computer-generated (eg, sequence allocation the of generating Method Strategies for achieving adequate participant enrolment to reach target sample size size sample target reach to enrolment participant adequate forachieving Strategies clinical and statistical assumptions supporting any sample size calculations calculations samplesize any supporting assumptions statistical and clinical Estimated number of participants needed to achieve study objectives and how it was determined, including including determined, it was how and objectives study achieve to needed participants of number Estimated 18a 18a 17b 17b 17a 17a 16c 16c 16b 16b 16a 16a 15 15 14 14 Implementation Implementation mechanism mechanism concealment concealment generation generation Sequence Sequence Allocation Allocation methods methods Data collection collection Data Methods: Data collection, management, and analysis and management, collection, Data Methods: Blinding (masking) (masking) Blinding Methods: Assignment of interventions (for controlled trials) controlled (for interventions of Assignment Methods: Recruitment Recruitment Sample size size Sample Allocation: Allocation: Page 25 of 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. 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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only from investigators and the sponsor sponsor the and frominvestigators Frequency and procedures for auditing trial conduct, if any, and whether the process will be independent independent be will process the and whether if any, conduct, trial forauditing procedures and Frequency events and other unintended effects of trial interventions or trial conduct conduct trial or interventions trial of effects unintended other and events Plans for collecting, assessing, reporting, and managing solicited and spontaneously reported adverse reported spontaneously and solicited managing and reporting, assessing, collecting, for Plans results and make the final decision to terminate the trial trial the terminate to decision final makethe and results Description of any interim analyses and stopping guidelines, including who will have access to these interim access to have will who including guidelines, stopping and analyses interim of any Description needed needed about its charter can be found, if not in the protocol. Alternatively, an explanation of why a DMC is not is not DMC a ofwhy explanation an Alternatively, theprotocol. in ifnot found, be can itscharter about whether it is independent from the sponsor and competing interests; and reference to where further details furtherdetails where to reference and interests; competing and sponsor from the isindependent it whether Composition of data monitoring committee (DMC); summary of its role and reporting structure; statement of statement structure; reporting and role ofits summary (DMC); committee monitoring data of Composition statistical methods to handle missing data (eg, multiple imputation) imputation) multiple (eg, data missing handle to methods statistical Definition of analysis population relating to protocol non-adherence (eg, as randomised analysis), and any any and analysis), randomised as (eg, non-adherence protocol to relating population ofanalysis Definition Methods for any additional analyses (eg, subgroup and adjusted analyses) analyses) adjusted and subgroup (eg, analyses additional any for Methods statistical analysis plan can be found, if not in the protocol protocol the in iffound,not be can plan analysis statistical Statistical methods for analysing primary and secondary outcomes. 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Reference to where details of data management management data of details where to Reference values). data for checks range entry; data double (eg, Plans for data entry, coding, security, and storage, including any related processes to promote data quality quality data promote to processes related any including storage, and security, coding, entry, fordata Plans collected for participants who discontinue or deviate from intervention protocols protocols from intervention deviate or discontinue who forparticipants collected Plans to promote participant retention and complete follow-up, including list of any outcome data to to be data outcome of list any including follow-up, complete and retention participant promote to Plans 23 23 22 22 21b 21b 21a 21a 20c 20c 20b 20b 20a 20a 19 19 18b 18b 24 24 approval (REC/IRB) board review committee/institutional ethics research seeking for Plans Research ethics ethics Research approval Ethics and dissemination dissemination and Ethics Harms Harms Data monitoring monitoring Data Methods: Monitoring Methods: Statistical methods methods Statistical Data management management Data Auditing Auditing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 5 Page 13 13 Page Page 15 15 Page Page 14 14 Page Page 11 11 Page Specific reference reference Specific protection data to the in law Spanish 3 page In protocol. manuscript, the of to reference laws national In the protocol protocol the In Page 14 14 Page N/A N/A BMJ Open http://bmjopen.bmj.com/ on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only how (see Item 32) 32) (seeItem how studies, if applicable if applicable studies, in order to protect confidentiality before, during, and after the trial trial afterthe and during, before, confidentiality protect to order in analyses) to relevant parties (eg, investigators, REC/IRBs, trial participants, trial registries, journals, journals, registries, trial participants, trial REC/IRBs, investigators, (eg, parties relevant to analyses) regulators) participation participation Provisions, if any, for ancillary and post-trial care, and for compensation to those who suffer harm from trial trial from harmsuffer who those to compensation for care,and post-trial and for ancillary ifany, Provisions, limit such access for investigators investigators for access such limit Statement of who will have access to the final trial dataset, and disclosure of contractual agreements that that agreements contractual of disclosure and dataset, trial final the to access have will of who Statement the public, and other relevant groups (eg, via publication, reporting in results databases, or other data data other or databases, results in reporting publication, via groups(eg, relevant other and public, the restrictions publication any including arrangements), sharing 31c 31c code andstatistical dataset, participant-level protocol, full the to access public for granting any, if Plans, N/A 31b 31b writers professional of use intended any and guidelines eligibility Authorship 28 28 site study each and trial overall forthe investigators principal for interests competing other and Financial 14-15 Page 31a 31a professionals, healthcare participants, to results trial communicate sponsorto and forinvestigators Plans 30 30 29 29 25 25 outcomes, criteria, eligibility to changes (eg, modifications protocol important communicating for Plans 26b ancillary in specimens and biological data ofuseparticipant and collection for provisions consent Additional Confidentiality Confidentiality 27 maintained and shared, be collected, will participants andenrolled potential about information personal How Declaration of Declaration interests Consent or assent assent or Consent 26a and surrogates, authorised or participants trial potential from assent or consent informed obtain will Who Appendices Dissemination policy Dissemination trial care trial Protocol Protocol amendments Ancillary and post- and Ancillary Access to data data to Access Page 27 of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. 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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only analysis in the current trial and for future use in ancillary studies, if applicable ifapplicable studies, ancillary in use future for and trial current the in analysis 32 32 surrogates authorised and participants to given documentation related other formand consent Model 33 N/A molecular or forgenetic specimens biological of storage and evaluation, laboratory collection, for Plans Attribution-NonCommercial-NoDerivs 3.0 Unported 3.0 Attribution-NonCommercial-NoDerivs *It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013 Explanation & Elaboration for important clarification on the items. items. the on clarification for important Elaboration & Explanation 2013 SPIRIT the with conjunction in read be thischecklist that recommended isstrongly *It “ Informed consent consent Informed materials Biological specimens Amendments to the protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT Group under the Creative Commons Commons Creative the under Group SPIRIT by the iscopyrighted checklist SPIRIT The dated. and tracked be should protocol the to Amendments 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from Design and rationale of a multicentre, randomized, double blind, placebo-controlled clinical trial to evaluate the effect of vitamin D on ventricular remodeling in patients with anterior myocardial infarction: The VITamin D in Acute Myocardial Infarction (VITDAMI) For peer reviewtrial only Journal: BMJ Open Manuscript ID bmjopen-2016-011287.R2 Article Type: Protocol Date Submitted by the Author: 18-May-2016 Complete List of Authors: Tuñón, José; Fundación Jiménez Díaz, Cardiology; Universidad Autonoma de Madrid, Medicine González-Hernández, Ignacio; Fundacion Jimenez Diaz, Cardiology Llanos-Jiménez, Lucía; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Research Unit Alonso-Martín, Joaquín; Hospital Universitario de Getafe, Cardiology; Universidad Rey Juan Carlos, Medicine Escudier-Villa, Juan; Hospital Universitario Puerta del Hierro Majadahonda, Cardiology http://bmjopen.bmj.com/ Tarín, Nieves; Hospital Universitario de Mostoles, Cardiology Cristóbal, Carmen; Hospital de Fuenlabrada, Cardiology; Universidad Rey Juan Carlos, Medicine Sanz, Petra; Hospital Rey Juan Carlos, Cardiology; Universidad Rey Juan Carlos, Medicine Pello, Ana ; Fundacion Jimenez Diaz, Cardiology Aceña, Álvaro; Fundacion Jimenez Diaz, Cardiology Carda, Rocío; Fundacion Jimenez Diaz, Cardiology Orejas, Miguel; Fundacion Jimenez Diaz, Cardiology Tomás, Marta; Fundacion Jimenez Diaz, Radiology on September 23, 2021 by guest. 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Beltrán, Paula; Fundacion Jimenez Diaz, Cardiology Calero-Rueda, María José; Hospital Rey Juan Carlos, Cardiology Marcos, Esther; Hospital Universitario de Mostoles, Cardiology Serrano-Antolín, José María; Hospital de Fuenlabrada, Cardiology Gutierrez-Landaluce, Carlos; Hospital de Fuenlabrada, Cardiology Jiménez, Rosa; Hospital de Fuenlabrada, Cardiology Cabezudo, Jorge; Hospital de Fuenlabrada, Cardiology Curcio, Alejandro; Hospital de Fuenlabrada, Cardiology Peces-Barba, Germán; Fundacion Jimenez Diaz, Neumology; Universidad Autonoma de Madrid, Medicine González-Parra, Emilio; Fundacion Jimenez Diaz, Nephrology; Universidad Autonoma de Madrid, Medicine Muñoz-Siscart, Raquel; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Research Unit González-Casaus, María Luisa; Hospital Gomez-Ulla, Laboratory of Renal Function Lorenzo, Antonio; Hospital Universitario de Mostoles, Cardiology For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 Huelmos, Ana; Hospital Universitario Fundacion Alcorcon, Cardiology 5 Goicolea, Javier; Hospital Universitario Puerta del Hierro Majadahonda, Cardiology 6 Ibáñez, Borja; Fundacion Jimenez Diaz, Cardiology; Fundacion Centro 7 Nacional de Investigaciones Cardiovasculares Carlos III 8 Hernández, Gonzalo; FAES FARMA 9 Alonso-Pulpón, Luis; Hospital Universitario Puerta del Hierro Majadahonda, 10 Cardiology; Universidad Autonoma de Madrid, Medicine 11 Farré, Jerónimo; Fundacion Jimenez Diaz, Cardiology; Universidad 12 Autonoma de Madrid, Medicine 13 Lorenzo, Óscar; Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Vascular Research Laboratory; Universidad Autonoma de 14 Madrid, Medicine 15 For peerMahíllo-Fernández, review Ignacio; Instituto deonly Investigacion Sanitaria de la 16 Fundacion Jimenez Diaz, Research Unit 17 Egido, Jesus; Fundacion Jimenez Diaz, Nephrology; Universidad Autonoma 18 de Madrid, Medicine 19 Primary Subject 20 Cardiovascular medicine Heading: 21 22 Secondary Subject Heading: Cardiovascular medicine, Renal medicine 23 Vitamin D, acute myocardial infarction, calcifediol, remodeling, cardiac 24 Keywords: 25 magnetic resonance imaging 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 Design and rationale of a multicentre, randomized, double blind, placebo 4 2 controlled clinical trial to evaluate the effect of vitamin D on ventricular 5 6 3 remodeling in patients with anterior myocardial infarction: 7 4 The VITamin D in Acute Myocardial Infarction (VITDAMI) trial 8 5 9 6 José Tuñón, MD, PhD,a,b,c Ignacio González Hernández, MD,a Lucía Llanos Jiménez, MD, 10 d e,f g 11 7 PhD, Joaquín Alonso Martín, MD, PhD, Juan M. Escudier Villa, MD, Nieves Tarín, MD, 12 8 PhD,h Carmen Cristóbal, MD, PhD,f,i Petra Sanz, MD,f,i Ana M. Pello, MD,a Álvaro Aceña, 13 14 9 MD,a Rocío Carda, MD,a Miguel Orejas, MD,a Marta Tomás, MD,k Paula Beltrán, MD,PhD,a 15 10 María JoséFor Calero Rueda, peer MD,j Esther Marcos,review MD,h José María onlySerrano Antolín, MD,i Carlos 16 17 11 Gutiérrez Landaluce, MD,i Rosa Jiménez, MD,i Jorge Cabezudo, MD,i Alejandro Curcio, MD,i 18 12 Germán Peces Barba, MD, PhD,b,l Emilio González Parra, MD, PhD,b,m Raquel Muñoz Siscart, 19 20 13 BSc,d María Luisa González Casaus, MD,n Antonio Lorenzo, MD,h Ana Huelmos, MD, PhD,o 21 g a,p q 22 14 Javier Goicolea, MD, PhD, Borja Ibáñez, MD, PhD, Gonzalo Hernández, MD, Luis M 23 15 Alonso Pulpón, MD, PhD,b,g Jerónimo Farré, MD, PhD,a,b Óscar Lorenzo, PhD,b,c Ignacio 24 d b,c,r 25 16 Mahíllo Fernández, PhD, Jesús Egido, MD, PhD 26 17 27 28 18 aDepartment of Cardiology, Fundación Jiménez Díaz, Madrid, Spain 29 19 bDepartment of Medicine, Autónoma University, Madrid, Spain, 30 20 cVascular Research Laboratory, IIS Fundación Jiménez Díaz, Madrid, Spain 31 21 dResearch Unit, IIS Fundación Jiménez Díaz, Madrid, Spain, 32 22 eDepartment of Cardiology, University Hospital of Getafe, Madrid, Spain, 33 f 23 Department of Medicine, Rey Juan Carlos University, Alcorcón, Spain http://bmjopen.bmj.com/ 34 24 gDepartment of Cardiology, University Hospital Puerta de Hierro, Madrid, Spain, 35 25 hDepartment of Cardiology, University Hospital of Móstoles, Móstoles, Spain, 36 26 iDepartment of Cardiology, Hospital de Fuenlabrada, Madrid, Spain 37 27 jDepartment of Cardiology, Hospital Rey Juan Carlos, Móstoles, Madrid, Spain 38 k 28 Department of Radiology, Fundación Jiménez Díaz, Madrid, Spain 39 29 lDepartment of Neumology, Fundación Jiménez Díaz, Madrid, Spain 40 30 mDepartment of Nephrology, Fundación Jiménez Díaz, Madrid, Spain 41 n 31 Laboratory of Renal Function, Hospital Gómez Ulla, Madrid, Spain on September 23, 2021 by guest. Protected copyright. 42 32 oDepartment of Cardiology, Fundación Hospital Alcorcón, Madrid, Spain 43 pCentro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain 44 33 34 qFAES FARMA S.A. laboratories, Vizcaya, Spain 45 r 46 35 CIBERDEM, Madrid, Spain 47 36 48 37 Word Count: 5,259 49 38 Corresponding author: José Tuñón, MD, PhD, Department of Cardiology, IIS Fundación 50 51 39 Jiménez Díaz, Avenida Reyes Católicos 2, 28040 Madrid (Spain), Phone 00-34-915504800 52 40 Ext: 3701, email [email protected] 53 54 55 41 Key words: Vitamin D; calcifediol; acute myocardial infarction; remodeling; cardiac magnetic 56 42 resonance imaging 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 ABSTRACT 4 2 Introduction: Decreased plasma vitamin D (VD) levels are linked to cardiovascular 5 3 damage. However, clinical trials have not demonstrated a benefit of VD supplements on 6 4 left ventricular (LV) remodeling. Anterior ST elevation acute myocardial infarction 7 5 (STEMI) is the best human model to study the effect of treatments on LV remodeling. 8 6 We present a proof of concept study that aims to investigate whether VD improves LV 9 10 7 remodeling in patients with anterior STEMI. 11 12 8 Methods and Analysis: The VITDAMI (VITamin D in Acute Myocardial Infarction) 13 9 trial is a multicenter, randomized, double blind, placebo controlled trial. One hundred 14 10 forty four patients with anterior STEMI will be assigned to receive calcifediol 0.266 mg 15 11 capsules For (Hidroferol® peer SGC)/15 days review or placebo on a 2:1only basis during 12 months. 16 12 Primary objective: to evaluate the effect of calcifediol on LV remodeling defined as an 17 13 increase in LV end diastolic volume≥10% (magnetic resonance imaging). Secondary 18 14 objectives: change in LV end diastolic and end systolic volumes, ejection fraction, LV 19 15 mass, diastolic function, sphericity index, and size of fibrotic area; endothelial function; 20 21 16 plasma levels of aminoterminal fragment of B type natriuretic peptide, galectin 3, and 22 17 monocyte chemoattractant protein 1; levels of calcidiol (VD metabolite) and other 23 18 components of mineral metabolism (fibroblast growth factor-23 [FGF-23], the 24 19 soluble form of its receptor klotho, parathormone, and phosphate). Differences in 25 20 the effect of VD will be investigated according to plasma levels of FGF-23 and 26 21 klotho. Treatment safety and tolerability will be assessed. This is the first study to 27 22 evaluate the effect of VD on cardiac remodeling in patients with STEMI. 28 29 23 Ethics and dissemination: This trial has been approved by the corresponding 30 24 Institutional Review Board (IRB) and National Competent Authority (AEMPS). It will 31 25 be conducted in accordance to Good clinical practice (ICH GCP) requirements, ethical 32 33 26 principles of Declaration of Helsinki and national laws. The results will be submitted to http://bmjopen.bmj.com/ 34 27 indexed medical journals and national and international meetings. 35 28 Trial registration number: NCT02548364. 36 29 37 38 30 39 40 31 STRENGTHS AND LIMITATIONS OF THIS STUDY 41 on September 23, 2021 by guest. Protected copyright. 42 32 • This study will assess the effect of vitamin D (VD) supplements on the 43 33 myocardium after an acute myocardial infarction, which is probably the best 44 34 model to study left ventricular remodeling. 45 46 47 35 • In addition to calcidiol plasma levels, other components of mineral metabolism 48 36 such as fibroblast growth factor 23 (FGF23) and its soluble receptor, klotho, will 49 37 be taken into account. 50 51 38 • As a limitation, this study is not powered to study if a potential benefit of VD on 52 39 myocardial remodeling translates into a clinical benefit. In case of a positive 53 40 result, a larger study would be necessary to further investigate this issue. 54 55 41 56 42 57 58 43 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 INTRODUCTION 4 2 Traditionally, changes in plasma levels of the components of mineral 5 6 3 metabolism [vitamin D (VD), fibroblast growth factor 23 (FGF 23), parathyroid 7 4 hormone (PTH), and phosphate (P)] have been associated with renal disease[1 3]. When 8 5 slight decreases in glomerular filtration rate appear, the excretion of P is reduced. 9 6 Compensatory responses are then activated to maintain P homeostasis, including an 10 7 increase in the levels of FGF 23 and a subsequent rise in those of PTH[1]. FGF 23 11 8 promotes phosphaturia and decreases levels of plasma VD, both by downregulating 12 9 synthesis and by increasing degradation[1]. 13 14 10 Although high P levels are associated with an increase in cardiovascular events 15 11 and mortality[2],For the aforementionedpeer adaptivereview mechanisms preventonly an increase of serum 16 12 P levels in the early stages of chronic kidney disease[1 3]. However, these 17 18 13 compensatory mechanisms themselves are also related to cardiovascular damage[4, 5]. 19 14 Thus, high FGF 23 plasma levels are independently associated with endothelial 20 15 dysfunction, arterial stiffness, atherosclerosis burden, vascular calcification, left 21 16 ventricular (LV) hypertrophy, progression of renal disease, and incidence of mortality 22 17 and cardiovascular events in the general population as well as in patients with coronary 23 18 artery disease, even after adjusting for renal glomerular filtration[4 10]. Similarly, 24 19 increased PTH plasma levels are related to LV hypertrophy, hypertension, and increased 25 20 cardiovascular events[11 16]. Finally, VD deficiency has been associated with 26 21 endothelial dysfunction, inflammation, and vascular smooth muscle cell proliferation, 27 28 22 vascular calcification, activation of the renin angiotensin system, hypertension, 29 23 myocardial infarction, and stroke[17 22]. However, low VD plasma levels are not only 30 24 associated to vascular damage, but they also play an important role in the state of the 31 25 myocardium. In this regard, VD deficiency is associated with rat LV hypertrophy and 32 26 systolic dysfunction, biatrial enlargement, metabolic changes, inflammation, fibrosis, 33 27 and apoptosis[23]. http://bmjopen.bmj.com/ 34 35 28 Of interest, abnormalities of mineral metabolism are not restricted to patients 36 29 with overt renal disease, as in more than 50% of patients with coronary artery disease 37 30 we have observed a deficiency of VD. However, only 20% of them had an estimated 38 31 glomerular filtration rate <60 mL/min/1.73 m2[10]. Moreover, abnormalities of mineral 39 32 metabolism were evident even at glomerular filtration rates >90 ml/min/1.73 m2[24]. In 40 33 addition, the inverse relationship between VD levels and risk of coronary heart disease 41 34 has also been seen in the general population[20, 25]. on September 23, 2021 by guest. Protected copyright. 42 43 35 Despite the negative association between VD deficiency and cardiovascular 44 36 disease described in multiple studies[10, 20, 26 35], clinical trials have failed to 45 37 convincingly demonstrate a benefit of VD supplements on CV health. One such study 46 38 was the PRIMO trial, which showed no improvement in ventricular mass index or any 47 39 other remodeling parameters by administering paricalcitol, a selective activator of VD 48 40 receptors, to patients with chronic renal failure[36]. However, experiments performed in 49 50 41 vitro and in several animal models of LV pressure overload show that VD supplements 51 42 attenuate LV hypertrophy, reduce cardiac fibrosis, and decrease the expression of 52 43 collagen, fibronectin, and transforming growth factor β (TGF β), along with an 53 44 improvement of the systolic and diastolic function[37 40]. The negative results of the 54 45 PRIMO trial may have several causes. The main cause could be that the population 55 46 selected was not ideal for the purpose of linking VD supplements and ameliorated CV 56 47 health. Second, hypertension leads to myocardial remodeling over the years, and it 57 48 seems difficult to modify this process in only 48 weeks of therapy. Another potential 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 reason is that FGF 23 plasma levels were not taken into account. Indeed, it has recently 4 2 been observed that low levels of VD were associated with increasing mass and diameter 5 3 when coexisting with high levels of FGF 23[41]. In accordance with this, we have 6 4 recently reported that low levels of VD were predictors of poor outcome in coronary 7 5 patients with FGF 23 plasma levels that were higher than the median value of 70 8 6 RU/ml, but they were not effective predictors if FGF 23 plasma levels were below the 9 10 7 median[10]. Other authors have shown similar data for the progression of chronic 11 8 kidney disease[42]. These data provide support for the notion that, in addition to being 12 9 an independent marker of cardiovascular risk, FGF 23 plasma levels influence the effect 13 10 of low VD levels. Finally, klotho plasma levels were not taken into account. This 14 11 protein is a co receptor for FGF 23, whose extracellular portion can be released and act 15 12 as an endocrineFor substance peer with multiple review functions. Low levels only of klotho are related to 16 13 kidney damage, but also to vascular calcification and cardiac hypertrophy and fibrosis, 17 14 causing klotho to be considered an anti aging protein[43]. Thus, it is possible that in 18 15 people without reduced glomerular filtrate, klotho levels are normal and could interfere 19 20 16 with the hypertrophic effect of FGF 23. The fact that VD may increase klotho levels 21 17 reinforces the possibility that this compound may have a protective cardiovascular 22 18 effect. 23 19 In summary, there is substantial evidence demonstrating the negative effects of VD 24 20 deficiency on the cardiovascular system, including the development of LV hypertrophy. 25 26 21 Despite the negative results of VD supplements in previous clinical trials, the convincing 27 22 evidence obtained in animal models in which it is shown that VD may protect the heart 28 23 supports the need for a new clinical trial designed to take into account the most recent 29 24 discoveries in the field. The VITDAMI trial has been designed as a proof of concept 30 25 study to test the effect of VD supplements in patients with anterior ST elevation 31 26 myocardial infarction (STEMI). The reason is that a great part of the remodeling process 32 27 following a large STEMI may be concentrated in the months following the acute event, 33 28 making these patients probably the best human model for studying therapeutic http://bmjopen.bmj.com/ 34 29 interventions on ventricular remodeling. Moreover, when STEMI affects the anterior wall 35 36 30 of the LV, it tends to be larger than in other locations, and remodeling is thus especially 37 31 intensive in these cases. In this regard, in the METOCARD trial comparing early versus 38 32 delayed beta blockade in patients with anterior STEMI[44, 45], the control group showed 39 33 an increase of 11.5% in mean LV end diastolic volume and a decrease of 22.8% in mean 40 34 LV mass at 6 months, along with a minimal increase of 2.2% in the ejection fraction. In 41 35 addition, we will see if this effect occurs only in those patients with FGF 23 above the on September 23, 2021 by guest. Protected copyright. 42 36 median or in all the study subjects. Similarly, we will assess possible differences in the 43 37 effect of VD in patients with klotho plasma levels above and below the median. Based on 44 45 38 the ideas developed above, it is possible that benefits could be present only in patients 46 39 with elevated levels of FGF 23, in those with klotho levels below the median, or in both 47 40 situations. 48 41 49 50 42 METHODS 51 52 43 Study aim 53 44 To compare the effect of one year treatment with calcifediol 0.266 mg 54 45 (equivalent to 15,960 units) soft gelatin capsules versus placebo on LV remodeling in 55 46 patients with anterior STEMI. 56 57 47 58 59 60 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 Primary Hypothesis 4 5 2 The oral administration of one calcifediol 0,266 mg soft gelatin capsule every 15 6 3 days to patients with anterior STEMI will reduce the presence of LV remodeling 7 4 assessed by cardiac magnetic resonance imaging (MRI), defined as an increase in LV 8 5 end diastolic volume of ≥10%, at one year as compared with the baseline assessment. 9 10 6 Secondary Hypotheses 11 12 7 1. Patients receiving calcifediol will show, as compared to those receiving placebo: 13 14 8 • Less increase in end diastolic and end systolic volumes. 15 9 • MoreFor increase peerin ejection fraction. review only 16 10 • Less decrease in diastolic sphericity index, defined as the ratio of long to short 17 18 11 axis dimension of the left ventricular cavity at end diastole[46]. 19 12 • Less increase in the area of fibrosis. 20 13 • Better diastolic function. 21 14 • Better endothelial function. 22 15 • A significant reduction in plasma levels of one or more of these biomarkers: NT 23 16 proBNP (N terminal brain natriuretic peptide) and galectin 3, as related to heart 24 17 failure and adverse prognosis; and monocyte chemoattractant protein 1 (MCP 25 26 18 1), related to inflammation and acute ischemic events[47]. 27 19 • Higher plasma levels of calcidiol (25OH VD) and/or klotho, and lower levels of 28 20 FGF 23 and/or PTH. 29 21 30 22 2. The results of the previous hypotheses will be more evident or even restricted to 31 23 those patients with FGF 23>median and/or klotho 1 2 3 1 curve[48]. Diagnostic anterior ST elevation in absence of LV hypertrophy or left 4 2 bundle branch block is defined according to current guidelines as new ST elevation at 5 3 the J point in at least 2 contiguous leads of ≥2 mm in V1 6 in men; in women ≥1.5 mm 6 4 in V2–V3 and/or ≥1 mm in the remaining anterior leads will be accepted[49]. Exclusion 7 5 criteria are listed in Table 1. Recruitment will be competitive. 8 6 9 10 7 Table 1. Exclusion Criteria 11 8 ______12 9 Death or complications compromising patient survival (i.e: cardiogenic shock) during the 13 10 index event 11 No primary angioplasty 14 1 15 12 ImpossibilityFor to perform peer the desirable review revascularization only 16 13 Indication of cardiac transplant 17 14 Surgical coronary revascularization during the index event 18 15 Revascularization pending at the moment of discharge 19 16 Complications that extend patient´s stay at the hospital for more than 7 days 20 17 Absence of akinetic area in the anterior wall of the left ventricle 21 18 Previous myocardial infarction 22 19 Valve prosthesis 23 20 Aortic stenosis with mean gradient>25 mm Hg (Doppler) and stenosis of any other valve 24 21 Moderate to severe valve regurgitation 25 22 Cardiomyopathy (Dilated, Hypertrophic or Restrictive) 26 23 Severe left ventricle hypertrophy (wall thickness ≥17 mm in men and ≥16 mm in women) 27 24 Conditions limiting survival 28 25 Inflammatory or immune disease 29 26 Estimated Glomerular Filtration Rate <40 ml/min/1.73 m2 30 27 Intolerance to vitamin D supplements 31 28 Indication or patient’s decision to take vitamin D or calcium 32 29 Therapy with drugs that can interfere absorption, distribution, metabolism or excretion of 33 30 Vitamin D: http://bmjopen.bmj.com/ 34 31 Anti epileptic (Phenitoine, Phenobarbital, Primidone, other enzymatic inducers) 35 32 Cholestiramine, cholestipol, Orlistat 36 33 Penicillins 37 34 Laxatives as paraphine and mineral oil 38 35 Digitalis 39 36 Magnesium salts 40 37 Verapamil 41 38 Steroids on September 23, 2021 by guest. Protected copyright. 42 39 Disorders that can interfere the pharmacokinetics or pharmacodynamics of Vitamin D: 43 40 Hepatic insufficiency, inflammatory bowel disease, sarchoidosis, Tuberculosis, or other 44 41 granulomatous disorders. 45 42 Plasma Calcium levels >10.5 mg/dl, history of hypercalciuria or calcium litiasis. 46 43 Contraindications for Magnetic Resonance Imaging: claustrophoby, pacemaker, 47 44 defibrillators, resynchronization devices, or high probability that they need them during the 48 45 study (among them, patients with ejection fraction<30% at discharge) 49 46 Impossibility to follow the patients 50 47 Difficult compliance of the therapy as estimated by the investigator 51 48 Patient rejects to participate and/or does not sign the informed consent 52 49 Pregnancy or lactation period 53 50 Patients participating in another clinical trial 54 51 1Severe stenoses (angiographic severity>70% or borderline with a positive intracoronary adenosine test) are 55 52 allowed only in secondary vessels considered either not relevant by the investigator because of small vessel diameter, 56 53 distal lesion, or technically unfeasible due to vessel calcification or tortuosity. 57 54 58 59 60 6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 4 2 Trial Design 5 6 3 The VITDAMI trial is a randomized, multicentre, double blind, placebo 7 4 controlled trial. 8 5 The protocol (version 2.1, July 1st, 2015) has been approved by the 9 6 corresponding IRB and the Spanish Drug Agency (AEMPS). One hundred forty four 10 7 patients with anterior STEMI, will be included at Cardiology Departments of the 11 8 participating sites in Spain, that have been chosen because they have the equipment and 12 9 programs needed to care for patients with STEMI, along with the facility for cardiac 13 10 MRI. After signing the informed consent they will undergo cardiac examination by MRI 14 11 and Echocardiography, blood extraction for plasma storage, electrocardiogram, and 15 For peer review only 16 12 non invasive endothelial function test (only in patients admitted to Fundación Jiménez 17 13 Díaz) (Figure 1) as soon as possible and no later than 7 days after admission. 18 14 Immediately after completing these tests, patients will be randomly assigned to receive 19 15 on a 2:1, double blind basis an oral dose of 0.266 mg of calcifediol or placebo every 15 20 16 days (±1 day) during one year. In addition to study treatment, patients will be managed 21 17 according to standard clinical practice based in European guidelines for STEMI[48]. 22 18 Given that it may be heterogeneity in calcidiol plasma levels due to different baseline 23 19 levels, a 2:1 instead of 1:1 randomization has been chosen in order to allow comparing 24 25 20 the outcomes across different ranges of calcidiol levels. 26 21 Forty five days after inclusion, blood will be extracted to perform a safety 27 22 determination of calcidiol and calcium plasma levels, to adjust the dose of study 28 23 medication according to the results. By phone contact, dose adjustment will be 29 24 communicated to the patient and the appearance of potential adverse effects will be 30 25 evaluated. At months 3 and 9 adverse effects will be checked by phone call. At month 6, 31 26 patients will be seen by the investigator to rule out adverse effects and to collect empty 32 27 blisters to confirm compliance of study medication, performing also a new blood 33 28 extraction for study plasma determinations. At this time they will be provided study http://bmjopen.bmj.com/ 34 35 29 medication for the last six months of the study. Finally, on month 12, procedures 36 30 performed at inclusion will be repeated, and the study drug will be discontinued. One 37 31 month after the last dose, a follow up visit will be performed by phone contact to 38 32 register any possible adverse events, and the study will be finished. Table 2 summarizes 39 33 the visit schedule. 40 34 Patient recruitment started in November 2015 and the trial is expected to 41 35 conclude in December 2017. on September 23, 2021 by guest. Protected copyright. 42 36 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 Table 2. Visit Schedule 4 2 5 6 V0 V1 V2 V2 V4 V5 V6 7 8 0 m 1.5 m 3 m 6 m 9 m 12 m 13m 9 Inclusion/exclusion Criteria X 10 11 Informed consent X 12 13 Clinical History X X X X X 14 15 ConcomitantFor medication peer reviewX only X X 16 17 Physical Exam X X X 18 19 Heart rate and Blood Pressure X X X 20 21 Hemogram and biochemistry X X X 22 23 Chest roentgenogram X X 24 Electrocardiogram X X X 25 26 Calcidiol and calcium X 27 determination 28 29 Biological samples X X X 30 31 Cardiac MRI1 X X 32 33 Echocardiogram X X http://bmjopen.bmj.com/ 34 35 Endothelial function2 X X 36 37 Dispense study medication/Collect X X X 38 empty blisters 39 40 Compliance Check X X X X X 41 42 Adverse Events X X X X X X on September 23, 2021 by guest. Protected copyright. 43 (1)MRI: Magnetic Resonance Imaging, (2) Only in FJD 44 45 3 46 47 4 Randomization and blinding 48 5 Patients will be randomly assigned to receive 1 calcifediol 0.266 mg soft gelatine 49 ® 50 6 capsule (Hidroferol SGC), or 1 soft capsule, containing placebo, every 15 days. 51 7 Allocation ratio will be 2:1 and randomization scheme will be computer generated by 52 8 the statistician at the coordinating centre and block balanced. Closed envelops with the 53 9 randomization sequence will be prepared and distributed to the participating centers. 54 10 Randomization will be performed by the study investigators. Treatment allocation will 55 11 be blind for patients and the research team. Unblinding will be allowed in case a patient 56 12 suffers a serious adverse event if the attending medical team considers it necessary to 57 58 13 preserve patient’s health. 59 60 8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 4 5 2 Study Medication 6 3 Hidroferol® SGC will be used for this trial. This is a new formulation containing 7 4 0.266 mg of Calcifediol (15,960 UI of VD) that improves bioavailability (22%) with 8 5 respect to the liquid Calcifediol immediate release oral formulation, due to its SEDDS 9 6 pharmaceutical technology (Self Emulsifying Drug Delivery Systems). 10 11 7 Calcifediol and placebo capsules will be provided and labeled by FAES FARMA 12 8 S.A. Laboratories to ensure the blindness of the study. Pharmacy Departments at each 13 9 centre will receive the study medication, and will keep a registry of the medication 14 10 received, dispensed and stored. The medication will be stored in appropriate conditions 15 11 and kept For locked under peer restricted access. review Any non used studyonly medication and all the 16 17 12 empty packages will be stored until the end of the study and adequately destroyed 18 13 locally afterwards. 19 14 Adherence to study medication will be evaluated by direct questions to the patient 20 15 in each visit on how many doses he/she has omitted. In addition, this information will 21 16 be checked with pharmacy registries to calculate the final adherence percentage. 22 17 23 24 18 Safety Issues 25 26 19 At 1.5 months a safety assessment of plasma calcidiol and calcium levels will be 27 20 performed after the intake of the first three doses as by this time calcidiol is expected 28 21 to reach its peak concentration. The study therapy will be adjusted following these 29 22 rules: 30 31 23 • Calcidiol > 70 ng/ml or calcium >10.5 mg/dl: Therapy will be stopped and the 32 24 patient will continue being followed. 33 http://bmjopen.bmj.com/ 34 25 • Calcidiol 30 70 ng/ml and calcium ≤10.5 mg/dl. The dose of study drug will be 35 36 26 reduced to one capsule every month as a maintenance dose. 37 27 • Calcidiol <30 ng/ml and calcium ≤10.5 mg/dl: The dose of the study drug will be 38 39 28 kept at 1 capsule every 15 days. 40 41 29 Of interest, no baseline calcidiol measurement is performed, as this is deemed 42 30 unnecessary due to different reasons. 1) In a previous study from our group in 704 on September 23, 2021 by guest. Protected copyright. 43 31 patients with coronary artery disease[10, 24], maximal calcidiol levels were 51 ng/ml, 44 32 far from the upper normal limit of 70 ng/ml. 2) The dose chosen is well below the 45 33 tolerable upper intake level of 4,000 UI/d[50,51]. 3) In the large VITAL clinical trial, in 46 34 primary prevention, a dose of 2,000 UI/d VD is being used for 5 years without assessing 47 35 basal levels and performing only one safety determination of calcidiol levels in a small 48 36 subgroup of patients[52]. 49 50 37 Criteria for Study Withdrawal 51 52 38 Patients may voluntarily leave the study at any time without giving any reason and with 53 39 no consequences for their subsequent care. They will also be withdrawn from the study 54 40 at investigator criteria for the following reasons: new myocardial infarction during 55 41 treatment period (as it may influence LV remodeling), lost to follow up, lost of the 56 57 42 capacity to consent, safety concerns (i.e unexpected serious adverse events), failure to 58 43 fulfill eligibility criteria and failure to collaborate or to comply with study procedures. 59 60 9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 Irrespective of the reason for withdrawal, efforts will be made by the investigator team 4 2 to perform the end of study visit and to register in the clinical records and case report 5 3 form (CRF) as much information as possible until the ending of patient participation. 6 7 4 8 5 Trial Procedures 9 10 6 Cardiac MRI 11 7 Comprehensive cardiac MRI will be carried out to study cardiac function, LV 12 8 mass, myocardial edema and myocardial fibrosis/necrosis. Scans will be performed with 13 14 9 1.5 Tesla equipments at each participating centre. For assessment of global and 15 10 segmentalFor left and right peer ventricular function,review and LV mass, only balanced steady state free 16 11 precession with sensitivity encoding fast parallel imaging technique (True FISP, SSFP) 17 12 sequence will be used for cine imaging. Images will be obtained at short axis (8 mm 18 13 slices from the apex to the base of the left ventricle), 4 chamber, 2 chamber, and 3 19 14 chamber. Myocardial edema will be assessed matching the slice position of the cine 20 15 images, using a T2 weighted triple IR turbo spin echo (STIR) sequence. For study of 21 16 fibrosis/myocardial necrosis, gadolinium based contrast agent will be intravenously 22 17 administered. Delayed enhancement imaging to assess necrotic myocardium will be 23 24 18 performed using IR Turbo FLASH (3D IR GRE, 2D IR GRE, and PSIR sequences). 25 19 The necrotic/fibrotic area is defined as area with delayed gadolinium up take 26 20 (high intensity STIR signals) and myocardium at risk as area with edema. Salvaged 27 21 myocardium is assessed as the difference between myocardial at risk and the necrotic 28 29 22 area. Myocardium at risk, the necrotic size and the salvaged myocardium will be 30 23 expressed as percentage of the total left ventricular mass. In addition, the necrotic area 31 24 will be also expressed in grams. All the results will be given in absolute numbers and 32 25 normalized by Body Surface Area. LV end diastolic and end systolic volumes, as well 33 26 as the ejection fraction and the LV sphericity index (maximal long axis/short axis of LV http://bmjopen.bmj.com/ 34 27 cavity at end diastole) will be assessed[46]. Finally, microvascular obstruction, a 35 28 parameter related to cardiac remodeling[53] will be assessed at the initial MRI 36 29 exploration. MRI studies will be analyzed blinded to treatment allocation at a central 37 30 core laboratory located at the Centro Nacional de Investigaciones Cardiovasculares 38 39 31 Carlos III with the QMass system (7.6). Fifteen percent of the MRI studies will be 40 32 randomly chosen to perform inter and intraobserver variability. 41 33 on September 23, 2021 by guest. Protected copyright. 42 34 Doppler-Echocardiography 43 44 35 This technique will be performed and interpreted at the centre where the patient 45 36 is included. Apical four chamber and two chamber views as well as long and short axis 46 37 parasternal views will be used. Bidimensional and M mode echocardiography will be 47 38 used to analyze diastolic and systolic diameters of the LV, septal and posterior wall 48 39 thickness, ejection fraction (Simpson method), segmental contractility using a 17 49 50 40 segment model and registering areas of akinesia, dyskinesia and hypokinesia. Diastolic 51 41 function will be assessed by analyzing the Deceleration Time (ms), peak E and A waves 52 42 (cm/s), E/A ratio, and the isovolumetric relaxation time (ms) by pulsed Doppler, and E’ 53 43 (cm/s) and A’ (cm/s) waves by Tissue Doppler Imaging. 54 55 44 56 45 57 58 46 Endothelial Function Test 59 60 10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 The ENDOPAT technology will be used, measuring changes of finger arterial 4 2 pulsatile volume (reactive hyperemia plethysmographic biosensors). This test will be 5 3 carried out in the subgroup of patients at the Fundación Jiménez Díaz. Given that this 6 4 group will have a small sample size, subgroup analysis will not be performed and only 7 5 comparisons between both groups of therapy will be carried out. 8 9 6 10 11 7 Blood Extractions and Assessments 12 8 At blood withdrawal, 26 ml will be obtained, from which 18 ml will be placed in 13 9 EDTA tubes and 8 ml in tubes without EDTA. Blood will undergo centrifugation for 10 14 10 minutes at 2,500 G and the obtained plasma will be stored in 2 ml criovials at 80ºC. 15 11 Half of theseFor samples peer will be stored reviewat Instituto de Investigación only Sanitaria Fundación 16 17 12 Jiménez Díaz (IIS FJD) and the other half at Móstoles University Hospital to limit the 18 13 probabilities of damaging the samples in case of failure of the freezer. Nevertheless, 19 14 both freezers have a CO2 release system and telephonic alarm for cases of malfunction 20 15 of the system. The study of mineral metabolism will be performed at the Laboratory of 21 16 Renal Function at Gómez Ulla hospital, and the remaining determinations will be 22 17 carried out at the Laboratories of Biochemistry and Vascular Pathology at Fundación 23 18 Jiménez Díaz. Calcidiol levels will be quantified using chemiluminescent immunoassay 24 19 (CLIA) with LIAISON ®XLanalyzer (total VD Assay DiaSorin, Saluggia, Italy). FGF 25 20 23 will be assessed by an ELISA that recognizes epitopes in the terminal portion 26 27 21 carboxyl terminus of FGF 23 (Human FGF 23, C Term, Immutopics Inc, San 28 22 Clemente, CA), klotho will be studied by ELISA (soluble alpha klotho ELISA, IBL 29 23 International, Hamburg, Germany), intact PTH by an automated chemiluminescent 30 24 method of second generation (2010 platform Elecsys, Roche Diagnostics, Mannheim, 31 25 Germany), and P will be assessed by enzymatic method (Integra 400 analyzer, Roche 32 26 Diagnostics, Mannheim, Germany). NT proBNP levels will be determined by 33 27 immunoassay (VITROS, Orthoclinical Diagnostics, USA), high sensitivity C reactive http://bmjopen.bmj.com/ 34 28 proteins by immunoturbidimetric latex and determinations of lipids, glucose and 35 29 creatinine will be carried out by standard methods (ADVIA 2400 Chemistry System, 36 37 30 Siemens, Germany). Plasma levels of MCP 1 and galectin 3 will be determined in 38 31 duplicate using commercially available ELISA kits (BMS279/2, Bender MedSystems, 39 32 Burlingame, California; and DCP00, R&D Systems, Minneapolis, Minnesota). Albumin 40 33 and calcium will be assessed by standard methods (ADVIA 2400 Chemistry System, 41 34 Siemens, Germany). 42 on September 23, 2021 by guest. Protected copyright. 43 35 Finally, if patient consents, the remaining plasma samples will be stored in a 44 36 registered collection (Instituto de Salud Carlos III, C.0003386) for future determinations 45 37 of plasma levels of other molecules that may be potentially related with the other 46 38 variables assessed, such as mineral metabolism or LV remodeling. 47 48 39 49 40 Trial Outcomes 50 41 Main outcome: Proportion of patients that develop LV remodeling defined as an 51 42 increase of ≥10% in the end diastolic volume measured by cardiac MRI at the end of 52 43 the study as compared with the baseline assessment. 53 54 44 55 45 Secondary Outcomes: 56 46 − % change in LV End diastolic volume. 57 47 − % change in LV End systolic volume. 58 59 60 11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 − % change in Ejection fraction. 4 2 − % change in Sphericity index. 5 3 − % change in size of the necrotic/fibrotic area, defined as delayed gadolinium up take 6 4 (high intensity STIR signals). 7 8 5 − % change in LV mass. 9 6 − % change in endothelial function. 10 7 − % change in diastolic function as assessed by Flow and Tissue Doppler. 11 8 − Adverse Events rate and description. 12 9 − Compliance rate. 13 14 10 − Incidence of heart failure, death or any acute coronary syndrome (STEMI or non 15 11 ST elevationFor acute peer coronary syndrome). review only 16 12 − Levels of the following biomarkers in plasma will be measured both at 6 and 12 17 13 months: 18 14 NT proBNP, galectin 3, MCP 1, and hs C reactive protein 19 15 Calcidiol, FGF 23, PTH, P, and klotho 20 16 21 17 In addition to comparing the changes in the final versus the baseline assessment of all 22 18 the mentioned variables, we will compare also the results obtained in the final visit 23 24 19 between both treatment groups. 25 20 26 21 Also, assessment of main and secondary outcomes will be performed in the following 27 22 subgroup of patients: 28 23 − FGF 23 plasma levels above and below the median. 29 24 − Klotho plasma levels above and below the median. 30 25 − eGFR above and below 60 ml/min/1.73 m2 31 32 26 − Different tertiles of calcidiol plasma levels. Also, pre specified cut off levels will be 33 27 set 10, 15, and 20 ng/ml plasma levels. http://bmjopen.bmj.com/ 34 28 − Different degrees of microvascular obstruction at baseline MRI. 35 29 − With/ without thrombectomy at primary angioplasty 36 30 − In patients that achieve TIMI III flow at primary angioplasty 37 31 38 39 32 Statistical considerations 40 33 Sample size 41 42 34 As there are no published data on the effect of VD on LV remodeling in patients on September 23, 2021 by guest. Protected copyright. 43 35 with STEMI, a formal sample size calculation based on the expected effect for the 44 36 primary end point has not been performed. From this point of view, the trial can be 45 37 considered exploratory for the primary outcome. First, we defined as remodeling an 46 38 increase in 10% of LV end diastolic volume, given that according to previous studies 47 39 this value is above the observed intra and interobserver variability for this parameter in 48 40 cardiac MRI[54]. Then, the probability that a variation higher than 10% in the final 49 50 41 study as compared to the baseline is due to observational variability is very low. Then, 51 42 we reviewed data from the METOCARD study[44], comparing early versus delayed 52 43 beta blockade in a similar population, and observed that 52% of patients from the group 53 44 of conventional beta blockade developed this outcome at six months. Given that we 54 45 expect this number to be higher at one year, we believe that a reduction of 24% in the 55 46 number of patients is a reasonable target if VD really has a positive effect. With these 56 47 numbers we estimate that 120 patients are needed to have a power of 80% (1 β=0.8) 57 48 using a two sided test with a level of significance α=0.05, assuming that the LV end 58 59 60 12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 diastolic volume measured by MRI is normally distributed. 4 2 To have 120 cases suitable for analysis we have estimated that it is necessary to 5 6 3 include a total of 144 patients. With this sample size, considering that mortality the first 7 4 year after a STEMI may be up to 5%[55], and taking into account that we have 8 5 observed a 2.6% of incidence of recurrent non fatal myocardial infarctions during this 9 6 period in our patients (unpublished data), we will have 11 patients not completing the 10 7 trial, leaving 133 patients. In addition, we estimate that up to 10% of these patients 11 8 could give up the study for other reasons, then leading 120 patients for analysis. 12 13 9 Endothelial function will be assessed only in one center. However, information 14 10 regarding endothelial function is available from one previous study by Tarcin et al[56]. 15 11 The authorsFor describe peer that flow mediated review vasodilation increasesonly significantly from 16 12 7.0±3.2% to 10.4±3.3% after treatment with VD. Assuming that similar differences will 17 13 be observed in our study, 33 subjects would be enough to have a power of 80% with a 18 14 two sided level of significance α=0.05. 19 20 15 21 16 Statistical Analysis 22 23 17 Analyses of treatment effect will be performed per protocol. No interim analyses 24 18 will be performed, given the short duration and the limited sample used in this proof of 25 19 concept study. A descriptive analysis of baseline characteristics of patients included in 26 20 both groups will be performed, to ensure that they are comparable. Qualitative variables 27 28 21 will be described as absolute numbers and percentages. Quantitative variables with 29 22 normal distribution (tested by Kolmogorov Smirnov test) will be reported as mean 30 23 (standard deviation), and those that do not follow a normal distribution will be 31 24 described as median (interquartile range). 32 25 To compare quantitative variables between the VD and the placebo groups, the 33 http://bmjopen.bmj.com/ 34 26 Student t test will be used in case data are normally distributed. In case distribution is 35 27 not normal, the Mann Whitney test will be performed. For the comparison of baseline 36 28 versus end of treatment values, the paired t test will be used for normally distributed 37 29 data and the Wilcoxon test will be carried out if normal distribution cannot be 38 30 demonstrated. For qualitative variables, chi squared test will be performed. 39 40 31 Also, differences in the same parameters will be assessed among the groups 41 32 defined by plasma calcidiol tertiles. For quantitative data, one way analysis of variance 42 33 (ANOVA) followed by post hoc tests will be used in cases of normal distribution. The on September 23, 2021 by guest. Protected copyright. 43 34 Kruskal Wallis test followed by Mann Whitney tests will be performed if the 44 35 distribution is not normal. Qualitative analyses will be performed by Chi2 test. 45 46 36 Interobserver variability will be assessed by the estimation of intraclass 47 37 correlation coefficients. Analyses will be considered significant when “p”<0.05 (two 48 38 tailed). Analyses will be performed with SPSS 19.0 statistical package. 49 50 39 51 40 ETHICS AND DISSEMINATION 52 53 41 This trial has been already approved by the corresponding Institutional Review 54 42 Boards and the National Competent Authority (AEMPS). Any relevant amendments to 55 43 the protocol will be adequately submitted for evaluation to the corresponding 56 44 institutions and properly communicated to relevant parties after approval. Patient 57 45 confidentiality will be warranted according to Spanish data protection laws. In the CRF 58 59 60 13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 and any other of the trial documents, patients will be identified by a numeric code and 4 2 will not contain any personal information that could allow identification. 5 3 We have contracted liability insurance to cover the patients from potential 6 4 adverse consequences secondary to their participation in the trial. 7 5 All patients must sign an informed consent before participating and keep a 8 6 copy for their records. Investigators are responsible for obtaining written informed 9 10 7 consent from each individual participating in this study after adequate explanation of 11 8 the aims, methods, objectives and potential hazards of the study. It should be made clear 12 9 that refusal to participate or withdrawal from the trial at any stage will have no 13 10 consequences in the patient’s subsequent care. A specific section to consent for the 14 11 storage of biological samples is included in the informed consent form. Clinical Trial 15 12 PharmacovigilanceFor andpeer Monitoring willreview be performed by only SCReN (Spanish Clinical 16 13 Research Network), every six months, reviewing CRF and confirming that they only 17 14 include data registered at the patient´s hospital clinical records. The results of the study 18 15 will be submitted to indexed medical journals and presented at national and 19 20 16 international meetings. The trial is registered in ClinicalTrials.gov (NCT02548364) and 21 17 EU Clinical Trials Register (EudraCT 2014 004512 11). 22 18 23 19 CONCLUSIONS 24 25 20 The VITDAMI trial is the first exploratory trial to evaluate the effect of VD 26 21 treatment on myocardial remodeling in patients with anterior STEMI and preserved 27 22 renal function. Furthermore, it will be the first study to analyze the influence of other 28 23 components of mineral metabolism, such as FGF 23 and klotho levels, on the effect of 29 24 VD. The results, expected by December 2017, will likely contribute to our 30 31 25 understanding of the complex role of VD and other components of mineral metabolism 32 26 in cardiovascular diseases. If the trial is successful, a large scale study should be 33 27 performed to see if the improvement in cardiac remodeling translates into clinical http://bmjopen.bmj.com/ 34 28 benefits. 35 36 29 37 30 Ackowledgements 38 39 31 We are indebted to Oliver Shaw (IIS Fundación Jiménez Díaz, Madrid, Spain) for 40 32 his assistance in editing this work. 41 33 on September 23, 2021 by guest. Protected copyright. 42 43 34 Funding 44 35 The VITDAMI trial is an investigator initiated study, sponsored by the IIS FJD. 45 36 Funding has been obtained from Fondo de Investigaciones Sanitarias (PI14/01567) 46 37 (http://www.isciii.es/) and Spanish Society of Cardiology (http://secardiologia.es/). In 47 38 addition, the study medication has been provided freely by the pharmaceutical 48 49 39 Company FAES FARMA S.A. (Leioa, Vizcaya, Spain) (http://faesfarma.com/). This 50 40 company was the only funder who collaborated in study design (G Hernández). None of 51 41 the funders will have a role in collection, management, analysis, interpretation of data; 52 42 writing the report; and the decision to submit the report for publication. 53 54 43 55 44 Contributors 56 57 45 José Tuñón, Emilio González Parra, and Jesús Egido conceived the study. 58 59 60 14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 All authors participated in the development of the protocol. 4 2 José Tuñón, Ignacio Hernández González and Lucía Llanos Jiménez raised the 5 6 3 manuscript. All other authors revised the manuscript for relevant scientific content. 7 4 All authors approved the final version of the manuscript. 8 9 5 10 6 Competing Interests 11 12 7 Professor Egido has been lecturer for Abbott Spain. There are no other potential 13 8 conflicts of interest. 14 15 9 For peer review only 16 10 Committees and organization of the trial 17 11 Coordinating Centre: IIS FJD. It holds the missions of acquiring and preparing the 18 19 12 material for the trial and organizes the investigator meetings. 20 13 21 14 Steering Committee: Designed the protocol, obtained funding, management of 22 15 economical resources, creates all policy related to the project, and resolves the obstacles 23 16 that may arise. It is composed by: José Tuñón, Joaquín Alonso, Juan Escudier Villa, 24 17 Nieves Tarín, Petra Sanz, Carmen Cristóbal, Jesús Egido, Emilio Rodríguez Parra, 25 18 Miguel Orejas. 26 19 27 20 End Point adjudication Committee: It will be in charge of analyzing the appearance of 28 29 21 cardiovascular and non cardiovascular adverse events. It will be composed by: José 30 22 Tuñón, Lucía Llanos Jiménez, Ana M. Pello, Álvaro Aceña, Rocío Carda, Emilio 31 23 Rodríguez Parra, Germán Peces Barba, and Jesús Egido. 32 24 33 25 Data Management Team: This Committee will guarantee that the data are kept safe and http://bmjopen.bmj.com/ 34 26 anonymous, and that statistical analyses will be conducted properly. Composition: José 35 27 Tuñón, Lucía Llanos Jiménez, Raquel Muñoz Siscart, and Ignacio Mahíllo Fernández. 36 28 These are the only investigators that will have full access to the final trial dataset. 37 38 29 39 30 Writting Committee: This Committee will be composed by: José Tuñón, Lucía Llanos 40 31 Jiménez, Joaquín Alonso, Miguel Orejas, Jesús Egido. There will be no professional 41 32 writers but the text will be checked by an English native speaker. 42 33 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 REFERENCES 4 5 2 1. Wolf M. Forging forward with 10 burning questions on FGF23 in kidney disease. J Am Soc 6 3 Nephrol 2010;21:1427 35. 7 4 2. Gonzalez Parra E, Tuñón J, Egido J, et al. Phosphate: a stealthier killer than previously 8 5 thought? Cardiovasc Pathol 2012;21:372 81. 9 10 6 3. Larsson T, Nisbeth U, Ljunggren O¨ et al. Circulating concentration of FGF 23 increases as 11 7 renal function declines in patients with chronic kidney disease, but does not change in 12 8 response to variation in phosphate intake in healthy volunteers. Kidney Int 2003; 64: 2272– 13 9 9. 14 15 10 4. Faul C,For Amaral AP, peer Oskouei B, et al.review FGF23 induces left ventricularonly hypertrophy. 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Saleh FN, Schirmer H, Sundsfjord J, et al. Parathyroid hormone and left ventricular 49 35 hypertrophy. Eur Heart J 2003;24:2054–60. 50 51 36 15. Aceña A, Pello AM, Carda R, et al. Parathormone levels are independently associated with 52 37 the presence of left ventricular hypertrophy in patients with coronary artery disease. The 53 38 Journal of Nutrition Health and Aging 2015; in press 54 39 16. Hagström E, Hellman P, Larsson TE, et al. Plasma parathyroid hormone and the risk of 55 40 cardiovascular mortality in the community. Circulation 2009;119:2765 71. 56 57 41 17. Gonzalez Parra E, Rojas Rivera J, Tuñón J, et al. VD receptor activation and cardiovascular 58 59 60 16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 disease. Nephrol Dial Transplant 2012;27(Suppl 4):17 21. 4 5 2 18. Watson KE, Abrolat ML, Malone LL, et al. Active serum vitamin D levels are inversely 6 3 correlated with coronary calcification. Circulation 1997;96:1755 60. 7 4 19. Syal SK, Kapoor A, Bhatia E, et al. Vitamin D deficiency, coronary artery disease, and 8 endothelial dysfunction: observations from a coronary angiographic study in Indian 9 5 10 6 patients. J Invasive Cardiol 2012;24:385 9. 11 7 20. Scragg R, Jackson R, Holdaway IM, et al. Myocardial infarction is inversely associated 12 8 with plasma 25 hydroxyvitamin D3 levels: a community based study. Int J Epidemiol 13 9 1990;19:559 63. 14 15 10 21. Lavie ForCJ, Lee JH, Milanipeer RV. Vitamin review D and cardiovascular only disease will it live up to its 16 11 hype? J Am Coll Cardiol 2011;58:1547 56. 17 18 12 22. De Borst MH, Vervloet MG, ter Wee PM, et al. Cross talk between the renin angiotensin 19 13 aldosterone system and VD FGF 23 klotho in chronic kidney disease. J Am Soc Nephrol 20 14 2011;22:1603 9. 21 22 15 23. Assalin HB, Rafacho BP, dos Santos PP, et al. Impact of the length of vitamin D deficiency 23 16 on cardiac remodeling. Circ Heart Fail 2013;6:809 16. 24 25 17 24. González Parra E, Aceña A, Lorenzo O, et al. Important abnormalities of bone mineral 26 18 metabolism are present in patients with coronary artery disease with a mild decrease of the 27 19 estimated glomerular filtration rate. J Bone Min Metabolism 2105; Aug 23. [Epub ahead of 28 20 print] PMID: 26298279 29 30 21 25. Karakas M, Thorand B, Zierer A, et al. Low levels of serum 25 hydroxyvitamin D are 31 22 associated with increased risk of myocardial infarction, especially in women: results from 32 23 the MONICA/KORA Augsburg case cohort study. J Clin Endocrinol Metab 2013;98:272 33 24 80. http://bmjopen.bmj.com/ 34 35 25 26. Joergensen C, Gall MA, Schmedes A, et al. VD levels and mortality in type 2 diabetes. 36 26 Diabetes Care 2010;33:2238 43. 37 27 27. Melamed ML, Muntner P, Michos ED, et al. Serum 25 hydroxyVD levels and the 38 28 prevalence of peripheral arterial disease: results from NHANES 2001 to 2004. Arterioscler 39 29 Thromb Vasc Biol 2008;28:1179 85. 40 41 30 28. Wang TJ, Pencina MJ, Booth SL, et al. VD deficiency and risk of cardiovascular disease. on September 23, 2021 by guest. Protected copyright. 42 31 Circulation 2008;117:503 11. 43 44 32 29. Giovannucci E, Liu Y, Hollis BW, et al. 25 hydroxyVD and risk of myocardial infarction in 45 33 men: a prospective study. Arch Intern Med 2008;168:1174–80. 46 47 34 30. Dobnig H, Pilz S, Scharnagl H, et al. Independent association of low serum 25 hydroxyVD 48 35 and 1,25 dihydroxy VD levels with all cause and cardiovascular mortality. Arch Intern Med 49 36 2008;168:1340–9. 50 51 37 31. Pilz S, Dobnig H, Nijpels G, et al. VD and mortality in older men and women. Clin 52 38 Endocrinol (Oxf) 2009;71:666–72. 53 54 39 32. Poole KE, Loveridge N, Barker PJ, et al. Reduced VD in acute stroke. Stroke 2006;37:243– 55 40 5. 56 57 41 33. Wang L, Song Y, Manson JE, et al. Circulating 25 hydroxy vitamin D and risk of 58 42 cardiovascular disease: a meta analysis of prospective studies. Circ Cardiovasc Qual 59 60 17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 Outcomes 2012;5:819 29. 4 5 2 34. Grandi NC, Breitling LP, Brenner H. Vitamin D and cardiovascular disease: systematic 6 3 review and meta analysis of prospective studies. Prev Med 2010;51:228 33 7 4 35. Brøndum Jacobsen P, Benn M, Jensen GB, et al. 25 hydroxyvitamin d levels and risk of 8 ischemic heart disease, myocardial infarction, and early death: population based study and 9 5 10 6 meta analyses of 18 and 17 studies. Arterioscler Thromb Vasc Biol 2012;32:2794 802. 11 7 36. Thadhani R, Appelbaum E, Pritchett Y, et al. Vitamin D therapy and cardiac structure and 12 8 function in patients with chronic kidney disease: the PRIMO randomized controlled trial. 13 9 JAMA 2012;307:674 84. 14 15 10 37. Wu J, ForGarami M, Chengpeer T, et al. 1,25(OH)2 review VD3, and retinoic only acid antagonize endothelin 16 11 stimulated hypertrophy of neonatal rat cardiac myocytes. J Clin Invest 1996;97: 1577 88. 17 18 12 38. Bodyak N, Ayus JC, Achinger S, et al. Activated vitamin D attenuates left ventricular 19 13 abnormalities induced by dietary sodium in Dahl salt sensitive animals. Proc Natl Acad Sci 20 14 U S A 2007;104:16810 5. 21 22 15 39. Meems LM, Cannon MV, Mahmud H, et al. The vitamin D receptor activator paricalcitol 23 16 prevents fibrosis and diastolic dysfunction in a murine model of pressure overload. J Steroid 24 17 Biochem Mol Biol 2012;132:282 9. 25 26 18 40. Koleganova N, Piecha G, Ritz E, et al. Calcitriol ameliorates capillary deficit and fibrosis of 27 19 the heart in subtotally nephrectomized rats. Nephrol Dial Transplant 2009;24:778 87. 28 29 20 41. Ky B, Shults J, Keane MG, et al; CRIC Study Investigators. FGF23 modifies the 30 21 relationship between vitamin D and cardiac remodeling. Circ Heart Fail 2013;6:817 24. 31 22 42. Nakano C, Hamano T, Fujii N, et al. Combined use of vitamin D status and FGF23 for risk 32 stratification of renal outcome. Clin J Am Soc Nephrol 2012;7:810 9. 33 23 http://bmjopen.bmj.com/ 34 24 43. Hu MC, Kuro o M, Moe OW. Renal and extrarenal actions of Klotho. Semin Nephrol 35 25 2013;33:118 29. 36 37 26 44. Pizarro G, Fernández Friera L, Fuster V, et al. Long term benefit of early pre reperfusion 38 27 metoprolol administration in patients with acute myocardial infarction: results from the 39 28 METOCARD CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute 40 29 Myocardial Infarction). J Am Coll Cardiol 2014;63:2356 62. 41 42 30 45. Ibáñez B, Macaya C, Sánchez Brunete V, et al. Effect of early metoprolol on infarct size in on September 23, 2021 by guest. Protected copyright. 43 31 ST segment elevation myocardial infarction patients undergoing primary percutaneous 44 32 coronary intervention: the Effect of Metoprolol in Cardioprotection During an Acute 45 33 Myocardial Infarction (METOCARD CNIC) trial. Circulation 2013;128:1495 503. 46 47 34 46. Van Dalen BM, Kauer F, Vletter WB, et al. Influence of cardiac shape on left ventricular 48 35 twist. J Appl Physiol 2010;108:146 51. 49 50 36 47. Tuñón J, Blanco Colio L, Cristóbal C, et al. Usefulness of a combination of monocyte 51 37 chemoattractant protein 1, galectin 3, and N terminal probrain natriuretic peptide to predict 52 38 cardiovascular events in patients with coronary artery disease. Am J Cardiol 2014;113:434 53 39 40. 54 55 40 48. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. 56 41 Circulation 2012;126:2020 35. 57 42 49. Task Force on the management of ST segment elevation acute myocardial infarction of the 58 59 60 18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 European Society of Cardiology (ESC), Steg PG, James SK, Atar D, et al. ESC Guidelines 4 2 for the management of acute myocardial infarction in patients presenting with ST segment 5 3 elevation. Eur Heart J 2012;33:2569 619. 6 7 4 50. Ross AC, Manson JE, Abrams SA, et al. The 2011 Report on Dietary Reference Intakes for 8 5 Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. 9 6 The Journal of Clinical Endocrinology and Metabolism 2011;96:53 58. 10 11 7 51. Hathcock JN, Shao A, Vieth R, et al. Risk assessment for vitamin D. Am J Clin Nutr 12 8 2007;85:6–18. 13 9 52. Manson JE, Bassuk SS, Lee IM, et al. The VD and OmegA 3 TriaL (VITAL): rationale and 14 10 design of a large randomized controlled trial of VD and marine omega 3 fatty acid 15 11 supplementsFor for the peerprimary prevention review of cancer and cardiovascular only disease. Contemp Clin 16 12 Trials 2012;33:159 71. 17 18 13 53. Romero J, Lupercio F, Díaz JC, et al. Microvascular obstruction detected by cardiac MRI 19 14 after AMI for the prediction of LV remodeling and MACE: A meta analysis of prospective 20 15 trials. Int J Cardiol 2015;202:344 8. 21 22 16 54. Luijnenburg SE, Robbers Visser D, Moelker A, et al. Intra observer and interobserver 23 17 variability of biventricular function, volumes and mass in patients with congenital heart 24 18 disease measured by CMR imaging. Int J Cardiovasc Imaging 2010 Jan;26:57 64. 25 26 19 55. López Sendón JL, González Juanatey JR, Pinto F, et al. Quality markers in cardiology: 27 20 measures of outcomes and clinical practice a perspective of the Spanish Society of 28 21 Cardiology and of Thoracic and Cardiovascular Surgery. Eur Heart J 2015 Oct 21. pii: 29 22 ehv527. [Epub ahead of print] Review. PubMed PMID: 26491106. 30 31 23 56. Tarcin O, Yavuz DG, Ozben B, et al. Effect of VD deficiency and replacement on 32 24 endothelial function in asymptomatic subjects. J Clin Endocrinol Metab 2009;94:4023–30. 33 http://bmjopen.bmj.com/ 34 25 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 25 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 1 FIGURE LEGEND 4 2 Figure 1. Flow chart of the VITDAMI Trial. ECG: Electrocardiogram; MRI: Magnetic 5 3 Resonance Imaging; STEMI: ST elevation myocardial infarction; VITDAMI: VITamin D in 6 4 Acute Myocardial Infarction. 7 5 (1) Only at Fundación Jiménez Díaz 8 6 9 10 7 11 8 12 13 9 14 10 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 25 BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Figure 1. Flow chart of the VITDAMI Trial. ECG: Electrocardiogram; MRI: Magnetic Resonance Imaging; 33 STEMI: ST-elevation myocardial infarction; VITDAMI: VITamin D in Acute Myocardial Infarction. http://bmjopen.bmj.com/ 34 (1) Only at Fundación Jiménez Díaz 35 352x264mm (72 x 72 DPI) 36 37 38 39 40 41 42 on September 23, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from Addressed on page page on Addressed number and and Blinding) Page 1 1 Page line to 1 4 2 Page line 28 applicable Not 7 Page line 5 14 Page line 34 1, Page 6 lines to 35, page and 15, 14 Section “Contributors” 1 Page line 38 14 Page line 34. Section “Funding” 15 Page line 10, Section “Committees and organization trial” ofthe to Pages3 4 the protocol In 4 Page to line page 43 line 5 37 from 7 Page 4 (Section line TrialDesign) and page line 8 (Section 5 Randomization d and unpublished) unpublished) and d vities vities BMJ Open http://bmjopen.bmj.com/ and interpretation of data; writing of the report; and and report; the of writing data; of interpretation and on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only , parallel group, crossover, factorial, single group), allocation ratio, and framework (eg, (eg, framework and ratio, allocation group), single factorial, crossover, group, , parallel Trial Registration Data Set Set Data Registration Trial population, interventions, and, if applicable, trial acronym trial acronym if applicable, and, interventions, population, protocol contributors contributors protocol responsibilities of the coordinating centre, steering committee, endpoint adjudication committee, data management team, team, management data committee, adjudication endpoint committee, steering centre, coordinating of the responsibilities Page 23 of 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 and harms for each intervention for each harms and Descriptive title identifying the study design, design, study the identifying title Descriptive Trial identifier and registry name. If not yet registered, name of intended registry intended of name registered, yet If not name. registry and Trial identifier identifier version and Date support other and material, financial, of types and Sources of roles and affiliations, Names, sponsor trial the for information contact and Name analysis, management, collection, design; study in any, if funders, and sponsor of study Role acti these of any over authority ultimate have will they whether including for publication, report the submit to the decision and roles, Composition, committee) monitoring data for 21a Item (see if applicable trial, the overseeing groups or individuals other and (publishe studies relevant of summary including trial, the for undertaking justification and question research of Description comparators of for choice Explanation or hypotheses objectives Specific (eg trial of type including design trial of Description exploratory) noninferiority, equivalence, superiority, All items from the World Health Organization Organization Health World the from items All ecommended items to address in a clinical trial protocol and related documents* related and protocol trial a clinical in address to items ecommended BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from Page 24 of 25 Section Section 8 Page Page Randomizationand blinding Page 8 8 Page Section Randomizationand blinding Page 8 8 Page Section Randomizationand blinding Page 8 8 Page Section Randomizationand blinding Page 8 8 Page Section will be competititve) will Page 6 6 Page line (recruitment 5 line 15 line Page 12 Page line page34 to 13 6 to to 6 11page line 39 page 8 table 8 page 2, 10page line Page 7 7 Page to line line10 35, line 31 line Page 11 Page line page41 to 12 16 to 1716 Page 6 table 6 Page , 1 7 Page line Page 9, 9, Page line 5 Study Withdrawal Study Page 9, 9, Page SectionforCriteria line 39 line Pages 7 line Pages7 2 page to 11 line 5 5 line and Table in page 1 6 Pages 5 line Pages5 38 to 6 page eg, change change eg, ical assumptions assumptions ical ent that is unavailable unavailable is that ent ts), and how how ts), and ention during the trial the during ention ome. Explanation of the of the Explanation ome. will perform the interventions interventions the perform will opaque, sealed envelopes), describing any any describing envelopes), sealed opaque, BMJ Open http://bmjopen.bmj.com/ assign participants to interventions to interventions participants assign on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml any procedures for monitoring adherence (eg, drug tablet return, laboratory tests) tests) laboratory return, tablet drug (eg, adherence monitoring for procedures any -ins and washouts), assessments, and visits for participants. A schematic diagram is is diagram schematic A for participants. visits and assessments, washouts), and -ins For peer review only reduce To stratification. for factors any of list and numbers), random -generated interventions for a given trial participant (eg, drug dose change in response to harms, participant participant to harms, response in change dose drug (eg, participant trial given for a interventions Figure) Figure) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 generating the allocation sequence (eg, computer (eg, sequence allocation the generating , secondary, and other outcomes, including the specific measurement variable (eg, systolic blood pressure), analysis metric ( metric analysis pressure), blood systolic (eg, variable measurement specific the including outcomes, other and , secondary, study sites can be obtained be can sites study who individuals and centres for study criteria eligibility applicable, If participants. for criteria exclusion and Inclusion (eg, surgeons, psychotherapists) surgeons, (eg, Interventions for each group with sufficient detail to allow replication, including how and when they will be administered be will they when and how including replication, to allow detail sufficient with group for each Interventions Criteria for discontinuing or modifying allocated allocated modifying or discontinuing for Criteria request, or improving/worsening disease) improving/worsening or request, Strategies to improve adherence to intervention protocols, and and protocols, to intervention adherence improve to Strategies Relevant concomitant care and interventions that are permitted or prohibited during the trial the during prohibited or are permitted that interventions and care concomitant Relevant from baseline, final value, time to event), method of aggregation (eg, median, proportion), and time point for each outc each for point time and proportion), median, (eg, of aggregation method to event), time final value, from baseline, clinical relevance of chosen efficacy and harm outcomes is strongly recommended strongly is outcomes harm and efficacy of chosen relevance clinical Time schedule of enrolment, interventions (including any run any (including interventions enrolment, of schedule Time highly recommended (see (see recommended highly Estimated number of participants needed to achieve study objectives and how it was determined, including clinical and statist and clinical including determined, it was how and objectives study achieve to needed participants of number Estimated supporting any sample size calculations size sample any supporting Strategies for achieving adequate participant enrolment to reach target sample size sample target reach to enrolment participant adequate for achieving Strategies predictability of a random sequence, details of any planned restriction (eg, blocking) should be provided in a separate docum a separate in provided be should blocking) (eg, restriction planned any of details sequence, random of a predictability to those who enrol participants or assign interventions assign or participants enrol who those to Mechanism of implementing the allocation sequence (eg, central telephone; sequentially numbered, numbered, sequentially telephone; central (eg, sequence the allocation implementing of Mechanism steps to conceal the sequence until interventions are are assigned interventions until the sequence conceal to steps Who will generate the allocation sequence, who will enrol participants, and who will will who and participants, enrol will who sequence, allocation the generate will Who Who will be blinded after assignment to interventions (eg, trial participants, care providers, outcome assessors, data analys data assessors, outcome providers, care participants, trial (eg, to interventions assignment after blinded be will Who If blinded, circumstances under which unblinding is permissible, and procedure for revealing a participant’s allocated interv allocated participant’s a revealing for procedure and is permissible, unblinding which under circumstances If blinded, Methods: Assignment of interventions (for controlled trials) controlled (for interventions of Assignment Methods: BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from 13 Page line 42-43 13 Page line 4543 to 14 Page lineto 6 11 14 Page lines 11-12 13 Page line page45 to 14 3 line 14 Page line 34, Section Funding Page 14 Page line 1411 to Page 14 Page lines and 12 4 Page 13 Page line 18-19 and and organization trial ofthe Page 15 Page Section Committees not applicable not Page 12 Page line 3122 to Page 13 Page line 3917 to not applicable not Study Withdrawal Study Page 9, 9, Page SectionforCriteria Reference to Referenceto endent from the the from endent nd the sponsor sponsor the nd s plan can be found, if found, be can s plan ect confidentiality ect confidentiality plicable plicable unintended effects of trial trial of effects unintended BMJ Open http://bmjopen.bmj.com/ on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml luding who will have access to these interim results and make the final decision to final decision the make and results interim these to access have will who luding tion of study instruments (eg, questionnaires, laboratory tests) along with their with along tests) laboratory questionnaires, (eg, instruments study of tion For peer review only -up, including list of any outcome data to be collected for participants who discontinue or or discontinue who participants for collected be to data outcome any of list -up, including further details about its charter can be found, if not in the protocol. Alternatively, an an Alternatively, the protocol. in not if found, be can charter its about further details -adherence (eg, as randomised analysis), and any statistical methods to handle missing missing handle to methods statistical any and analysis), randomised as (eg, -adherence modifications (eg, changes to eligibility criteria, outcomes, analyses) to relevant parties (eg, (eg, parties relevant to analyses) criteria, outcomes, eligibility to changes (eg, modifications (eg, subgroup and adjusted analyses) analyses) adjusted and subgroup (eg, consent or assent from potential trial participants or authorised surrogates, and how (see Item 32) Item 32) (see how and surrogates, authorised or participants trial potential from assent or consent Page 25 of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 coding, security, and storage, including any related processes to promote data quality (eg, double data entry; range checks for checks range entry; data double (eg, quality data to promote processes related any including storage, and security, coding, participant retention and complete follow complete and retention participant ). Reference to where details of data management procedures can be found, if not in the protocol the in not found, if be can procedures management data of details to where ). Reference duplicate measurements, training of assessors) and a descrip and assessors) of training measurements, duplicate protocol the in if not found, be can forms collection data where to Reference known. if validity, and reliability deviate from intervention protocols from intervention deviate Plans for data entry, for data Plans Statistical methods for analysing primary and secondary outcomes. Reference to where other details of the statistical analysi the statistical of details other where to Reference outcomes. secondary and primary analysing for methods Statistical Methods for any additional analyses additional for any Methods Definition of analysis population relating to protocol non to protocol relating population analysis of Definition data (eg, multiple imputation) multiple (eg, data Composition of data monitoring committee (DMC); summary of its role and reporting structure; statement of whether it is indep is it whether of statement structure; reporting and role its of summary (DMC); committee monitoring data of Composition sponsor and competing interests; and reference to where where to reference and interests; competing and sponsor explanation of why a DMC is not needed not is a DMC of why explanation Description of any interim analyses and stopping guidelines, inc guidelines, stopping and analyses interim any of Description Plans for collecting, assessing, reporting, and managing solicited and spontaneously reported adverse events and other other and events adverse reported spontaneously and solicited managing and reporting, assessing, for collecting, Plans interventions or trial conduct trial or interventions Frequency and procedures for auditing trial conduct, if any, and whether the process will be independent from investigators a from investigators independent be will process the whether and if any, conduct, trial for auditing procedures and Frequency Plans for seeking research ethics committee/institutional review board (REC/IRB) approval (REC/IRB) board review committee/institutional ethics research for seeking Plans protocol important for communicating Plans regulators) journals, registries, trial participants, trial REC/IRBs, investigators, informed obtain will Who to prot order in maintained and shared, collected, be will participants enrolled and potential about information personal How trial the after and during, before, site study each and trial overall the for investigators for principal interests competing other and Financial Additional consent provisions for collection and use of participant data and biological specimens in ancillary studies, if ap if studies, ancillary in specimens biological and data participant of use and for collection provisions consent Additional BMJ Open: first published as 10.1136/bmjopen-2016-011287 on 5 August 2016. Downloaded from Page 26 of 25 Page 15 Page line31-32 applicable Not applicable not 11 Page lines to 3936 rent trial and for future future for and trial rent items. Amendments to the protocol should be tracked and dated. dated. and tracked be should protocol the to Amendments items. ” license. license. ” BMJ Open http://bmjopen.bmj.com/ on September 23, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml For peer review only Attribution-NonCommercial-NoDerivs 3.0 Unported Attribution-NonCommercial-NoDerivs or other data sharing arrangements), including any publication restrictions publication any including arrangements), sharing data other or full protocol, participant-level dataset, and statistical code code statistical and dataset, participant-level protocol, full eative Commons “ Commons eative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 under the the Cr under via publication, reporting in results databases, results in reporting publication, via the to access public granting for if any, Plans, surrogates authorised and participants to given documentation related other form and consent Model cur the in analysis molecular or genetic for specimens biological of storage and evaluation, laboratory for collection, Plans applicable if studies, ancillary in use Authorship eligibility guidelines and any intended use of professional writers professional of use intended any and guidelines eligibility Authorship that this checklist be read in conjunction with the SPIRIT 2013 Explanation & Elaboration for important clarification on the the on clarification for important Elaboration & Explanation 2013 the SPIRIT with conjunction in read be checklist this that