01/01/2024
Dilated Cardiomyopathy Study Overview
1. Study Title:
Improving Survival Time of Doberman Pinschers with Stage III Dilated Cardiomyopathy by addition of Herbal Medicines Zhen Wu Tang and Compound Dan Shen
2. Principal Investigators (PI):
Name and position/title: Gregory Todd DVM, Assistant Professor
Institution: Chi University, Reddick, FL
Email address: [email protected]
Mailing address: 1355 Pinehurst Road, Dunedin, FL 34698
Co-investigators
Meg Sleeper, VMD, DACVIM (cardiology), Clinical Professor (Cardiology), University of Florida, Gainesville, Florida Email: [email protected]
Deng-Shan Shiau, PhD (Statistics), Associate Professor, Chi Institute, Reddick, Florida; Email: [email protected]
Collaborators
Kelli Weaver, VMD, DACVIM, Internist
3. Agency or Institution Information
Institution name: Chi Institute of Traditional Chinese Veterinary Medicine
Mailing address: 9650 W Hwy 318 Reddick, FL 32686
4. Signatures:
Dated signature of principle investigator and appropriate Institutional official:
Gregory Todd DVM
II. Scientific Summary
Dilated cardiomyopathy (DCM) in Doberman Pinscher dogs (DP) is often fatal. It is an idiopathic and non-ischemic cardiomyopathy disease that is widespread in the population. It has been reported that the percentage of affected DPs over the age of 5 may be as high as 58.5%, and when diagnosed with stage III DCM, the patient would have a mean survival time of 6 months under the treatment of currently available pharmaceuticals. Given the high prevalence and its short survival time under the current treatment, a more effective treatment for this clinical condition is needed.
The overall goal of this project is to determine whether integrating two Chinese herbal medicines (CHMs), Zhen Wu Tang and Compound Dan Shen, into current treatments can improve survival time of DPs in stage III DCM. Studies in humans and other species suggested the potential of Zhen Wu Tang, which has been used to treat heart failure, and Compound Dan Shen, a patented herbal recipe, to mitigate metabolic changes related to diabetic cardiomyopathy and diseases. These findings, along with investigators’ clinical observations, let to the rationale for this investigation.
The study proposed herein will be a two-group randomized controlled trial, in which 40 DPs will be randomized into two treatment groups – 30 patients in the Test Group (conventional treatment + CHMs) and 10 patients in the Control Group (conventional treatment + placebo). These patients will be monitored until the end of this 18-month study for their survivals. Success of this study will provide a foundation to improve the treatments available for treating DPs affected with DCM.
III. Lay Abstract
Dilated cardiomyopathy (DCM) is a disease of the heart muscle which affects many dogs and dog breeds in the North America and Europe. In Doberman Pinscher Dogs (DP), more than 50% of breed may be susceptible to this disease. The disease can progress to create abnormal cardiac rhythms or lead to congestive heart failure (CHF). CHF is a condition where the heart fails in its ability to pump blood sufficiently, which leads to retention of fluids, especially in the chest, coughing, shortness of breath, elevated respiratory rates, arrhythmias and death. This is considered stage III of DCM. Once signs of congestive heart failure are present, these patients will usually survive only 6 months or less.
Presently, there are pharmaceutical drugs available to treat this disease, however, survival time in DP patients with stage III DCM remains to be poor.
Based on the published clinical studies in humans and clinical observations in PDs, this study seeks to scientifically evaluate the ability of two Chinese Herbal Medicines (CHM), Compound Dan Shen, and Zhen Wu Tang, to improve the survival times in DPs that have reached stage III of DCM with the expectation that dogs receiving the CHMs in addition to their regular pharmaceutical medications will survive longer.
IV. Continuation or Renewal Studies: N/A
V. Study Proposal:
A.1 Significance and Background
Dilated cardiomyopathy (DCM) is a common cause of congestive heart failure and sudden death in dogs, especially in Doberman Pinschers (DPs). It is reported that nearly 60% of DPs over five years old are affected by the disease.1 Dobermans with DCM may have a long period of subclinical disease during which there are no (or only slight) welfare problems. When the disease advances to stage III patients have a mean survival time of 6 months or less under the present pharmaceutical protocols.2 Only 8% of DP’s survive 6 months after the onset of congestive heart failure signs and only 3% survive to 1 year or more.2 Given its high prevalence in the DP population and the short survival time (when affected) under the current treatment, a more effective treatment strategy for this clinical condition is needed.
Standard pharmacological intervention focuses on modulating preload, afterload, and systolic function. This includes a variety of pharmaceutical combinations but generally includes pimobendan, angiotensin converting enzyme inhibitor (ACEI) such as enalapril or benazepril, diuretics, such as furosemide, and when indicated due to arrhythmias, beta blockers such as sotalol are commonly employed.3-4 A possible reason that these pharmaceutical therapies have not been satisfactorily effective could be because the present treatments have little effect on the addressing inflammatory signaling and increasing the resistance of the tissue to oxidative injuries. These limitations have been well documented in similar diseases in humans.
Recent research conducted by Taggart et al. showed that a mutation in pyruvate kinase dehydrogenase 4 (PKD4) is highly associated with the development of DCM in DPs.5 This may prevent cardiomyocytes from changing to oxidative phosphorylation (OP) from glycolysis during low nutrient availability and thus predispose the cell to mitochondrial induced apoptosis. The switching between glycolysis and OP in the heart is common in all cardiomyopathies and plays a role in resulting structural changes seen with the disease.
Several studies have examined the potential of Chinese herbal medicines (CHMs) to decrease these changes in human cardiomyopathies, especially diabetic DCM.6,8-12 A review article by Tian et al. reported that certain CHMs can actively block the pro-inflammatory signaling (NF-kB) resulting in decreased inflammation as well as potentiate the action of Nrf2, which increases the cells’ own protective machinery against oxidative injury.6 Both of these could lead to decreased myocardial injury. The article identified the mechanism of action of chemicals isolated in some CHMs. One examined specifically was Dan Shen (Salvia miltiorrhiza), demonstrated to attenuate myocardial fibrosis in STZ-induced diabetic rats. Another herb examined was Atractylodes (Bai Zhu), one of the herbs included in the herbal formula Zhen Wu Tang. Previous analysis of this formula reveals that one of its active compounds is sesquiterpene lactones,7 which has potent anti-inflammatory actions.8-9 Another component of the examined formula Dan Shen is Tian San Qi or Notoginseng. This herbal has been shown to have a cardioprotective effect through mechanisms including limiting ROS generation and increasing Nrf2 mediated anti-oxidant enzymes.10
A.2 Objectives and Hypothesis
The overall objective of this clinical research project is to improve outcomes for DPs with stage III DCM, which has a short survival time (~ 6 months) under the current pharmaceutical treatments. The specific aim of this study is to determine whether integrating two herbal formulas, Zhen Wu Tang and Compound Dan Shen, into current protocols for treating stage III DCM in DPs can potentially improve the clinical outcome for the patients.
The hypothesis of this study is that DPs diagnosed with stage III DCM treated with the integrated treatment that combines conventional pharmaceuticals with herbal medicine Zhen Wu Tang and Compound Dan Shen will have a longer survival time than those receiving only conventional pharmaceuticals.
A.3 Preliminary Data - Clinical Experience/Cases
The Principal Investigator (Dr. Todd) has had clinical experiences with several client-owned dogs with DCM in breeds not limited to DPs. While other dog breeds responded well to the proposed treatment, DPs presenting with signs of CHF required a different approach. This herbal approach may provide greater protection from ischemia and increase NrF2 which has been indicated to provide more energy to the myocardium. The herbals which have the Chinese Medicine designation of moving stagnant Blood, such as Salvia, may be one part of the improved response. This treatment strategy has had clinical success.
A.4 Experimental Methods and Design:
1) Subject Recruitment - The subjects will be DP patients of any age and either s*x admitted at the collaborative clinics for treatment of DCM with the following criteria:
• Inclusion criteria: (1) diagnosed with stage III DCM, characterized by morphological and electrical abnormalities with symptoms of congestive heart failure (CHF)within the last 2 weeks; and (2) owners must agree to complete a quality of life questionnaire.
• Exclusion criteria: (1) with concomitant congenital heart disease or primary mitral valve disease be excluded, and (2) with co-existing diseases having a prognosis of 6 months.
2) Treatment Groups - Each qualified subject will be randomly assigned to either the Control or the Test treatment group. Randomization will be accomplished by drawing tokens from a container filled with tokens of “C” and tokens of “T”, with the token numbers based on the planned sample size (see Sample Size section).
Each subject will be treated with conventional pharmaceuticals as dictated by their attending clinician. Subjects in the Test group will also receive two herbal formulas, Zhen Wu Tang and Compound Dan Shen, whereas those in the Control group will receive placebo. Both herbal medications and placebo will be administered orally at 0.5g/10 lbs. (or 1.1g/kg) of body weight twice daily. All subjects in both groups will continue to receive or add any pharmaceuticals deemed appropriate by the clinician in charge of their care. These include but are not limited to pimobendan, any ACEI, beta blockers, and furosemide.
3) Outcome Measurements
The primary end point from each subject will be the survival time from the start of the treatment, which is expected to be soon after the diagnosis of stage III DCM. Survival times in subjects surviving over the end of study will be considered censored data, although the survival of these subjects will remain to be monitored for follow-up reports.
The owner of each subject will complete a previously validated quality of life (QoL) questionnaire.13 Secondary outcome measurements include QoL and frequency of cardiac arrhythmias (FoCA), which will be defined as the number of detected cardiac arrhythmias (by Holter monitor) per 24 hours. QoL and FoCA data will be collected at baseline and then every 3 months during the study.
4) Statistical Hypothesis and Inference
The first statistical hypothesis is to compare survival curves between the two treatment groups: H0: Two survival curves are the same vs. HA: Two survival curves are different. To test the above hypothesis, the Kaplan-Meier Log-Rank test, a commonly used statistical test in survival analysis, will be applied. The test will be two-sided, and the null hypothesis will be rejected if the resulting p-value 0.05.
The 2nd and the 3rd hypotheses are to compare mean improvements in QoL and FoCA, respectively: H0: The mean improvements are the same vs. HA: The mean improvements are different. These hypotheses will be tested for each 3 months, for which the improvement will be calculated with respect to measurements at the baseline. As these improvements will be numerical outcomes, two-sample t test or Wilcoxon Rank Sum test will be employed for statistical inference, depending on the outcome of the normality test on the data.
5) Sample size
The investigators proposed a sample size of 30 subjects in the Test group and 10 in the Control group. Having this unbalanced group size design enhances the feasibility of the project (reducing cost for placebo medicine) and could still offer an acceptable study power. Assuming that the 12-month survival rate in the Control group is 3% and is 25% in the Test group, such a sample size can offer a 78% power to reject the null hypothesis with a significance level of 0.05.
For the tests on QoL and FoCA improvements, respectively, the power depends on the survival rate at each 3-month assessment time point. Assuming 80% survived at month 3, the test should have 69% power to reject H0 with a 0.05 significance level if the true group difference is at least as large as the pooled standard deviation.
6) Potential Pitfalls and Alternative Approaches
If the number of subjects qualified for the study at any of the collaborative clinical sites is lower than expected, the PI will contact additional clinical sites to increase subject enrollments. If subjects enrolled in the study succumb to unrelated diseases, or subjects must be withdrawn from the study due to non-compliance; other subjects will be recruited.
If a subject develops any adverse gastrointestinal signs during the study, the CHMs will be stopped for up to 3 days and resumed on a gradually increasing dosing scale starting with ½ the prescribed dose PO SID and reaching the full prescribed dose by 7 days.
VI. Timeline
Task 1: Subjects will be recruited from multiple centers. Given the strict criteria for enrollment, additional centers may be recruited.
Task 2: Monitoring of subjects will provide additional parameters which can provide secondary data and outcomes. These include but are not limited to QoL, frequency of arrhythmias, degree of tachycardia.
Task 3-6: These represent statistical analysis of all outcomes performed each 3 months of the study.
Task 7: Final statistical analysis on survival times will be concluded.
Justification:
• Personnel
Dr. Gregory Todd, DVM, CVA, FACVBM – Dr. Todd is a licensed veterinarian with extensive training in Traditional Chinese Veterinary Medicine (TCVM). He is currently an Assistant Professor at Chi University, Reddick, FL and also serves as a staff veterinarian at the Animal Hospital of Dunedin. For this project, Dr. Todd will have the overall responsibility for conducting the proposed clinical study. He will direct and oversee the subject recruitment/enrollment, treatment, and data collection processes as proposed. He will ensure that the study proceeds in a direction that will guarantee the scientific and statistical merits, and will lead the interpretation of results and in generating scientific and technical reports resulting from the research.
Dr. Meg Sleeper, VMD, DACVIM - Dr. Sleep is a board-certified Veterinary Cardiologist. She currently holds the position of Clinical Professor in the Department of Small Animal Clinical Sciences at the University of Florida, College of Veterinary Medicine. For this project, Dr. Sleepers will lead the effort at the UF site, including recruitment/enrollment, diagnosis, and (standard/conventional) treatment procedures. She will also participate in the interpretation of results and in generating scientific and technical reports resulting from the research.
Dr. Deng-Shan Shiau, PhD - Dr. Shiau is a biostatistician with over 20 years of experience in clinical research. He has led the efforts in experimental design and statistical analysis on several NIH-funded projects, serving as Principal Investigator or Co-investigator. He is currently a faulty member of the Master program of TCVM at the Chi Institute supervising and mentoring students on their clinical research projects. For this project, Dr. Shiau will work closely with Dr. Todd on implementing the study design and data collection as proposed, and will have the overall responsibility for the statistical data analysis. He will also participate in generating scientific and technical reports resulting from the research.
• Supplies & Equipment
Herbal medicines and Placebo - The investigators received support from the American Holistic Veterinary Medical Foundation in the covering expense of the proposed herbal medicines to be included in the treatment plan for Test group. The fund requested is calculated based on the cost of the medicine in 30 test subjects for 180 days (6-month treatment based on present estimated survival times).
The cost of additional expenses will be added by institutional support from the Chi Institute of Traditional Chinese Veterinary Medicine.
VII. Animal Involvement Justification
All animals in this study in both the Control and Test groups will be client owned. They will be housed with their owners unless hospitalized under the advice and supervision of a clinician to provide medical necessary for their health or quality of life. IACUC protocols (for AHD/Chi Institute and for UF) have been approved.
Routine monitoring of the described parameters such as echocardiograms, chemistry, CBC, etc. are procedures already established as standard care for this disease. Patients in this study will be subject to blood draws, ECG/ Holter monitors and restrained for echocardiograms. This falls into USDA Category C This study only adds the addition of oral herbal medicine capsules twice daily to the pet’s existing protocol. Humane animal restraint will be required for blood draws, applying EKG leads or Holter monitoring equipment and performing echocardiograms. None of these procedures are likely to require sedation or involve pain greater than that described in USDA category C. The oral medication will be administered by owners and may be given in food or treats.
All animals in the study will remain housed with owners and receive continued veterinary care by their family veterinarians and cardiologists. There are no restrictions on enrichment, socialization or exercise unless deemed medically necessary due to congestive heart failure or the nature of their disease.
A total of 40 Doberman Pinschers will be included in this study. The numerical justification of animals proposed is based on the feasibility, statistical inference methods, the desired statistical considerations (power and significance level), and assumptions on outcome parameters. With the Log-rank test for comparison of the survival curves, assuming that the 12-month survival rate in the Control group is 3% and is 25% in the Test group, the proposed sample size can offer an 78% power to reject the null hypothesis with a significance level of 0.05.
For the tests on QoL and FoCA improvements, respectively, assuming a 80% survival rate after 3 months, with this sample size the statistical test should have approximately 69% power to reject the null hypothesis with a 0.05 significance level if the true group difference is at least as large as the pooled standard deviation.
All medications or foods may include unwanted side effects. The two patent formula Chinese Herbal Medicines included in this study are widely used and considered safe. The most likely unwanted side effect would be limited to loose stool or gastric upset which would end with withdrawal of the Chinese Herbal Medication. The herbal medication will be withdrawn and reinstituted at a lower dose. If the patient continues to have any unwanted affects the medication will be terminated.
While substantial information exists on the effectiveness of these herbal formulas in other species and conditions, no controlled, prospective studies have been published to document their effectiveness in Doberman Pinschers with dilated cardiomyopathy. This proposal constitutes a humane, safe and statistically sound approach to documenting the effectiveness of this treatment with far reaching potential benefit to this breed.
There is little to no risk to subjects and the potential to benefit the lives of more than 50% of the breed.
VIII. References
1. Wess, G. Schulze, A., Butz, V., Simak, J., Killich, M., Keller, L.J.M., Maeurer, J., Hartman, K. Prevalence of Dilated Cardiomyopathy in Doberman Pinschers in Various Age Groups. Journal of Veterinary Internal Medicine 24: 533-538, 2010.
2. Calvert, C., Pickus, C. Jacobs, G., Brown, J. Signalment, Survival, and Prognostic Factors in Doberman Pinschers With End-Stage Cardiomyopathy. Journal of Veterinary Internal Medicine 11(6): 323-326, 1997.
3. The COVE Study Group. Controlled clinical evaluation of enalapril in dogs with heart failure: Results of the Cooperative Veterinary Enalapril Study Group. J Vet Int Med 9: 243-252, 1995.
4. O’Grady M., Minors S. O’Sullivan M. and Horne, R. Effect of Pimobendan on Case Fatality Rate in Doberman Pinschers with congestive heart Failure Caused by Dilated Cardiomyopathy. J Vet Int Med 22: 897-904, 2008.
5. Taggert, K., Estrada, A., Thoompson, P., Lourenco, F., Kirmani, S., Silveli s., Pacak, C. PDK4 Deficiency Induces Intrinsic Apoptosis in Response to Starvation in Fibroblasts from Doberman Pinschers with Dilated Cardiomyopathy. Biores Open Access. 6(1): 182-191, 2017.
6. Tian, J., Zhao, Y., Liu, Y., Liu, Y., Chen, K., and Shuzheng L. Roles and Mechanisms of Herbal Medicine for Diabetic Cardiomyopathy: Current Status and Perspective. Oxidative Medicine and Cellular Longeity. 8214541, 2017.
7. Dharmananda, S. Atractylodes: Baizhu and Cangzhu. http://www.itmonline.org/arts/atract.htm
8. Hall, I., Starnes, C., Lee, K., Waddell, T. Mode of action of sesquiterpene lactones as anti-inflammatory agents. Journal of Pharmaceutical Sciences. 69(5): 537-543, 1980.
9. Rungleler, P., Castro, V., Nezhun, G., Vichnewski, W., Heike, P., Mefort, I., Schmidt, T. Inhibition of transcription factor NF-kB by sespuiterpene lactones: a proposed molecular mechanism of action. Bioorganic & Medicinal Chemistry 7(11): 2343-2352, 1999.
10. Zhang, B., Zhang, J., Zhang, C., Zhang, X., Ye, J., Kuang, S., Sun, G., Sun, X. Notoginsenoside R1 Protects Against Diabetic Cardiomyopathy Through Activating Estrogen Receptor Alpha and Its Downstream Signaling. Frontiers in Pharmacology 9:1227, 2018.
11. McCulloch, M., Broffman, M., Gao, J., Colford, J. Chinese Herbal Medicine and Interferon in the Treatment of Chronic Hepatitis B: A Meta-Analysis of Randomized, Controlled Trials. American Journal of Public Health; Oct 2002; 92, 10; Proquest Central pg. 1619.
12. Han, J. Fan, J. Horie, Y. Miura, S. Cui, D., Ishii, H., Hibi, T., Tsuneki, H., Kimura, I. Ameliorating effects of compounds derived from Salvia miltiorrhiza root extract on microcirculatory disturbance and target organ injury by ischemia and reperfusion. Pharmacology & Therapeutics 11(7): 280-295, 2008.
13. Freeman LM, Rush, JE, Farabugh AE. Development and evaluation of a questionnaire for assessing health-related quality of life in dogs with cardiac disease. JAVMA 225: 1864-1868, 2005.
IX. Curriculum Vitae
Name Gregory Todd
Position/Role Principal Investigator
Current Position Assistant Professor, Chi Univeristy, Reddick, Florida
Education/Training • DVM Univeristy of Florida, Gainesville, FL, 1988.
• BS (Microbiology) University of Florida, Gainesville, FL, 1983,
Previous Positions and Honors • 2023: Outstanding Achievement Award World Association of Traditional Chinese Veterinary Medicine (WATCVM)
• 2018- present: Partner, Medical Director, The Animal Hospital of Dunedin, Dunedin, FL
• 1988- 2018: CEO, Medical Director, The Animal Hospital of Dunedin, Dunedin, FL
• 2018-present: American Association of Traditional Chinese Veterinary Medicine President
• 2018: Outstanding Achievement Award World Association of Traditional Chinese Veterinary Medicine (WATCVM)
• Board Member, Executive Council Member, Inter-committee Liaison, WATCVM
• 2018-present: Member of the WATCVM Research Committee
• 2015: Pet Plan Veterinarian of the Year Finalist
• 2012: Recipient of the Ma Shi Huang Award (TCVM) Practitioner of the Year
• 2012: Excellent Speaker Award for the 3rd Chinese Veterinary Conference (CVC) of the Chinese Veterinary Medical Association (ChVMA), Oct 28-30, Su Zhou, China
• 2003: Recipient of the “Colonel Edward T. Imparato” Award, in Celebration of the Human-Animal Bond.
• 2004-present: Instructor for the International Veterinary Acupuncture Society
Selected Peer-Reviewed Publications
1. Todd, Gregory. The Diagnosis and Treatment of Four TCVM Patterns Related to Pancreatitis. American Journal of Traditional Chinese Veterinary Medicine, 5(1), 79-87.
2. Todd, Gregory. Gastrointestinal, Pancreatic, and Hepatobilliary Disorders. Ed. Xie, H. Ed. Wedemeyer, L. Ed. Chrisman, C. Ed. Trevisanello, L. Reddick, FL: Chi Institute
