Study Protocol: Traditional Chinese Medicine (TCM) Syndrome Differentiation for Heart Failure patients and its Implication for Long-term Therapeutic Outcome of Qiliqiangxin Capsules


 BackgroundSyndrome differentiation is a commonly used methodology and practice in Traditional Chinese Medicine (TCM) guiding the diagnosis and treatment of diseases including heart failure (HF). However, previous clinical trials seldom consider the impact of syndrome patterns on the outcome evaluation of TCM formulae. Qiliqiangxin (QLQX) capsule is a TCM formula with cardiotonic effect to improve the cardiovascular function for heart failure with proven efficacy from well-designed clinical trials. Though, there is no clinical trial with a large sample size and long assessment period that considers the relationship between TCM syndrome differentiation and the treatment efficacy of QLQX. In the present study, we design a study protocol to evaluate the relationship between TCM syndrome differentiation and the severity of heart failure as well as its progression. Furthermore, we will evaluate the impact of the TCM syndrome patterns on the efficacy of QLQX in the outcome of heart failure. MethodsThis is a clinical study conducted in conjunction with an ongoing clinical trial (QUEST Study 1 ) to evaluate the efficacy of QLQX to improve the outcome of HF treatment through the assessment of morbidity and re-hospitalization, which involves over 100 hospitals in mainland China and Hong Kong SAR with 3,080 HF patients. Firstly, we will apply a modified TCM Questionnaire to collect the clinical manifestations of HF and acquire the tongue images of the patients to facilitate the syndrome differentiation. We will base on the “2014 Consensus from TCM experts on diagnosis and treatment of chronic heart failure” to evaluate the TCM syndromes for the patients. Secondly, we will investigate the characteristic of TCM syndrome distribution of HF patients and its correlation with the functional and biochemical data. Furthermore, we will evaluate the relationship between the TCM syndrome patterns and the efficacy of QLQX in the treatment of heart failure. Lastly, we will investigate the implication of tongue diagnosis in the severity and therapeutic outcome of HF. Expect OutcomesTo our knowledge, this will be the latest and well-designed clinical trial to evaluate the rules of TCM syndrome differentiation in the progression and therapeutic outcome of HF patients. We expect to obtain direct clinical evidence to verify the importance of TCM syndrome differentiation for the diagnosis and treatment of HF.Trial Registration1The trial was registered at Chinese Clinical Trial Registry, http://www.chictr.org.cn. (Registration No.: ChiCTR1900021929); Date: 2019-03-16.

However, previous clinical trials seldom consider the impact of syndrome patterns on the outcome 23 evaluation of TCM formulae. Qiliqiangxin (QLQX) capsule is a TCM formula with cardiotonic effect 24 to improve the cardiovascular function for heart failure with proven efficacy from well-designed 25 clinical trials. Though, there is no clinical trial with a large sample size and long assessment period 26 that considers the relationship between TCM syndrome differentiation and the treatment efficacy of 27 QLQX. In the present study, we design a study protocol to evaluate the relationship between TCM 28 syndrome differentiation and the severity of heart failure as well as its progression. Furthermore, we 29 will evaluate the impact of the TCM syndrome patterns on the efficacy of QLQX in the outcome of 30 heart failure. 31 Methods: This is a clinical study conducted in conjunction with an ongoing clinical trial (QUEST 32 Study 1 ) to evaluate the efficacy of QLQX to improve the outcome of HF treatment through the 33 assessment of morbidity and re-hospitalization, which involves over 100 hospitals in mainland China 34 and Hong Kong SAR with 3,080 HF patients. Firstly, we will apply a modified TCM Questionnaire to 35 collect the clinical manifestations of HF and acquire the tongue images of the patients to facilitate the 36 syndrome differentiation. We will base on the "2014 Consensus from TCM experts on diagnosis and 37 treatment of chronic heart failure" to evaluate the TCM syndromes for the patients. Secondly, we will 38 investigate the characteristic of TCM syndrome distribution of HF patients and its correlation with the 39 functional and biochemical data. Furthermore, we will evaluate the relationship between the TCM 40 syndrome patterns and the efficacy of QLQX in the treatment of heart failure. Lastly, we will 41 investigate the implication of tongue diagnosis in the severity and therapeutic outcome of HF. 42 Expect Outcomes: To our knowledge, this will be the latest and well-designed clinical trial to evaluate 43 the rules of TCM syndrome differentiation in the progression and therapeutic outcome of HF patients. 44 TCM syndrome differentiation on the disease progress of HF and the therapeutic outcome of QLQX. 123 The study is coached by three specific objectives to answer the following questions: 1) Whether TCM 124 syndromes are associated with the severity of heart failure; 2) Whether different TCM syndrome 125 patterns have different therapeutic outcomes in QLQX treatment for heart failure; and 3) Whether 126 TCM tongue diagnostic characteristics could be an effective index for the severity of heart failure and 127 the indication of the progression as well as the therapeutic outcomes. 128 129 Methods/Design 130

Patient Recruitment and Selection Criteria 131
Our study is conducted in conjunction with a multicenter, randomized, double-blind, placebo-132 controlled, parallel-group, event-driven clinical study named the QUEST on chronic heart failure 133 patients. This study is carried out in approximately 100 centers located in China and Hong Kong SAR. 134 These centers are eligible hospitals or affiliated hospitals of the medical universities. The target number 135 of patient recruitments will be 3,080, which is calculated according to the PARADIGM-HF study 136 based on the cardiovascular death or hospitalization rate for heart failure (36). This is an event-driven 137 study and all the recruited patients will remain in the study (whether taking the study drug or not) until 138 the number of the primary endpoint events reaches the predicted target of 620 cases, or the study meets 139 1)Provision of signed informed consent prior to any study specific procedures; 2)Male or female, aged ≥18 years at the time of consent; 3)Established documented diagnosis of heart failure for at least three months ago according to "Chinese Heart Failure Diagnosis and Treatment Guideline" issued by the Chinese Medical Association Cardiovascular Branch. 4)Left ventricular ejection fraction (LVEF) ≤40% (echocardiogram, radionuclide, ventriculogram, contrast angiography or cardiac MRI ); 5)NYHA cardiac functional grading II to III, with stable clinical symptoms; including those diagnosed as grade IV within 2 weeks before enrollment; 6)Serum NT-proBNP ≥ 450pg/ml; 7)Those who have received standardized baseline treatment regimens without doses adjusted and given intravenously for at least two weeks prior to enrollment; standardized drug treatment includes: angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) or angiotensin receptor neprilysin inhibitor (ARNI), beta blocker, and aldosterone receptor antagonist (the optimal therapeutic dose should be achieved, except for contraindications or intolerance);

Exclusion criteria:
Patients should not enter the study if any of the following exclusion criteria are fulfilled 1)Heart failure caused by valvular disease, congenital heart disease, pericardial disease, arrhythmia or non-cardiogenic disease, or caused by vital organ failure (such as renal, hepatic failure, etc.); and right heart failure caused by pulmonary or other definite causes; and acute heart failure; 2)Coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) or cardiac synchronization therapy planned to undergo after randomization, or had received cardiac resynchronization therapy prior to enrolment; 3)Any condition outside the CV diseases such as but not limited to malignant tumor, severe mental illness, hematopoietic diseases, neuroendocrine system disease, liver transaminase and alkaline phosphatase ≥ 3 x upper limit of normal (ULN), abnormal renal function serum creatinine > 2 mg/dl (176.82 umol/L), potassium >5.5mmol/L; 4)Patient with left ventricular outflow tract obstruction, myocarditis, aortic aneurysm, aortic dissection, or obvious hemodynamic changes caused by unrepaired valve; 5)Cardiogenic shock, uncontrollable malignant arrhythmia, sinus or atrioventricular block at second degree type II or above without pacemaker treatment, progressive unstable angina pectoris or acute myocardial infarction; 6)Uncontrolled hypertension systolic blood pressure (SBP) ≥ 180mmHg and/or diastolic blood pressure (DBP) ≥ 110mmHg; or SBP < 90mmHg and/or DBP <60mmHg; 7)Participation in another clinical study with an IP during the last month prior to enrolment; 8)Women of child-bearing potential (i.e., those who are not chemically or surgically sterilized or who are not post-menopausal) who are not willing to use a medically accepted method of contraception that is considered reliable in the judgment of the investigator, from the time of signing the informed consent throughout the study and 4 weeks thereafter, OR women who have a positive pregnancy test at enrolment or randomization OR women who are breast-feeding; 9)Allergic constitution; known to be allergic to research drug; 10) Inability of the patient, in the opinion of the investigator, to understand and/or comply with study medications, procedures or any conditions may render the patient unable to complete the study.

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Before the recruitment, patients must be "clinically stable" by receiving at least two weeks of 150 standardized medication treatment according to the local treatment guideline for heart failure with 151 fixed drug type and dosage, as well as have not taken any intravenous anti-HF drug nor oral TCM 152 medication with similar composition as the QLQX capsules. Once the patients are clinically stable, 153 they will be assigned to the QLQX group or the control group in a ratio of 1-to-1 through the double-154 blind computerized randomize allocation. The patient will be given either QLQX capsules or placebo 155 capsules during the assessment period in addition to their standard treatment for heart failure following 156 the guidelines for diagnosis and treatment of HF in China 2018 (25) or local guideline. The QLQX 157 capsules and placebo are identical in size and shape. The dosage used in this study is 4 capsules of 158 QLQX or placebo 3 times daily. During the assessment period, patients should not take any TCM or 159 herbs which have similar contents to the QLQX capsule. 160

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The entire study will last for approximately 36 months with the first 24 months as the recruitment 162 period. The study will be terminated once the last patient has finished the 12-months assessment. Once 163 recruited, the patient is required to visit the hospitals for efficacy and safety assessment according to 164 the study schedule. All patients are required to sign the Informed Consent Form before the recruitment. 165 For each visit, the patient will be assessed by the researchers/physician. A range of clinical information 166 and parameters will be collected and tests will be performed for the assessment of TCM syndrome, the 167 treatment efficacy, and safety including laboratory and ECG results, etc. The assessment of safety of 168 this study will base on the reporting of the adverse events, SAEs, and laboratory abnormalities, which 169 are closely monitored by the Data Safety Monitoring Committee (DSMC). Two interim efficacy 170 analyses will be conducted when 1/2 and 2/3 primary endpoint events (i.e. around 310 and 414 patients 171 respectively) are gathered. Patients are allowed to withdraw from the study for any reason but the 172 reason is required to be recorded in the case report form. If the patient has an intolerable adverse event 173 that is related to the study drug based on the researcher's judgment, the patient should immediately 174 discontinue the treatment with the study drug. The study flowchart is shown in Fig. 1.  All enrolled patients are required to complete this questionnaire in a total of 6 specific study visits to 211 the hospitals (i.e. Visit 1 at (Day 0), Visit 2(1M), Visit 3(3M), Visit 6(12M), Visit 10(24M) and Visit 212 14(36M)/EOS). The visit schedule and list of parameters are shown in Table 2. For each scheduled 213 visit, the physician/researcher will conduct a face-to-face interview with the patient to go through this 214 survey questionnaire. The entire interview process will last for approximately 8 to 10 minutes. The 215 data collected will be first recorded manually in the paper SDQHF and then input into the Epidata 216 software(43) which is the centralized database for the collection of research data from the QUEST 217 study. 218 219 According to the "2014 Consensus from TCM experts on diagnosis and treatment of chronic heart 230 failure" (17), there are 3 major types of TCM syndrome for heart failure: 1) qi-deficiency with blood 231 stasis syndrome; 2) qi-yin deficiency with blood stasis syndrome; 3) yang-qi deficiency with blood 232 stasis syndrome, and each can be associated with the phlegm-retention syndrome. These syndromes 233 are comprised of a combination of 2-4 syndrome elements including 1) qi-deficiency; 2) yin-deficiency, 234 3) yang-deficiency; 4) blood stasis and 5) phlegm-retention. The list of clinical manifestations 235 including signs and symptoms, pulse, and tongue features of the 3 TCM syndrome types are shown in 236 Our primary objective is to explore the implication of TCM syndrome to the severity of heart failure 254 and the therapeutic outcome of QLQX capsules. We hypothesize that the efficacy of QLQX Capsule 255 on heart failure could be related to the clinical syndrome patterns in TCM diagnosis and likely be 256 favorable to the patients with qi-deficiency with blood stasis and yang-qi deficiency with blood stasis. 257

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The efficacy of QLQX capsule will be evaluated with reference to the "2012 Guiding Principles for 259 Clinical Study on New Drug for Use in Traditional Chinese Medicine". We will evaluate the 260 correlation between TCM syndrome patterns and the severity of heart failure the re-hospitalization 261 rates and mortality. The distribution of TCM syndrome will also be evaluated by NYHA classification, 262 results from an electrocardiogram (ECG), cardiac ultrasound interpretation, and biochemical 263 parameters from routine blood tesst such as NT-proBNP, urine test, etc. Other outcomes include: 1) 264 the distribution of TCM syndrome patterns in heart failure patients; 2) the correlation between TCM 265 syndrome patterns and the severity of heart failure and 3) the dynamic changes between biomedical 266 parameters and the TCM syndrome patterns of heart failure, etc. is determined as not in good quality for drawing the conclusion after reviewed by the separate TCM 292 practitioner and professor, that tongue image will be excluded from the study. 293 Outcomes of the tongue analysis include 1) determination of the TCM syndrome differentiation of 294 patients throughout the assessment period with the clinical information collected through the SDQHF; 295 2) tongue features in heart failure patients in accordance to the TCM syndrome, NYHA classification, 296 and other biomedical data; 3) dynamic patterns of tongue condition in relation to the treatment efficacy 297 and other biomedical indicators 298

Data Management 299
The patient's demographic data and all clinical data will be recorded and kept in the physical medical 300 record folder during each study visit. The data will then be input into the Epidata software for 301 centralization of all research data and all the tongue images will be kept in a separate centralized image 302 database. The data management process will be complied with the regulatory requirements of Clinical 303

Trial Quality Management Regulations and Clinical Trial Data Management Work Technical 304
Guidelines to ensure the authenticity, integrality, accuracy, and traceability of data. 305 306

Sample size estimations 307
This study is benchmarked with the QUEST study in which 3080 patients will be enrolled in over 100 308 centers (1540 patients per group) and followed up for at least 12 months. The sample size was 309 estimated referring to the PARADIGM-HF study (44). For QUEST study, the estimated incidence of 310 cardiovascular death and hospitalization for heart failure is 25% in all patients receiving basic 311 treatment + placebo group within 36 months of follow-up and 20% with those receiving basic 312 treatment + QLQX Capsule group. The random distribution ratio is 1:1 between the study group and 313 the control group. With the consumption of type I error in the interim analysis, α is adjusted to 314 unilateral 0.02314. The sample size is the number of cases with composite endpoints events. Thus, 620 315 composite endpoint events are expected for the QUEST study to provide 80% power of test (β = 0.2), 316 and the 20% risk can be reduced in the study group by the log-rank test. 317 For the current study, a pilot test with at least 342 patients will be conducted to evaluate the 318 acceptability, reliability, and validity of the questionnaire. The number of patients for pilot testing is 319 calculated based on the confidence level of 95%, population size of 3,080, and 5% margin of error 320 for this 36-item questionnaire. 321 322

Data analysis and statistic methodology 323
Analysis of the TCM Questionnaire will be performed with the SPSS statistical software package, 324 version SPSS 24.0 (Chicago, IL,USA). Data will be presented by Mean±S.D. Principal Component 325 Analysis (PCA) will be applied to the questionnaire to examine the factor structure. Logistic regression 326 analysis will be used to evaluate the capability of SDQHF to diagnose the severity of HF from a 327 functional perspective. Pearson's correlation coefficient will be used to determine the existence of 328 correlations between TCM syndrome differentiation and various parameters such as treatment efficacy, 329 NT-proBNP, NYHA classification, etc. An independent t-test will be used to compare quantitative 330 variables for the two-group designed study. Fisher's Exact test and the chi-squared test will be applied 331 to compare categorical variables between groups. Multiple groups designed data will be analyzed by 332 two-way ANOVA. etc. To ensure the image quality, we have a constant quality check on all tongue photos so that feedback 365 for improvement could be provided to the researchers/physicians on a timely basis. Thus, the quality 366 of tongue images could meet our requirement for the analysis of tongue features and patterns of heart 367 failure. We will also put efforts into patient communication to ensure all patients have a thorough 368 understanding of the trial so that they can strictly follow through the requirement and attend all 369 scheduled visits. With the high standard and high-quality clinical trial, we expect to achieve following 370 outcomes: (1) To verify that QLQX could be an adjunct therapy with conventional treatment to reduce 371 the mortality and re-hospitalization with worsening heart failure in the QUEST study.

Competing interest 425
The design of the study, data collection, data analysis and interpretation are independent to the funding 426 body. 427 All executive committee members of QUEST study have received consulting fees as well as travel and 428 research support in the planning and conduct of the QUEST study. The authors declare that they have 429 no other conflict of interest to disclose.