Online Exhibit A

CLINICAL PROTOCOL

Title: Treatment with Ranolazine in Microvascular Coronary Dysfunction (MCD): Impact on Angina and Myocardial Ischemia

Original Protocol Date: June 10, 2010Amendment 1 Date: April 2011 (Cedars-Sinai Site)Amendment 2 Date: June 2011 (Cedars-Sinai Site)

Amendment 3 Date: October 2011 (Cedars-Sinai Site and Univ. of Florida Site)Amendment 4 Date: November 2011 (Cedars-Sinai Site and Univ. of Florida Site)

Amendment 5 Date: March 2012 (Cedars-Sinai Site and Univ. of Florida Site)Amendment 6 Date: April 2012 (Cedars-Sinai Site and Univ. of Florida Site)

Amendment 7 Date: May 2012 (Cedars-Sinai Data Coordinating Center)Amendment 8 Date: December 2013 (Cedar-Sinai Site and Univ. of Florida Site)Amendment 9 Date: May 12, 2014 (Cedars-Sinai Site and Univ. of Florida Site)Amendment 10 Date: Feb 6, 2015 (Cedars-Sinai Site and Univ. of Florida Site)

Amendment 11 Date: June 3, 2015 (Cedars-Sinai Site)Amendment 12: August 24, 2015 (Cedars-Sinai Site and Univ. of Florida Site)

CONFIDENTIAL

Study Coordinating CenterCedars-Sinai Medical CenterC. Noel Bairey Merz, MD, Principal Investigator

Study Investigative Sites:

1. Cedars-Sinai Medical Center C. Noel Bairey Merz, MD, Principal InvestigatorChrisandra Shufelt, MD, Co-InvestigatorPuja K. Mehta, MD, Co-InvestigatorMargo Minissian, NP, Co-InvestigatorJanet Wei, MD, Co-Investigator

2. University of FloridaCarl J. Pepine, MD, Principal InvestigatorEileen Handberg, PhD, Co-Investigator

Data Coordinating Center:Cedars-Sinai Medical CenterAndre Rogatko, PhDGalen Cook-Wiens, MS

WISE Communication Coordinating CenterUniversity of Pittsburgh

Core Laboratories:Cedars-Sinai Medical Center Cardiac Magnetic Resonance Imaging Core LabLouise Thomson, MBChB, Co-InvestigatorDaniel Berman, MD, Co-InvestigatorMichael Nelson, PhD, Co-Investigator

University of Florida, Coronary Angiography and Coronary Physiology Core LabJohn Petersen, MD, Co-investigatorDavid Anderson, MD Co-investigator

Emory University Consulting Services:Leslee Shaw, PhD, Consultant

Research Support Grant provided by:Gilead Science Inc.Bruce Koch, PharmD, Medical Director

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Summary of Protocol Amendments/Revisions

1. April 2011:a. Revisions to Specific Aims:

1) Angina measured by the “angina stability” domain of the SAQ in 134 subjects with signs and symptoms of ischemia but no obstructive coronary artery disease (CAD); 2) A secondary outcome is angina measured by the “angina frequency” domain of the Seattle Angina Questionnaire (SAQ) in 134 subjects with signs and symptoms of ischemia but no obstructive CAD; 3) Determine the impact of 2 weeks of ranolazine 1,000 mg po bid compared to placebo on angina frequency measured by diary in 134 subjects with signs and symptoms of ischemia but no obstructive CAD

b. Revisions to Specific 2: angina frequency measured by diary in 134 subjects with signs and symptoms of ischemia but no obstructive CAD.

c. Revisions to duration of study drug impact: 2 weeks of ranolazine 1,000 mg po bid compared to placebo

d. Revisions to Study duration: December 2010 – November 2012e. Revisions to DCC: Cedars-Sinai Medical Center: Andre Rogatko, PhDf. Revisions to Table 2. Seattle Angina Questionnaire Scores on Ranolazine vs. Placebog. Revisions to inclusion and exclusion criteria: Re-formattedh. Revisions to Schedule of data collection: 6 weeks

2. June 2011: a. Add blood work to Week 2 Visit b. Add a new co-investigator to Cedars-Sinai site

3. October 2011: a. Revisions to MPRI cutoff for enrollment 1.8.

4. October 28, 2011:a. Added that a non-Women’s Ischemia Syndrome Evaluation (WISE) screening cardiac magnetic resonance imaging (CMRI) can qualify patients for RWISE if they were not previously part of WISE and otherwise qualify for RWISE. For the subjects who are/were not participants in the WISE Coronary Vascular Dysfunction (CVD) study, either a screening CMRI will be performed in this study or a clinical scan performed within 1 year of study participation may be used as the screening CMRI in order to verify eligibility.b. Added as an inclusion criteria that patients must withdraw ranolazine at least 2 weeks prior to entry to qualify for the study.

5. March 2012:

Added a timeline (± month for qualifying CMRI) and a time eligibility of an angiogram.

6. April 2012:Extend coronary cath inclusion criteria to 2.5 years.Expand eligibility for subjects with an abnormal invasive coronary reactivity test defined as measured CFR <2.5 or ACH response of no dilation or constriction or coronary blood flow <50%, determined by local site read; Extend the CMRI eligibility to 2.5 years, provided no intercurrent event, and provided the most recent CMRI is used.

7. May 2012:Added details of statistical analysis plan as per Data Safety Monitoring Board (DSMB) request.

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8. December 2013: Added Fitbit Tracker (Cedars-Sinai Site only)

Increased CMRI myocardial perfusion reserve index (MPRI) eligibility to 2.0 (Cedars-Sinai Site and University of Florida Site)

9. May 2014:Updated inclusion criteria to include 1) measured noninvasively using Society of Cardiovascular Computed Tomography threshold of <50% stenosis, and 2) CMRI as one of the noninvasive methods for objective evidence of ischemia (Cedars-Sinai Site and University of Florida Site)

10. February 2015:Updated 2-week visit details to include a treatment window period (i.e. 2-weeks ± 5 days)Updated Specific Aim 1 to include newly validated and available SAQ-7 score as a co-primary outcome

11. June 2015:Updated Potential risks: Kidney failure risk in patients who have severe kidney problems

Risks related to Ranolazine withdrawal12. August 2015:

Clarified enrolled vs completed sample size; unified language for 3 co-primary, secondary, and other outcomes throughout the document; added the “angina frequency” domain based on new QWISE data; updated investigator list to reflect changes/additions to key personnel, transition of the DCC from University of Pittsburgh to Cedars-Sinai Medical Center, and the change of Gilead Medical Director from Dr. Checani to Dr. Koch; updated the time duration to the actual duration of the trial; unified language of inclusion criteria throughout the document; unified language for the Fitbit physical activity substudy throughout the document, extended the study to the U Florida site and added the study protocol (APPENDIX D); updated abstracts and manuscripts published during the trial that support amendments related to statistical power, analyses, CMRI MPRI inclusion thresholds and SAQ angina frequency outcome; updated the NT-pro BNP assay methods based on a new publication of relevance (MESA); revised the statistical power and analysis to reflect ongoing discussions among the study team regarding the most appropriate way to meet the objectives of the trial; all changes from the initial draft of the statistical methods have been made while the study team has been masked to the data (APPENDIX A); updated the data management system to reflect the transition to the Cedars-Sinai Medical Center Data Coordinating Center (DCC) from University of Pittsburgh DCC; added the reference lists.

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PROTOCOL SYNOPSIS

TITLE: Treatment with Ranolazine in Coronary Microvascular Dysfunction (CMD): Impact on Angina and Myocardial Ischemia

OBJECTIVES: In a randomized, placebo-controlled, cross-over trial of 134 women and men with microvascular coronary dysfunction the specific aims are:

Specific Aim 1.In a randomized, double-blinded, placebo-controlled, cross-over trial, to determine the impact of 2 weeks of ranolazine 500-1,000 mg po bid compared to placebo on: angina measured by the co-primary outcomes of 1a. “angina stability”, and 1b. “angina frequency” domains of the Seattle Angina Questionnaire (SAQ), 1c. SAQ-7 score in 134 subjects with signs and symptoms of ischemia but no obstructive coronary artery disease (CAD).

Specific Aim 2.In a randomized, double-blinded, placebo-controlled, cross-over trial, to determine the impact of 2 weeks of ranolazine 500-1,000 mg po bid compared to placebo on the secondary outcome of angina frequency measured by diary in 134 subjects with signs and symptoms of ischemia but no obstructive CAD.

Specific Aim 3.3a. In a randomized, double-blinded, placebo-controlled, cross-over trial of 2-weeks of ranolazine 500-1,000 mg po bid compared to placebo on the other outcomes of: a) cardiac magnetic resonance imaging (CMRI) perfusion and diastolic function; b) Quality of Life (SF-36, DASI) and healthcare costs; c) hemoglobin A1C (HbA1c), insulin resistance measured by the homeostasis model assessment (HOMA) and N terminal pro b-type natriuretic peptide (NT-proBNP) in 134 subjects with signs and symptoms of ischemia but no obstructive CAD.3b. To determine if improvement in the SAQ is positively related to improvement in CMRI myocardial perfusion reserve index (MPRI) in subjects with signs and symptoms of ischemia but no obstructive CAD.

Specific Aim 4.In a randomized, double-blinded, placebo-controlled, cross-over trial of 2-weeks of ranolazine 500-1,000 mg po bid compared to placebo in subset of subjects on the exploratory outcome of physical activity measured by Fitbit.

STUDY DESIGN: A randomized, double-blinded, placebo-controlled, cross-over trial

TREATMENT: Ranolazine

ANTICIPATED TOTAL NUMBER OF PATIENTS: 147 enrolled with projected 9-10% dropout for an anticipated completed 134 total women and men.

ANTICIPATED NUMBER OF PATIENTS AT EACH SITE: 67-74

ANTICIPATED START/COMPLETION DATES: December 2010 - October 2015

STUDY COUNTRY LOCATION: USA

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ABSTRACT Women with persistent signs and symptoms of myocardial ischemia are more likely to have no obstructive coronary artery disease (CAD) compared to obstructive CAD. We have described a high prevalence of limited coronary flow reserve (CFR) by direct left coronary artery Doppler catheter flow measurements and also limited subendocardial and mid wall perfusion reserve by cardiac magnetic resonance (CMRI) consistent with myocardial ischemia and coronary microvascular dysfunction (CMD) in these subjects. The NHLBI-sponsored WISE documented that such subjects are at increased risk of adverse outcomes similar to those with obstructive CAD. However, it is unknown if limited subendocardial perfusion leading to ischemia is a mechanistic pathway for the signs, symptoms, morbidity and mortality in these subjects with no obstructive CAD. A high proportion of these subjects are obese and many have other features suggesting pre-diabetes and/or insulin resistance. The novel anti-anginal medication ranolazine is known to prevent angina and ischemia and also improve insulin resistance among patients with obstructive CAD. Preliminary data suggest that ranolazine also improves angina and insulin resistance and may improve myocardial perfusion in subjects with CMD who have no obstructive CAD. These data support the hypothesis that ranolazine may impact an anti-ischemia mechanistic pathway and therefore reduce morbidity and mortality in patients with CMD without obstructive CAD.

The following application is a clinical trial of ranolazine in subjects with signs and symptoms of ischemia and no obstructive CAD but abnormal perfusion CMRI. We will conduct a randomized, double-blinded, placebo- controlled, cross-over trial of ranolazine 1,000 mg po bid for 2 weeks in 134 subjects with signs and symptoms of myocardial ischemia, no obstructive CAD, and abnormal CMRI. The Co-Primary Outcomes will be: 1a) “angina stability”, 1b) “angina frequency” measured by the Seattle Angina Questionnaire (SAQ) and 1c) SAQ-7; the Secondary Outcome will be: 2) Angina frequency measured by self-reported diary; and other outcomes will include: a) CMRI perfusion and left ventricular (LV) diastolic function; b) Quality of Life and Healthcare costs; c) Hemoglobin A1C (HbA1c), homeostasis model assessment (HOMA) and N terminal b-type natriuretic peptide (NT-proBNP). We will also determine if improved SAQ scores are positively related to improvement in myocardial perfusion measured by CMRI. A subset of subjects will have physical activity measured as an exploratory outcome by Fitbit.

The Core laboratories (CMRI, Angiography, and Coronary Flow Reserve [CFR]) will analyze qualitative and quantitative measures of: CMRI-myocardial perfusion and LV diastolic function, coronary angiograms, and CFR masked to all clinical information and treatment assignment. It is anticipated that this intermediate outcome clinical trial will provide the needed information for design and implementation of a large, definitive and practical outcome trial funded by NIH-NHLBI, or other federal agency to improve the morbidity and mortality of subjects with CMD who have no obstructive CAD.

Bairey Merz, C. Noel, M.D. Cedars-Sinai Medical Center Principal InvestigatorShufelt, Chrisandra, M.D. Cedars-Sinai Medical Center Co-InvestigatorMehta, Puja, M.D. Cedars-Sinai Medical Center Co-InvestigatorMargo Minissian, N.P. Cedars-Sinai Medical Center Co-InvestigatorPepine, Carl J, M.D. Univeristy of Florida, Gainesville Co-investigatorHandberg, Eileen Ph.D. University of Florida, Gainesville Co-investigatorPetersen, John, M.D. University of Florida, Gainesville Co-investigatorDavid Anderson, M.D. University of Florida, Gainesville Co-investigatorThomson, Louise, M.B.Ch.B. Cedars-Sinai Medical Center Co-InvestigatorNelson, Michael, Ph.D. Cedars-Sinai Medical Center Co-InvestigatorBerman, Daniel, M.D. Cedars-Sinai Medical Center Co-investigatorRogatko, Andre, Ph.D. Cedars-Sinai Medical Center Co-InvestigatorGalen Cook-Wiens, MS Cedars-Sinai Medical Center Co-InvestigatorShaw, Leslee, Ph.D. Emory University ConsultantBirkeland, Kade, M.D. Cedars-Sinai Medical Center Co-InvestigatorKhandwalla, Raj M, M.D. Cedars-Sinai Medical Center Co-InvestigatorKedan, Ilan, M.D. Cedars-Sinai Medical Center Co-Investigator

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Background

Coronary Microvascular Dysfunction (CMD) and Angina. New data support a role of CMD in subjects with signs and symptoms of ischemia but no obstructive coronary artery disease (CAD) that among women may play a more prominent role than obstructive CAD (Reis 2001, Johnson 2004). Data from the Women’s Ischemia Syndrome Evaluation (WISE) indicate that CMD may be the underlying factor responsible for signs and symptoms of effort intolerance (Olson 2003) for this large cohort of women with no obstructive CAD (Buchthal 2000, Johnson 2004, Pepine 2004).

Relation of CMD and Diastolic Dysfunction. Kaul and coworkers (Kaul 2008) have speculated that CMD may lead to repeated bouts of ischemia and contribute to left ventricular (LV) fibrosis resulting in LV diastolic dysfunction. Furthermore, ischemia is more prevalent in diastolic dysfunction due to the increased wall stress, resulting in the cycle of elevated LV end-diastolic pressure (LVEDP) that also further limits subendocardial perfusion.

Outcome Data in Patients with CMD. The WISE investigations suggest that CMD, defined as limited coronary flow reserve (CFR), predicts adverse outcomes in women presenting with signs/symptoms of angina/effort intolerance. Among 189 women who underwent coronary vascular reactivity testing, here were 79 index events in 5-years follow-up with a total 138 events. CFR (adenosine response) was a predictor of combined major and cardiovascular events respectively) (Table 1) (Pepine 2010). While coronary endothelial function (acetylcholine response) predicted more frequent hospitalization for angina recurrence (p=<0.0001) (von Mering 2004). These findings have been confirmed in a much larger study and also extended to men using CFR measured by positron emission tomography (PET)(Murthy 2011).

Cost of Care. The greater symptom burden, effort intolerance, and functional disability reported for women with no obstructive CAD is associated with a greater proportion of drug costs that resulted in higher indirect costs due to increased copayment expenses. Based upon WISE data, the societal economic burden for symptomatic care for women with angina/effort intolerance exceeds $162 billion dollars annually in the US, with an estimated half of this expenditure on women with no obstructive CAD and signs and symptoms of diastolic dysfunction (Shaw 2008).

Measurement of CMD and Subendocardial Ischemia. Stress cardiac magnetic resonance

imaging (CMRI) uniquely allows assessment of subendocardial perfusion. In an initial report of 19 symptomatic Page 6 of 40

Patient A

Patient B

Stress Perfusion Rest Perfusion

Table 1: Decreasing CFRlog and Adverse Outcomes Risk

Figure 1

women with abnormal stress tests and no obstructive CAD, subendocardial perfusion limitations consistent with ischemia were frequently observed. Data from our ongoing R01 HL090957-01A1 WISE Coronary Vascular Dysfunction, a study of 375 women with signs/symptoms of ischemia, with no obstructive CAD, to determine the relation between 1) Coronary Reactivity Testing, and 2) CMRI for noninvasive detection of CMD document the feasibility of the current application. Two cases in Figure 1 (above) illustrate CMRI subendocardial perfusion abnormalities (arrows) that are evident in myocardial segments with normal wall thickness and no evidence of scar in subjects with signs and symptoms of angina/effort intolerance, elevated LVEDP and abnormal CFR at coronary angiography.

Measurement of Diastolic Dysfunction using CMRI. Normal diastolic function allows adequate filling of the ventricles during rest and exercise without abnormal elevation of filling pressures. Although echocardiography may be the most practical method for assessing filling patterns, CMRI is an alternative noninvasive technique for analysis of diastolic function (Rathi 2008). One of CMRI’s advantages is the option of acquiring images in any selected plane or axis. To demonstrate feasibility, we analyzed diastolic function noninvasively by CMRI and microvascular coronary function in 41 women with signs and symptoms of angina/effort intolerance and no obstructive CAD (Wei 2009). Diastolic dysfunction was present in 36/41 (88%) women and in 33/35 (94%) women with microvascular dysfunction measured by CFR. Time to peak filling rate (tPFR) increased with age (r= 0.37, p= 0.017) and LV septal wall thickness (r= 0.47, p= 0.002), while peak filling rate (PFR) decreased with age (r= -0.45, p= 0.003). There was an inverse relationship between CFR and tPFR (r= -0.3, p= 0.058) and between CBF and PFR (r= -0.28, p= 0.08). Univariate logistic regression analysis was nonsignificant, but a trend toward significance was found between PFR and age (β= 0.07, p= 0.072). These data suggest a relationship between CMD and diastolic dysfunction that could have therapeutic implications.

Obesity, Insulin Resistance and the Metabolic Syndrome. Visceral obesity, insulin resistance, and diabetes are also associated with a pro-inflammatory state (Grundy 2002) that is associated with elevated CHD risk and diastolic dysfunction (Stahrenberg 2010), particularly in women. Post-hoc analyses of large randomized trials of angiotensin converting enzyme (ACE) inhibitors in at risk subjects demonstrate reductions in the onset of diabetes (Francis 2000). As these classes of medications appear to interrupt important neurohumoral and inflammatory pathways, these results suggest a common causal mechanism for the metabolic syndrome. In the MERLIN trial, ranolazine significantly improved HbA1c and recurrent ischemia in patients with diabetes and reduced the incidence of increased HbA1c in those without evidence of previous hyperglycemia. While the mechanism of this effect is under investigation, further documentation of this effect in women at risk for diabetes is needed. A convenient and validated measure of insulin resistance is the Homeostasis Model Assessment (HOMA) using the formula: fasting plasma glucose (mmol/L) times fasting plasma insulin (mU/l) divided by 22.5.

Clinical Trials in CMD. Prior small trials in women and men with CMD have suggested effectiveness for anti-ischemic therapies, including beta-blockers, statins, ACE-I and L-arginine for symptoms and functional improvement. The hypothesis that subendocardial ischemia is a mechanistic pathway for angina in subjects with CMD has not been tested. Results of the current application will be used to plan a large scale, definitive, practical outcome trial in subjects with CMD using a novel mechanistic pathway of subendocardial ischemia.

A Novel Medication. Ranolazine is a novel anti-ischemic drug, which was approved in January 2006 by the FDA for use in patients with chronic angina who are symptomatic on nitrates, beta-blockers, or calcium antagonists. Subsequent approval in 2009 extended use to a primary anti-anginal therapy. Ranolazine is a racemic mixture available in an oral and intravenous form and chemically described as 1-piperazineacetamide, N-(2,6-dimethylphenyl)-4-[2-hydroxy-3-(2-methoxyphenoxy)propyl]-,(+/-)(Chaitman 2006). The mechanism of action is not fully understood, but unlike other antianginal medications, the anti-ischemic effects of ranolazine are not related to heart rate or systemic blood pressure lowering (Chaitman 2006). Most recent evidence suggests that ranolazine reduces calcium overload in the ischemic myocyte through inhibition of the late sodium current (Chaitman 2006).

Ranolazine Clinical Trials. There are published data documenting the efficacy and safety of extended release ranolazine. Four randomized double blind randomized clinical trials (MARISA, CARISA, ERICA and MERLIN-

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TIMI 36) have demonstrated improvement in angina for people on this medication (Chaitman 2006, Wilson S. 2009). MARISA, (Monotherapy Assessment of Ranolazine in Stable Angina) a monotherapy study with 3 doses of ranolazine, demonstrated that all doses resulted in significant increase in exercise duration compared to placebo (p 0.005) in a dose-dependent fashion, but benefit was attenuated at doses >1000 mg twice daily (Chaitman 2006). The CARISA trial (Combination Assessment of Ranolazine in Stable Angina) tested 823 patients with chronic reproducible treadmill-induced exercise induced-angina on atenolol, diltiazem or amlodipine with serial exercise tests. Results showed that compared with placebo, ranolazine significantly increases symptom-limited exercise duration (Chaitman 2006). The primary end point for both MARISA and CARISA was symptom-limited exercise duration after trough ranolazine dosing 12 hours after dose.

ERICA (Efficacy of Ranolazine in Chronic Angina) was a trial of 565 patients randomized to ranolazine 500 mg twice daily or placebo for one week followed by 1000 mg twice daily or placebo for 6-wks in addition to amlodipine. The primary outcome was average number of angina attacks/wk and used the SAQ score and showed a statistically significant decrease in angina frequency (p=0.028) and nitroglycerin use (p=0.014) (Chaitman 2006).

More recently the efficacy and safety of ranolazine has been studied in a subgroup of 3,565 patients with prior chronic angina who were enrolled in the randomized, double-blind, placebo-controlled MERLIN-TIMI (Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST Elevation Acute Coronary Syndromes) 36 trial of patients with acute coronary syndrome. The primary end point of this trial was the first occurrence of cardiovascular death, myocardial infarction, or recurrent ischemia with electrocardiographic changes, requiring hospitalization, revascularization, or additional medication with length of follow-up of over 1-year. Results found that ranolazine reduced the incidence of recurrent ischemia by 22% (p= 0.002) and had a 24% (p=0.048) reduction in the incidence of worsening angina. Exercise duration at 8 months was greater with ranolazine (p = 0.002). The primary end points of cardiovascular death, myocardial infarction, and recurrent ischemia were less frequent with ranolazine (p=0.017)(Wilson 2009). Notably, subgroup analyses demonstrated greater and statistically significant benefit in women (HR 0.83 [0.7-0.99]) compared to men, and among subjects with elevated BNP (p=0.001), while additional benefit was observed in reduction of ventricular tachycardia, atrial fibrillation and other forms of tachycardias (RR range 0.51-0.72, p=0.0001) with ranolazine compared to placebo. These data suggest that ranolazine may be effective for the treatment of diastolic dysfunction and diastolic heart failure (DHF). Indeed, under chronic ischemic conditions, ranolazine has been shown to improve diastolic performance in non-infarcted myocardium (Hayashida 1994). The mechanism is improving regional wall lengthening during the isovolumic relaxation period and increasing regional peak filling rates.

Ranolazine Pilot Trial in CMD. To attest to feasibility, we conducted a pilot randomized, 1-month cross-over trial of ranolazine 1,000 po bid in 20 women with signs and symptoms of ischemia but no obstructive CAD and evidence of ischemia by CMRI. Qualifying CMRI required a ≥10% reversible perfusion abnormality indicated by a visual read qualitative summed stress score (SSS). The CMRI parameters were read and analyzed blinded to patient characteristics and randomized treatment. The intervention and study was well-tolerated without study drop-outs or adverse effects. Table 2 demonstrates significant improvement in SAQ physical limitation and improvement in the hypothesized direction in SAQ angina stability with ranolazine compared to placebo. Additionally, in this small sample size, SSS trended insignificantly improved, similar to the trend in the predicted direction for improvement observed in the quantitative Myocardial Perfusion Reserve Index (MPRI)(p=0.356), and the measure of diastolic function, PFR (p=0.56). There was no difference in results according to the 2 subjects who only tolerated the 500 bid dosing vs the 18 subjects who tolerated the 1,000 bid dosing (data not shown). While there was no significant overall group differences in SAQ angina frequency (73.8 vs 70.8, ranolazine vs placebo), when stratified by responders vs non-responders, MPRI scores trended toward better improvement in the SAQ angina frequency responders (MPRI 2.2 vs 1.9, p=0.13) compared to non-responders (MPRI 2.3 vs 2.3, p=0.99). When stratified by concurrent beta blocker, ACE-I, angiotensin-renin blocker (ARB), statin use or nitrate, subjects using these medications trended toward better improvement on ranolazine compared to non-users with the exception of no trend with nitrates. Results of this pilot study were presented at the American Heart Association Scientific Sessions, November 2010 and published in 2011 (Mehta 2011).

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Table 2. Seattle Angina Questionnaire Scores on Ranolazine vs. Placebo

RanolazineMedian (min, max) Placebo Median (min, max) Treatment effect (p-

value)Physical Functioning 30.2 (12.9, 40.3) 83.3 (63.9, 98.6) 0.046Angina Stability 75 (50, 100) 50 (25, 75) 0.008Angina Frequency 80 (50, 100) 75 (60, 87.5) 0.197Treatment Satisfaction 87.5 (75, 100) 93.8 (75, 100) 0.058Quality of Life 75 (60.4, 83.3) 66.7 (58.3, 75) 0.021

Table 3. Visual and Quantitative CMRI Defects on Ranolazine vs. Placebo

Ranolazine Median (min, max) Placebo Median (min, max) Treatment effect (p- value)% ischemic myocardium 11.7 % (8.0, 19.3) 16.0 % (8.6, 22.7) 0.64Global MPRI 2.1 (2.2, 2.4) 1.9 (1.7, 2.5) 0.66Midventricular MPRI 2.4 (2.0, 2.8) 2.1 (1.7, 2.5) 0.074Subendocardial MPRI(whole)

2.0 (1.7, 2.2) 1.8 (1.5, 2.3) 0.66Subendocardial MPRI(midventricular)

2.1 (1.7, 2.5) 1.9 (1.5, 2.3) 1.0Subepicardial MPRI(whole)

2.3 (2.1, 2.6) 2.0 (1.8, 2.5) 0.18Subepicardial MPRI(midventricular)

2.6 (2.2, 3.0) 2.2 (1.9, 2.5) 0.18

MPRI=myocardial perfusion reserve index where higher is better perfusion

Unifying New Hypotheses of CMD. These data support a unifying new hypothesis that subendocardial ischemia is a mechanistic pathway for morbidity and mortality in subjects with signs and symptoms of ischemia but no obstructive CAD. Specifically, we hypothesize that:

1. Ranolazine improves the co-primary outcomes of: 1a. SAQ angina stability, 1b. SAQ angina frequency*, 1c. SAQ-7 compared to placebo.2. Ranolazine improves the secondary outcome of: 2) angina frequency measured by diary compared to placebo3a. Ranolazine improves the other outcomes of a) myocardial perfusion and diastolic function measured by CMRI; b) Quality of Life and healthcare costs; c) HbA1c, HOMA and NT-proBNP, compared to placebo.3b. Improvement in the SAQ will be positively related to improvement in MPRI measured by CMRI.4. Ranolazine improves the exploratory outcome of physical activity measured by Fitbit in subset of subjects.

*The SAQ “angina frequency” domain was added as a co-primary in 2015 following the publication of WISE results (Pauley 2010, Bavry 2011) indicating that this SAQ domain was relevant and related to improvement in CFR in CMD subjects.

In pursuit of elucidating mechanistic pathways for a clinical trial for treatment of CMD, we will perform an intermediate outcome randomized clinical trial in subjects with signs and symptoms of ischemia but no

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obstructive CAD to provide data to design a large scale, definitive, practical outcome trial of the novel anti-ischemia medication ranolazine compared to placebo funded by NIH-NHLBI.

Potential Impact. The potential impact of this application could be large. There are an estimated 2-3 million patients with CMD in the USA alone; this number is projected to increase concomitant with the aging and obesity epidemics. Existing preventive and treatment strategies are limited and not effective, resulting in relatively high morbidity, mortality and cost. The current application proposes to test a Food and Drug Administration (FDA)-approved medication that is safe and well-tolerated which addresses a novel pathophysiological link with CMD. Accordingly, should this intermediate outcome project be successful, a large, practical, outcome randomized clinical trial could be rapidly implemented due to the size of the population available for recruitment, the availability and safety of the intervention. Additionally, the current application will provide additional understanding of the pathophysiology of CMD with regard to subendocardial ischemia, which

can serve as a template for additional innovative therapeutic target development.

B. ApproachTo address the specific aims efficiently, an integrated organizational approach will be used. We will perform a randomized, placebo-controlled, cross-over trial in 147 enrolled subjects. With a projected 9-10% dropout, we anticipate 134 completed subjects with 2 wks of ranolazine 500-1000 mg po bid vs placebo, over a 5-year recruitment period. Randomization will be stratified by clinical site.

Timeline. The timeline is 5-years, with rolling recruitment into the randomized clinical trial. The investigative team is highly productive and experienced with this type of timeline and iterative work pattern. The methods and analyses proposed are valid and feasible to be accomplished during the study period. Study duration can be shortened by reducing the length of the treatment period, including additional sites, and/or providing funding for accelerated CMRI screening (beyond current WISE protocol).

Subject Recruitment – Randomized Clinical Trial (Figure 2). Following informed consent, up to 147 subjects meeting criteria will undergo baseline testing and then be randomized to a cross-over trial with stepped dosing of ranolazine or placebo 1,000 mg po bid for 2-wks with testing followed by cross-over to the alternate treatment (ranolazine or placebo) and repeat exit testing. Due to the ongoing WISE-CVD R01 study for the next three years, recruiting can be efficiently and economically performed. To account for 10% dropout, 147 subjects will be enrolled to project 134 completed subjects for evaluation.

Inclusion Criteria:1. Men or women age >18 yrs from diverse racial/ethnic groups;2. Competent to give informed consent; 3. Patients with chronic angina or its equivalent;

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Recruitment147 recruited with signs/symptoms of myocardial

ischemia and no obstructive CAD with either:

An invasive measured CFR < 2.5 or ACH Response of no dilation or constriction

ORMPRI ≤ 2.0 on CMRI in prior 2.5 years

Entry and Exit Testing: History and Physical, ECG

CMRI perfusion, MPRI and diastolic functionSAQ, Angina Frequency,

QoL, Healthcare costs, A1c, HOMA, BNP

RandomizationRanolazine 500-1000 mg po bid or placebo for 2

weeks eachSeparated by 2 week washout period

Exit testing after each periodPrimary and Secondary Outcomes: SAQ, Angina

Other Outcomes:CMRI,QoL/Healthcare Costs,A1C,HOMA, BNP

Figure 2

4. Coronary angiogram revealing CMD with no obstructive CAD (epicardial coronary stenosis <50% luminal diameter stenosis); or measured noninvasively using the Society of Cardiovascular Computed Tomography threshold of <50% stenosis.

5. Left ventricular ejection fraction ≥45%; 6. Objective evidence of ischemia by noninvasive methods such as exercise stress test, stress Echo,

CMRI or single photon emission tomography (SPECT);7. Patients with CMD defined as an invasive measured CFR <2.5 or acetylcholine (ACH) response of no

dilation or constriction, determined by local site read, or a CMRI derived MPRI ≤2.0**.8. Patients must have withdrawn from ranolazine at least 2 weeks prior to study entry.9. Either a qualifying WISE or clinical CMRI scan must be completed within 2.5-yrs ±1 month of study

participation.10. Qualifying angiograms must have been within 2.5 yrs ±1 month of study enrollment.

Exclusion Criteria:1. Acute coronary syndrome (defined by World Health Organization [WHO]), cardiogenic shock or

requiring inotropic or intra-aortic balloon support; 2. Planned percutaneous coronary intervention or coronary bypass surgery or established obstructive

CAD with ischemia eligible for revascularization, acute myocardial infarction (MI); 3. Prior non-cardiac illness with estimated life expectancy <4-yrs; 4. Unable to give informed consent; 5. Allergy or contra-indication to CMRI testing, including renal failure, claustrophobia, and asthma,

uncontrolled moderate hypertension (sitting blood pressure (BP) >160/95mmHg with measurements recorded on at least 2 occasions), other conditions likely to influence outcomes: Severe lung, creatinine >1.8 or creatinine clearance [CrCl] ≤50ml/min) or hepatic disease;

6. Surgically uncorrected significant congenital or valvular heart disease and other disease likely to be fatal or require frequent hospitalization within the next six months;

7. Adherence or retention reasons;8. Unwilling to complete follow-up evaluation including repeat testing, documented obstructive

hypertrophic cardiomyopathy; 9. Aortic stenosis (valve area <1.5 cm); 10. LV dysfunction (ejection fraction <45%);11. History of significant cocaine or amphetamine abuse; 12. Taking potent CYP3A4 inhibitors (ketoconazole, itraconazole, nefazodone, troleandomycin,

clarithromycin, ritonavir, nelfinavir);13. Women who are pregnant.

**We increased the MPRI Criteria to ≤1.8 in 2011 following the publication of WISE results (Mehta 2010 Pauley 2010, Bavry 2011), and to ≤2.0 in 2013 following the WISE results showing an MPRI threshold of 1.84 predicted disease status with sensitivity 73% and specificity 74% (Shufelt 2013, Haftbaradaran 2013, Thomson 2015). Given the standard deviation variance of the measure, a threshold of 2.0 was appropriate for the population, study design and recruitment feasibility.

Clinical Trial – Design. The application is focused to collect relevant data to test the hypothesis that subendocardial ischemia is a mechanistic pathway in CMD and angina, in order to design a large, practical clinical trial to test that the anti-ischemic therapy ranolazine reduces morbidity and mortality in CMD. Subjects who have a MPRI ≤2.0 on the WISE CMRI or screening or clinical CMRI (if not a WISE subject) or abnormal CRT (CFR<2.5, or ACH response of no dilation or constriction or coronary blood flow [CBF] <50%, determined by local site read) with at least 2 anginal episodes/wk and otherwise meet inclusion criteria with no exclusions as listed below will be approached. Those providing written informed consent will be randomized initially to either ranolazine or placebo, followed by cross-over to the alternate after a 2 week washout. Ranolazine will be preferentially used as first-line anti-anginal therapy, however subjects will be maintained on their existing medical therapy as needed. Dosing for ranolazine or placebo will be twice a day (500 mg bid) for 1-wk, and then 2 pills twice a day (1000 mg bid) as tolerated until exit testing at 2 wks for both the ranolazine and placebo periods (Figure 3). Study subjects have four clinic visits (Baseline 0 -wk, 2-wks, 4-wks, Exit 6-wks). At 0, 2 and

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6-wks an ECG will be monitored for safety assessment. At the 6-wk exit visit subjects will undergo exit testing for each ranolazine and placebo period. The schedule of data collection is listed in Table 4. Patients will be instructed to take their study pills up to and including the day of their CMRI scans.

Subject Symptom, Demographic, Clinical History, and Risk Factor Assessment. Subjects will undergo a physical examination that includes heart rate, blood pressure, height, weight, body mass index (BMI), and waist-hip ratio determination, demographics, and medical history.

Table 4. Schedule of Data Collection for Each Period (Ranolazine and Placebo)N = 134 0 wk

BaselineVisit 1

1 wks

2 Wks

Visit 2

One day before Visit 3(phone call)

4 wks

Visit 3 (phone

call)

5 wks

6 wksExit

Visit 4

Demographics, Physical Examination, Medical History X X

Electrocardiogram ECG for Safety Assessment X X X

Blood Work for BNP, A1c, & HOMA X X XQuestionnaires: QoL, SAQ, DASI, Healthcare Costs X X X X X

Urine Pregnancy Testing XMedications X X*Cardiac MRI and Procedure Sx Questionnaire X X

Screening CMRI for non-WISE subjects XAssessment of Compliance with trial medication X X

Follow-up Events and Procedures (mortality, hospitalizations, myocardial infarction, Stroke, congestive heart failure (CHF), percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG)

XX

Fitbit profile setup/education XCall reminder to place Fitbit device X xFitbit charging X X X XFitbit data downloading X XFitbit recovery/sterilization XCall Reminder to start 2nd set of study drugs X

*with 2-week window period ± 5 days

0-Week Baseline Visit:Page 12 of 40

Figure 3

1. Screening and recruitment2. Obtain written informed consent3. Obtain baseline data:

a. Demographicsb. Physical examinationc. Medical Historyd. ECGe. Blood and Urinef. Questionnairesg. Medicationsh. Screening CMRI for non-WISE subjects. Note that if the subject has had a clinical scan within 2.5

years of ±1 month of study participation, it may be used as the screening CMRI in order to verify eligibility.

i. For Physical Activity Substudy: Educate patients on how to use Fitbit. Patients will be given a fitbit+charging station to plug into an outlet in their home.

1-Week visit – Call Reminder:Remind/confirm that patient has charged the fitbit. Patient will be now instructed to place the fitbit into the wristband and wear the device on their dominant arm for the next week.

2-Week visit: 1. ECG2. Blood3. Questionnaires4. CMRI and Procedure Questionnaire5. Assessment of compliance with trial medication (with 2-wk window period ±5-days)6. Follow-up events and procedures7. Collect previous one wk of Fitbit and download respective data to secure database. 8. Patients will be given the 2nd set of study drugs which will include a treatment window buffer (i.e. 2 wks

± 5 days)

4-Week Visit (by phone):1. Questionnaires2. Medications3. One day before this visit, the research team will call patients to remind them of starting the 2nd set of study drugs.4. Reminder of charging Fitbit- Patients will be reminded of charging Fitbit in their home (plugging the Fitbit into its special charging adapter and an outlet in their home).

5-Week visit – Call Reminder:Remind/confirm that patient has charged the Fitbit. Patient will be now instructed to place the Fitbit into the wrist band and wear the device for the next week.

6-Week Exit Visit:1. Demographics2. Physical examination3. Medical History4. ECG5. Blood6. Questionnaires7. Cardiovascular MRI and Procedure Questionnaire8. Assessment of compliance with trial medication9. Follow-up events and procedures

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10. Collect previous one week Fitbits and download respective data to a secure database

Study Procedures:

Angina Measurement. Angina will be measured by diary for frequency of episodes, as well as nitroglycerine (NTG) use, using methods in the ongoing Gilead CVT 3041 Study.

Quality of Life, Symptoms and Healthcare Costs Questionnaires. The SAQ and the SAQ-7 will be used and scored as published (Kimble 2002). We added the SAQ-7 as a co-primary outcome following its validation and availability in 2014 (Chan 2014). QOL will be measured by selected questions from the Medical Outcomes Study(MOS)-Short Form-36 Health Survey (SF-36, www.sf36.com), the MOS-116, and the HIS-GWB Mental Health. Functional status will be measured by the Duke Activity Status Inventory (DASI). Healthcare costs will be summed based upon prior guidance documents and published reports using a hybrid model applying detailed medical resource consumption to hospital-specific charges (adjusted by hospital-specific cost-charge ratio) and published costs (Mark 2003, Mark 2002a, Mark 2002b, Buxton 1997, Smith 2001). Drug costs will be derived from the Red Book® (www.pdrbookstore.com). Annual costs include cardiovascular hospitalizations, coronary revascularization and angiography, outpatient testing, and visits to generalist, specialists, nurse practitioners/physician’s assistant, or community clinics. Indirect costs will be estimated by self-reported hours lost from work for health care, reduced productivity, transportation costs, and out-of-pocket costs for drugs, medical devices (e.g., glucometer), and alternative therapies (e.g., vitamins). Smoking costs will be estimated by consumption levels. Costs will be discounted using an annual rate, inflation-corrected by the US medical service sector estimate (city average) of the consumer price index (for urban wage earners and clerical workers) (http://data.bls.gov/cgi-bin/surveymost).

CMRI Methods. CMRI Acquisition. A comprehensive CMRI examination will be used and includes a combination of tomographic views in cine mode, which will be acquired using the ECG-gated steady-state-free-precession (SSFP), quantitative phase velocity mapping, first pass contrast myocardial perfusion imaging and imaging of myocardial viability via contrast enhancement. The CMRI morphologic and functional data will be used to measure LV volumes, LVEF, LV mass, and assessment of regional wall motion and thickening. Volumetric data, acquired from the short axis views and long axis views, will be used for evaluation of regional wall motion and thickening. Blood flow velocity data acquired at the level of the ascending aorta, will be used to assess forward cardiac output. Myocardial perfusion will be assessed from first pass contrast images obtained in the short axis view. Rapid assessment of ventricular function will be performed during adenosine infusion. Contrast enhanced data will be used to assess presence and extent of myocardial fibrosis and microinfarction (delayed enhancement). These CMRI methods are previously published and used extensively our group. Lexiscan will be used for the CMRI for subjects who cannot take adenosine.

Phase-Contrast CMRI. Phase-contrast velocity-encoded images are obtained using retrospective ECG gating and over a complete cardiac cycle, resulting in a high temporal resolution. Contours of the cross section of the mitral valve leaflets or pulmonary vein are used to create velocity vs time graphs, yielding mitral diastolic E and A waves and pulmonary diastolic S and D waves. The deceleration time is calculated from the time of the peak E wave and the E wave downslope. Additionally, diastolic perfusion time can be evaluated.

HbA1c HOMA and BNP methods. A 5-ml blood sample for NT-pro b-type natriuretic peptide (NT-proBNP) will be collected by venipuncture in EDTA tubes and immediately centrifuged and stored at -70 C until batch analyzed. NT-proBNP levels will be measured using a highly sensitive and specific Elecsys electrochemiluminescence immunoassay (Roche Diagnostics Corporation, Indianapolis, Indiana)(Mitchell 2015). Hemoglobin A1C will be analyzed using standard methods also by the Core Laboratory. The degree of insulin resistance in each subject was estimated by the Homeostasis Model Assessment (HOMA) using the formula: fasting plasma glucose (mmol/L) times fasting plasma insulin (mU/l) divided by 22.5 according to the method by Matthews (1985), where high values indicate high insulin resistance.

Follow-Up Methods. Follow-up information will be obtained at scheduled visits and by telephone interview. The follow-up queries patients for occurrence of cardiovascular events, medical history, and treatments.

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Specifically, information will be collected on changes in status and symptomology; types and doses of medications and number of adjustments in regime; change in risk factors, reproductive status, co-morbid conditions, non-cardiac-related hospitalizations, physical activity level and quality of life; cardiac hospitalization; cardiac procedures; and continued medical resource use. Study medication compliance will be assessed by pill count.

Ranolazine Pilot Trial in CMD - Fitbit TrackerWe use a novel, commercially available, mobile accelerometer, the Fitbit, to measure ranolazine’s effectiveness in increasing activity levels as measured by step-count in patients with demonstrated angina and CMD. The Fitbit apparatus consists of a flexible wristband made of durable elastomer material that contains an insertable accelerometer chip. The accelerometer chip is housed within the wristband and is transferable between wristbands. In order to limit loss of device as well as contact with the accelerometer chip and the patient’s skin, sterilized tape will be placed on the inferior aspect of the wristband (see appendix for more details). Subjects who have a MPRI ≤2.0 on the WISE CMRI or screening CMRI (if not a WISE subject) or abnormal coronary reactivity testing (CFR<2.5, or ACH response of no dilation or constriction, determined by local site read) with at least 2 anginal episodes per week and otherwise meet inclusion criteria and have no exclusions as listed below will be randomized initially to either ranolazine or placebo followed by cross-over after a 2-week washout. At time of randomization, patient will be given a fitbit attached to a Fitbit charging station. Patient will be instructed to plug the fibit charging station into an outlet in her home. In addition, the patients will be educated on how to place the fibit into the wristband. At weeks one and five, subjects will be instructed to remove the Fitbit from the charging station and place the fitbit into the wristband. Patients will then wear the wristband for the next week. At weeks 2 and 6, the fitbits will be collected and the data will be downloaded. Ranolazine will be preferentially used as first-line anti-anginal therapy; however, subjects will be maintained on their existing medical therapy as needed. Dosing for ranolazine or placebo will be 1 pill twice a day (500 mg bid) for 1-week, and then 2 pills twice a day (1000 mg bid) as tolerated until exit testing at 2-weeks for both the ranolazine and placebo periods. Study subjects have four clinic visits (Baseline 0-week, 2-weeks, 4-weeks, Exit 6-week). 0, 2 and 6-weeks ECG will be monitored for safety assessment. At the 6 week exit visit, the subjects will undergo exit testing for each ranolazine and placebo period, devices will be removed and collected, and data downloaded. The schedule of data collection is listed in Table 4.

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Clinical Protocol References

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Buchthal SD, Den Hollander JA, Hee-Won K, et al. “Metabolic evidence of myocardial ischemia by 31-P NMR spectroscopy in women with chest pain by no significant coronary stenoses: pilot phase results from The NHLBI WISE Study.” New Engl J Med 2000;342:829-35.

Buxton MJ, Drummond MF, Van Hout BA, Prince RL, Sheldon TA, Szues T, Vray M. Modeling in economic evaluation: an unavoidable fact of life. Health Econ 1997 May-Jun;6(3):217-27.

Chaitmen BR. Ranolazine for the Treatment of Chronic Angina and Potential Use in Other Cardiovascular Conditions. Circulation. 2006; 113: 2462-2472 doi: 10.1161/CIRCULATIONAHA.105.597500

Chan PS, Jones PG, Arnold SA and Spertus JA. Development and Validation of a Short Version of the Seattle Angina Questionnaire. Circ Cardiovasc Qual Outcomes. 2014;7:00-00.

Francis GS. ACE inhibition in cardiovascular disease. N Engl J Med. 2000 Jan 20;342(3):201-2.

Grundy SM. Obesity, metabolic syndrome, and coronary atherosclerosis. Circulation. 2002 Jun 11;105(23):2696-8.

Haftbaradaran A, Mehta P, Zaya M, Agarwal M, Johnson DB, Petersen J, Sedlak T, Lentz G, Azarbal B, Samuels B, Shufelt C, Slomka P, Berman D, Pepin C, Bairey Merz CN, Thomson, L, Sensitivity and Specificity of CMRI for Diagnosis of Microvascular Coronary Dysfunction in Women With Signs and Symptoms of Ischemia and No Obstructive Coronary Artery Disease: Results from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) J am Coll Cardiol. 2013;61(10_S).

Hayashida W1, van Eyll C, Rousseau MF, Pouleur H. Effects of ranolazine on left ventricular regional diastolic function in patients with ischemic heart disease. Cardiovasc Drugs Ther. 1994 Oct;8(5):741-7.

Johnson BD, Shaw LJ, Buchtal S, et al. Myocardial ischemia in symptomatic women in the absence of obstructive CAD – prognosis and cost: Results from the NIH-NHLBI-sponsored women’s ischemia syndrome evaluation (WISE). Circulation 2004;109(24):2993-9.

Kaul S. Myocardial contrast echocardiograpy: a 25-year retrospective. Circ 2008;118:291-308.

Kimble LP1, Dunbar SB, Weintraub WS, McGuire DB, Fazio S, De AK, Strickland O. The Seattle angina questionnaire: reliability and validity in women with chronic stable angina. Heart Dis. 2002 Jul-Aug;4(4):206-11.

Mark DB, Hlatky MA. Medical economics in the assessment of value in cardiovascular medicine. Part I. Circulation 2002a;106(4):516-520.

Mark DB, Hlatky MA. Medical economics in the assessment of value in cardiovascular medicine. Part II. Circulation 2002b;106(5):626-630.

Mark DB, Shaw LJ, Lauer MS, O’Malley P, Heidenreich P. 34th Bethesda Conference: Task force #5 - Is atherosclerotic imaging cost effective? From the 34th Bethesda Conference on Atherosclerotic Imaging. J Am Coll Cardiol 2003;41(11):1906-17.

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Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985;28:412-9.

Mehta PK, Goykhman P, Thomson LE, Shuftelt C, Wei J, Yang Y, Gill E, Minissian M, Berman DS, Bairey Merz CN, Ranolazine Improves Angina in Women with Evidence of Ischena but No Obstructive Coronary Artery Disease; A Pilot, Randomized-Controlled Trial. Circulation, 23 November 2010; 122: A16283.

Mehta PK, Goykhman P, Thomson LE, Shuftelt C, Wei J, Yang Y, Gill E, Minissian M, Berman DS, Bairey Merz CN. Ranolazine Improves Angina in Women with Evidence of Ischemia but No Obstructive Coronary Artery Disease; A Pilot, Randomized-Controlled Trial. J Am Coll cardiol Cardiovascular Imaging 2011; 4:514-522).

Mitchell A, Misialek PR, Folsom AR, Duprez D, Alonso A, Jerosch-Herold M, Sanchez OA, Watson KE, Sallam T, Konety SH. Usefulness of N-terminal Proebrain Natriuretic Peptide and Myocardial Perfusion in Asymptomatic Adults (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol 2015;115:1341e1345.

Murthy VL, Naya M, Foster CR, Hainer J, Gaber M, Di Carli G, Blankstein R, Dorbala S, Pencina MJ, Di Carli MF. Improved cardiac risk assessment with noninvasive measures of coronary flow reserve. Circulation. 2011 Nov 15;124(20):2215-24. doi: 10.1161/CIRCULATIONAHA.111.050427. Epub 2011 Oct 17.

Olson MB, Kelsey SF, Matthews K, et al. Symptoms, myocardial ischaemia and quality of life in women: results from the NHLBI-sponsored WISE Study. Eur Heart J 2003;24:1506-14.

Pauly DF, Johnson BD, Anderson RD, Handberg EM, Smith KM, Cooper-DeHoff RM, Sopko G, Sharaf BM, Kelsey SF, Bairey Merz CN, Pepine CJ. In women with symptoms of cardiac ischemia, non-obstructive coronary arteries, and microvascular dysfunction, ACE inhibition is associated with improved microvascular function: a double-blind randomized study from the NHLBI Women’s Ischemia Syndrome Evaluation (WISE) Am Heart J. 2011;162:678-84.

Pepine CJ, Balaban RS, Bonow RO, et al. Women's Ischemic Syndrome Evaluation: current status and future research directions: report of the National Heart, Lung and Blood Institute workshop: October 2-4, 2002: Section 1: diagnosis of stable ischemia and ischemic heart disease. Circulation 2004;109:e44-6.

Pepine CJ, Anderson RD, Sharaf BL, Reis SE, Smith KM, Handberg EM, Johnson BD, Sopko G, Bairey Merz CN. Coronary Microvascular Reactivity to Adenosine Predicts Adverse Outcome in Women Evaluated for Suspected Ischemia: Results from the NHLBI Women’s Ischemia Syndrome Evaluation (WISE) Study. J Am Coll Cardiol. 2010 June 22; 55(25): 2825-32.

Rathi IK, Doyle M, Yamrozik J, Williams RB, Caruppannan K, Truman C, Vido D, and Biederman RWW. Routine evaluation of left ventricular diastolic function by cardiovascular magnetic resonance: A practical approach. Journal of Cardiovascular Magnetic Resonance 2008, 10:36 doi:10.1186/1532-429X-10-36.

Reis SE, Holubkov R, Conrad Smith AJ, Kelsey SF, Sharaf BL, Reichek N, Rogers WJ, Bairey Merz CN, Sopko G, Pepine CJ. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: Results from the NHLBI-sponsored WISE study. Am Heart J 2001;141:735-41.

Shaw LJ, Bairey Merz CN, Bittner V, Kip K, Johnson BD, Reis SE, Kelsey SF, Olson M, Mankad, S, Sharaf, BL, Rogers, WK, Pohost, GM, Sopko G, Pepine CJ. Importance of Socioeconomic Status as a Predictor of Cardiovlascular Outcome and Costs of Care in women with Suspected Myuocardial Ischemia. Results from the NIH, NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE). Journal of Women’s Health, 2008; Vol 17 No. 2; 1081-1092.

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Shufelt CL, Thomson LEJ, Goykhman P, Agarwal M, Mehta PK, Sedlak T, Li N, Gill E, Samuels B, Azabal B, Saibal K, Kothawade K, Minissian M, Slomka P, Berman DS, Bairey Merz CN, Cardiac Magnetic Resonance Imaging Myocardial Perfusion Reserve Index Assessment in Women with Microvascular Coronary Dysfunction and Reference Controls. Cardiovasc Diagn Ther Sept 2013;3(3):153-160.

Smith DH, Hugh Gravelle H. The practice of discounting in economic evaluations of healthcare interventions. Int J Tech Assess Health Care 2001;17:236-243.

Spertus JA, Jones P, McDonell M, Fan V, Fihn SD. Health Status Predicts Long-Term Outcome in Outpatients With Coronary Disease. Circulation 2002:106:43-49.

Stahrenberg R, Edelmann F, Mende M, Kockskämper A, Düngen HD, Scherer M, Kochen MM, Binder L, Herrmann-Lingen C, Schönbrunn L, Gelbrich G, Hasenfuss G, Pieske B, Wachter R. Association of glucose metabolism with diastolic function along the diabetic continuum.Diabetologia. 2010;53(7):1331.

Thomson LEJ, Wei J, Agarwal M, Haft-Baradara A, Shufelt C, Mehta PK, Gill E, Johnson D, Kenkre T, Handberg E, Li D, Sharif B, Berman DS, Petersen J, Pepine CJ, Bairey Merz CN, Cardiac Magnetic Resonance Myocardial Perfusion Reserve Index Is Reduced in Women With Coronary Microvascualr Dysfunction A Heart, Lung, and Blood Institute-Sponsored Study From the Women’s Ischemia Syndrome Evaluation. Circ Cardiovasc Imaging, 2015;8e002461.)

von Mering GO, Arant CB, Wessel TR, et al. Abnormal coronary vasomotion as a prognostic indicator of cardiovascular events in women: results from the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation (WISE). Circulation 2004;109(6):722-5.

Wei J. Thomson L, Shufelt C, Yang Y, Gill E, Minissian M, Kar S, Berman D, Bairey Merz CN. Diastolic Dysfunction by Cardiac Magnetic Resonance Imaging in Women with Open Coronary Arteries and Microvascular Dysfunction. JACC 2009:A341:1041-153.

Wilson SR1, Scirica BM, Braunwald E, Murphy SA, Karwatowska-Prokopczuk E, Buros JL, Chaitman BR, Morrow DA. Efficacy of ranolazine in patients with chronic angina observations from the randomized, double-blind, placebo-controlled MERLIN-TIMI (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Segment Elevation Acute Coronary Syndromes) 36 Trial. J Am Coll Cardiol. 2009 Apr 28;53(17):1510-6. doi: 10.1016/j.jacc.2009.01.037.

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APPENDIX A - Statistical Methods

Introduction

This section of the protocol has been revised to reflect new information acquired since the protocol was drafted (Pauley 2010, Mehta 2011, Bavry 2011, Chan 2014) ongoing discussions among the study team regarding the most appropriate way to meet the objectives of the trial. All changes from the initial draft of the statistical methods have been made while the study team has been masked to the data.

Power and Sample Size

The original power and sample size justification was based on dichotomized measures and has been judged to be suboptimal. While the original basis for the trial size is largely irrelevant now, the study team felt it important to confirm that the study is appropriately sized using methods that closely adhere to the crossover design, directly use the co-primary outcome measures, and are supported by data.

Current Power. Based on new data published since the start of the trial (Mehta et al., 2011), we revisited the power calculation for the primary endpoints of the study. Results in Mehta et al. 2011 showed that the standard deviation for the paired difference in SAQ scores for angina stability was 43.4. With that standard deviation, a sample size of 116 in a 2x2 crossover design achieves 90% power to detect a mean difference of 15 in SAQ score using a two-sided t-test at the 0.017 Bonferroni corrected level of significance. The effect size of 15 is justified by being similar to the one obtained in WISE by Pauly et al. (2011) for angina frequency, and is smaller than the effect size observed in WISE by Mehta et al. (2011) for angina stability. Given the smaller standard deviation of the difference for angina frequency in Mehta et al. (2011), (SD =13.3), the current trial is well powered for the three co-primary endpoints.

Prior Power. Using these reports, “clinically relevant” differences, and effect sizes estimated in the pilot randomized controlled trial, we have updated the prior power calculations. Our prior power from the pilot trial, the SAQ Subscale of Angina Stability was identified a priori as the most clinically relevant subscale. A clinically significant improvement was defined as a difference in score of 25 points, based on the improvement in survival reported by Spertus et al. (Circulation, 2002). Applying these criteria to our pilot data, there was an observed rate of improvement of 60% on ranolazine as compared to 35% on placebo. Based on this potential difference, our prior power estimate of a total of 134 patients (allowing for 10% drop-out rate) yielded 80% power to reject the null hypothesis that the improvements rates for ranolazine and placebo are equal. The Type I error probability associated with this test of this null hypothesis was 0.05 using an uncorrected chi-squared statistic. Thus the current design is adequately powered.

Statistical Analysis Plan

The specific aims of this trial are:1) Determine the impact of ranolazine compared to placebo on angina measured by 1a) “angina stability”, 1b) “angina frequency” domains of the Seattle Angina Questionnaire (SAQ), 1c) SAQ-7 score. These represent the 3 co-primary outcome measures.2) Determine the impact of ranolazine compared to placebo on the secondary outcome of angina frequency measured by diary.3a) Determine the effect of ranolazine compared to placebo on other outcomes of: a) cardiac magnetic resonance imaging (CMRI) perfusion and diastolic function; b) Quality of Life (SF-36, DASI) and healthcare costs; c) hemoglobin A1C (HbA1c), insulin resistance measured by the homeostasis model assessment (HOMA) and b-type natriuretic peptide (NT-proBNP).3b) Determine if improvement in the SAQ is positively related to improvement in CMRI myocardial perfusion reserve index (MPRI).4) Estimate the effect of ranolazine compared to placebo in a subset of subjects on physical activity measured by Fitbit.

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The fundamental analytic approach will be based on a within-subjects comparison (paired) of the relevant outcome measured on ranolazine versus that measured on placebo in this crossover trial. The distribution of within-subjects differences for each outcome will be assessed for distributional characteristics to ensure that appropriate statistical techniques are applied. The primary approach will be a standard paired t-test. Non-normal data will be tested by nonparametric analogs of this test. The overall type I error rate for the 3 co-primary outcome measures will be controlled at 5%.

Angina stability (specific aim 1a), Angina frequency (specific aim 1b), and SAQ-7 (specific aim 1c) will be defined as the domains of SAQ angina stability, SAQ angina frequency, and SAQ-7, respectively, with ranges 0-100, obtained from 19 self-reported items. Higher values indicate better outcome, and prior work demonstrates that a 10 point change in either is clinically relevant (Kimble 2002).

Angina frequency (specific aim 2) as measured by diary is a recorded count over an interval of time. It will be defined as number of episodes per week and summarized with mean +/- SD.

Data will first be assessed for reliability and general integrity (e.g., distribution characteristics) to ensure that appropriate statistical techniques are applied. In particular, several Box-Cox transformations will be applied to the difference in mean angina frequency per week between treatment and placebo arms. Our basic approach to the analysis assumes there are no carry-over effects between the two treatment periods. This is justified by the established pharmacology of ranolazine and prior clinical trial results in CAD. All subjects entered into the trial will be included in the analysis. Strictly speaking, this is not an “intent-to-treat” policy because the crossover design should assure that each participant receives both ranolazine as well as placebo in the appropriate treatment periods. If a study participant did not receive one or both treatments, they cannot be included in the primary analysis for efficacy because that analysis relies on within-subject differences between the treatments. The status of all participants will be reported in the analysis as in the CONSORT recommendations. The fundamental analytic approach will be based on a within-subjects comparison of the relevant outcome measured on ranolazine versus that measured on placebo. The primary approach will be a standard paired t-test. Non-normal data will be tested by nonparametric analogs of this test.

Each primary endpoint will be handled in the same fashion. For each subject, the difference between SAQ score at baseline and the end of the period will be calculated. The average paired difference in the treatment group is Yt and in the control group is Yc. The difference between treatment and control is the estimated effect of ranolazine and is YD = Yt – Yc with µD denoting the corresponding population mean difference. We will test the null hypothesis µD = 0 vs the alternative hypothesis µD ≠ 0 using Student’s paired t-test and the Holm-Bonferroni (Holm, 1979) sequential procedure to control the overall type I error rate at 0.05. The trial will be declared clinically significant if at least one of the three co-primary endpoints is statistically significant. If no suitable transformation of the data for the angina frequency variable as reported by diary is found, the Wilcoxon-signed rank test will be utilized. If there is an excessive number of ties in the data or the counts are over-dispersed or under-dispersed, we will fit the data using a bivariate Poisson regression model described in Karlis and Ntzoufras (2003) with the R package bivpois (Karlis and Ntzoufras, 2005). Then, we will use the bootstrap technique to make inference about the difference in mean rates.

Carry-over effects will be tested by examining the interaction between treatment and period. This test will be carried out by comparing the mean within patient with means between the arms (Pocock, 1983). In the unlikely event of a statistically significant carry over effect, only data from the first period will be used for the analysis. Similar analyses will be carried out for the secondary endpoints including CMRI MPRI, diastolic function, Quality of Life (SF-36, DASI), healthcare costs, hemoglobin HbA1c, HOMA and BNP. For ordinal (or semi-continuous) outcomes, generalized linear mixed models will be applied with a cumulative logit link function. Exploratory analyses studying the effects of baseline demographic and clinical characteristics such as blood pressure and heart rate on the difference in SAQ scores and MPRI will be performed using linear models. The association between the improvement in SAQ scores and improvement in MPRI will be assesses by constructing a 95% confidence interval for Pearson’s correlation coefficient. Next, a multivariable linear model to correlate these two variables will be constructed adjusting for potential baseline demographic and clinical factors. For all exploratory and secondary objectives, a 0.05 level of significance will be used.

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Patterns in missing data will be examined and, if the assumptions are met, a multiple imputation will be employed to assess whether the results of the analysis are changed (Allison, 2001). A patient will be considered to have completed treatment if they have completed SAQ at baseline, SAQ and MRI for both treatment periods, and at least 50% drug compliance for both treatment periods.

Analyses will be performed using SAS v9.3 (SAS Institute Inc, Cary, NC).

Summary

The necessary and sufficient sample size for this trial, based upon our preliminary pilot trial, is 134 patients while still retaining sufficient power to reject the null hypothesis that mean outcome scores are equal between ranolazine and placebo.

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Statistical References

Allison, PD. 2001. Missing Data. Sage University Papers Series on Quantitative Applications in the Social Sciences. Thousand Oaks: Sage.

Holm, S. (1979). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6, 65–70.

Karlis D, Ntzoufras I (2003). “Analysis of Sports Data by Using Bivariate Poisson Models.” Journal of the Royal Statistical Society D (The Statistician), 52, 381 – 393.

Karlis D, Ntzoufras I (2005). “Bivariate Poisson and Diagonal Inflated Bivariate Poisson Regression Models in R.” Journal of Statistical Software, 14, Issue 10.

Kimble LP, Dunbar SB, Weintraub WS, McGuire DB, Fazio S, De, AK, Strickland O. The Seattle Angina Questionnaire: Reliability and Validity in Women With Chronic Stable Angina. Heart Dis. 2002 ; 4(4): 206–211.

Pocock, SJ. (1984). Clinical Trials‐ a practical approach. John Wiley & Sons Ltd.Mehta PK, Goykhman P, Thomson LEJ, Shufelt C, Wei J, Yang Y, Gill E, Minissian M, Shaw LJ, Slomka PJ, Slivka M, Berman DS, Merz CN. Ranolazine Improves Angina in Women with Evidence of Myocardial Ischemia but no Obstructive Coronary Artery Disease. J Am Coll Cardiol Img. 2011; 4: 514-22.

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APPENDIX B - HUMAN SUBJECTS

Description of subjects: The application population will consist of 147 enrolled with a projected 9-10% dropout and anticipated 134 completed subjects aged 18 and over, with signs and symptoms of CMD despite usual medical care. Study inclusion criteria are: men or women aged 18 and over from diverse racial/ethnic groups and competent to give informed consent, patients with chronic angina or its equivalent, coronary angiogram revealing CMD with no obstructive CAD (epicardial coronary stenosis <50% luminal diameter stenosis), left ventricular ejection fraction 45%, objective evidence of ischemia by noninvasive methods such as exercise stress test, stress Echo, CMRI or SPECT, and patients with MPRI ≤2.0 measured by CMRI or abnormal coronary reactivity testing (CFR<2.5, or ACH response of no dilation or constriction, determined by local site read) . Although men are included, because of the advantage of using CMRIs from the ongoing WISE study which specifically studies only women due to the relatively high prevalence of CMD in women, the majority of subjects in RWISE will be women. Study exclusion criteria are conditions that preclude accurate or safe testing, specifically: acute coronary syndrome (defined by WHO), cardiogenic shock or requiring inotropic or intra-aortic balloon support; planned percutaneous coronary intervention or CABG or established obstructive CAD with ischemia eligible for revascularization, acute MI; prior non-cardiac illness with an estimated life expectancy <4 years; unable to give informed consent; allergy or allergy or contra-indication to CMRI testing, including renal failure, claustrophobia, and asthma, uncontrolled moderate hypertension (sitting blood pressure >160/95mmHg with measurements recorded on at least 2 occasions), conditions likely to influence outcomes: Severe lung, creatinine >1.8 or CrCl ≤50ml/min) or hepatic disease, surgically uncorrected significant congenital or valvular heart disease and other disease likely to be fatal or require frequent hospitalization within the next six months, adherence or retention reasons, unwilling to complete follow-up evaluation including repeat testing, documented obstructive hypertrophic cardiomyopathy; aortic stenosis (valve area <1.5cm); LV dysfunction (ejection fraction <45%); history of significant cocaine or amphetamine abuse; taking potent CYP3A4 inhibitors (ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, nelfinavir). Following screening CMRI, subjects with CMRI of an MPRI ≤2.0 are eligible. Women of childbearing potential may be enrolled but must agree not to become pregnant during the course of the study and must practice a method of birth control considered reliable by the investigator. If established on hormonal contraceptives for more than 3 months, patients will be allowed to participate providing this therapy remains constant throughout the study. If a patient becomes pregnant or begins breast-feeding during the study, she must be withdrawn immediately. Dosages of lipid lowering medications and diet should remain constant for the duration of the study. Ranolazine will be used as first-line anti-anginal therapy, however concurrent use of ACE/ARB, Ca++ antagonists, -blockers, long acting nitrates and sublingual nitroglycerin will be allowed as needed as long as the dose is stable. These vasoactive medications with the exception of -blockers and sublingual nitrates will be stopped before the CMRI: short acting Ca++ antagonists and long acting nitrates will be withheld for at least 24 hours before these tests, long acting Ca++ antagonists will be withheld 48 hours before these tests, and sublingual nitrates may be taken up to 2 hours preceding the tests.

Ranolazine Indications, Safety, Contraindications and Warnings. Extended release ranolazine is indicated for the treatment of chronic angina and may be used with beta-blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid lowering agents, ACE inhibitors, and angiotensin receptor blockers. Contraindications include patients with pre-existing QT prolongation, patients with clinically significant hepatic impairment, patients on QT prolonging drugs, and patients on potent CYP3A inhibitors. Other warnings include consideration that ranolazine prolongs the QTc interval in a dose-related manner and other drugs with this potential have been associated with arrhythmias and sudden death.

No dosage adjustment is needed for patients with diabetes mellitus, but patients with severe renal impairment should have regular blood pressure measurements. Dosage adjustment is maximum dose of ranolazine 500mg twice a day when on diltiazem, verapamil and other moderate CYP3A inhibitors. There are no studies of the effect of ranolazine on fertility, on the developing fetus, in nursing mothers or in pediatric patients. Geriatric patients 75 years did have increase rates of adverse reactions and events.

The package insert reviews adverse reactions from three double-blinded, placebo-controlled randomized studies (1,026 enrolled subjects). The most frequent adverse events (>4%), occurring more often than placebo

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included dizziness (6.2%), headache (5.5%), constipation (4.5%), and nausea (4.4%). The most frequent reasons for discontinuation (6% ranolazine vs. 3% placebo) were dizziness, nausea, asthenia, constipation and headache. Small, reversible elevations in creatinine and blood urea nitrogen (BUN) were observed. Other adverse events at an incident of >0.5 to <2.0% that occurred more frequent off ranolazine vs. placebo included palpitations, abdominal pain, dry mouth, vomiting, peripheral edema and dyspnea (package insert). Other adverse events occurring at 0.5% included bradycardia, hematuria, hypoesthesia, hypotension, orthostatic hypotension, parasthesia, tremor and blurred vision.

Sources of research material: Data collected will include baseline questionnaires of symptoms, demographic, clinical, risk factor, and questionnaire information; BNP, HOMA, HbA1c data collection; as well as CMRI.

Recruitment: At the request of the physician performing the evaluation for CMD, the study nurse coordinator will contact the patient to discuss the purpose and methods of the study with the patient. After that, if the patient is still interested, a physician co-investigator will obtain informed consent.

Consent procedures: If an individual wishes to volunteer for the study, he or she will sign a fully detailed, institutional review board (IRB)-approved informed consent prior to admission into the study. This form describes the nature and purpose of the study, and the potential risks and benefits. Finally, the form states that participation in the study is voluntary, that the subject is free to withdraw at any time, that there are no costs to the individual for participation in the study,that all records of the subject’s participation will be kept confidential, and that individuals will not be identified in any scientific reports on the information collected.

Potential Risks: Extended release ranolazine can cause rare but serious side effects of irregular heart rhythm due to prolonged QT interval. Ranolazine may cause kidney failure in people who already have severe kidney problems. If participants experience relief of angina symptoms while on study drug (placebo / ranolazine), those symptoms may return after being taken off two weeks later. The most frequent less serious side effects occurring more often than placebo included dizziness (6.2%), headache (5.5%), constipation (4.5%), and nausea (4.4%). Small, reversible abnormalities in kidney function were observed, which will be minimized by excluding patients with abnormal creatinine. CMRI with Adenosine may cause claustrophobia and may not be tolerated, or may also cause discomfort during administration of the adenosine, such as chest pain, headache, shortness of breath, flush and nausea. These are very short-lived (seconds) because of the short duration of adenosine. One or more side effects occur in 30% of patients, which will be minimized by pre-test education and pre-treatment. Quality of Life Questionnaires may provoke certain emotional responses such as depression, anxiety or stress. In the event that patients are found to be in need of psychiatric evaluation for major depressive symptoms or suicidality, they will be referred to a mental health expert. Blood Testing may cause damage to the vein or bruising. This will be minimized by the use of training staff. Incidental Findings related to the CMRI may detect other abnormalities that would otherwise not have been detected. These will be reported to the treating physician and patient.

Confidentiality: Confidentiality is vigorously maintained. Participant names are encoded into alphanumeric IDs upon entry at the clinical sites. Patient names do not appear on any documents or data. Passwords are needed to obtain access to the database. File protection layers within the database allow individuals to “read” data without the ability to write or change data.

Importance of the knowledge to be gained: Important knowledge to be gained in the study includes the understanding of links between angina, CMD, diastolic dysfunction and subendocardial ischemia, as well as knowledge to plan a large, practical outcome trial of ranolazine for CMD.

Collaborating sites: Two clinical sites are participating: 1) Cedars-Sinai Medical Center, FWA 00000468; 2) University of Florida, FWA00005790.

Plan for Data and Safety Monitoring: A DSMB will review the safety of the subjects. The DSMB will include expertise in cardiology, bioethics, and biostatistics.

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Inclusion of Women: The application proposes to study women and men, and is anticipated to enroll greater than 50% women, due to higher prevalence of CMD in women compared to men.

Inclusion of Minorities: Minorities are targeted to represent 23% of the proposed study cohort, including 5% Hispanic, 17% African-American, and 1% Asian.

Inclusion of Children: Children (under the age of 18 years) were not included in the original population, because the prevalence of ischemic heart disease in this group is negligible.

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APPENDIX C - Data Management, Security and Confidentiality, and Data Quality Control

Data Management

1. Introduction

Cedars-Sinai Medical Center (CSMC) is the Data Coordinating Center (DCC) for this study, and data for this study is housed in the OpenClinica Electronic Data Capture (EDC) system.

OpenClinica is an open source web-based software platform for managing single or multi-site clinical research studies. It facilitates protocol configuration, design of electronic Case Report Forms (eCRFs), Electronic Data Capture (EDC), data extraction, and clinical data management. OpenClinica supports HIPAA and other regulatory guidelines, and is architected as a standards-based extensible, modular and open source platform.

2. Architecture

OpenClinica is developed using the Java J2EE framework, with a database abstraction layer interoperable with Oracle 10g. The OpenClinica DCC instance runs on a Windows Server, on top of a Tomcat application server (Servlet/JSP container) that implements the Servlet 2.x and JavaServer Pages 2.x specifications from the Java Community Process. This architecture provides a secure, robust and extensible system for managing multiple clinical research studies within a centralized repository.

The web and database servers are located at the CSMC Enterprise Information Systems (EIS) secure Data Center. The Enterprise Information System (EIS) Data Center is a modern facility with 24/7/365 power, cooling, connectivity, security and monitoring. Only authorized EIS Data Center staff will have access to manage the physical server.

Database Security and Confidentiality

1. Database Security:

Authentication: Assurance of identity of person or originator of data.

• Secure Login: The OpenClinica application uses the Tomcat standard to authenticate the identity of users that log into the system.

• Encrypted Passwords and Auto-Expiry: The application uses the Java encryption packages to protect user passwords. Each user is assigned a unique password; system has password expiration enabled with expiration time configurable by system administrator.

• Secure Connection: Usage of HTTPS and SSL in the OpenClinica server is enabled so that users are accessing a secure connection to the web server.

Integrity: Verify integrity and prevent unauthorized modification of data entered.

• All database updates and changes are logged using database-level triggers and an application-level logging API as part of the J2EE standard libraries.

Authorization: Ensure users have the rights to perform certain actions.

• Security Roles & Privileges: A privilege system is implemented at both the server level (protecting the application) and at the servlet level (protecting specific functions), regulating access to only the authorized users and roles.

Auditing: Track who accesses healthcare information.

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• Audit Triggers: Database-level Triggers are implemented for auditing all changes to clinical data, together with application-level logging for monitoring usage through the application.

• Tracking Data Updates: The system captures, stores and allows reporting of all updaters’ user IDs for any data updated, inserted or deleted in the database. The last user to update a record is instantly shown on the record itself and all updates available for auditing.

2. Database Confidentiality:

The DCC has extensive experience in complying with patient confidentiality requirements of the Institutional Review Board (IRB) and federal Health Insurance Portability and Accountability Act (HIPAA) regulations. Each patient will be assigned a unique identification number that cannot be linked to the patient that does not include names or contact information.

The OpenClinica EDC system meets the HIPAA Security Rule requirements, Title 45 CFR Part 160 and subparts A and C of Part 164, and other state and federal statutes when applicable, and established national standards to protect individuals’ electronic personal health information that is created, used, stored or maintained within the database. Appropriate administrative, physical, and technical safeguards are in place to ensure the confidentiality, integrity and security of electronic protected health information (EPHI).  Consistent with the HIPAA Privacy and Security Rules, the access, use and disclosure of any record and information within the OpenClinica EDC system is limited to the ‘minimum necessary.’

Measures in place include technical policies and procedures that allow only authorized persons to access EPHI, and for access activity to be recorded and auditable.  Security measures for the database include password management, transmission security and data encryption to guard against unauthorized access to EPHI while it is being transmitted over the network.  Physical safeguards are in place to control facility access to the EIS Data Center where the OpenClinica EDC system is housed.  The EIS Data Center has implemented operational policies and procedures to ensure proper processes are in place for the transfer, removal, disposal, and re-use of electronic media, to ensure appropriate protection of EPHI.

The OpenClinica EDC system and CSMC EIS information security standards and practices follow the code of practice for Information Security Management, ISO 17799, and other best practices as deemed necessary.

Data Quality Control

Multiple levels of data quality control will be carried out. Validation rules such as range checks are part of the OpenClinica entry process at the clinical sites. Once data are submitted to the DCC, additional data checks are performed. The project coordinator at the DCC will maintain contact via email and telephone with a designated research coordinator at each clinical site to correct errors, inconsistencies and obtain missing data. Final checks of data quality are carried out during initial data analysis when more complex, unanticipated inconsistencies often require queries to the clinical sites for verification or corrections. The DCC will track enrollment and follow-up status. Sites will be notified when data forms are due with “window” dates for followup contact requirements. The OpenClinica DCC dashboard view summarizes completeness of patient contact and form completion by site and allows for feedback to individual sites as to how they compare with the other sites. Confidential reports on data quality will be included in semi-annual reports to the DSMB.

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APPENDIX D – Fitbit Protocol

Fitbit Tracker Study - Substudy for Treatment with Ranolazine in Coronary Microvascular Dysfunction (CMD): Impact on Angina and Myocardial Ischemia (RWISE)

Anginal symptoms in the absence of obstructive coronary disease are not fully understood but are estimated to affect 2-3 million people, most commonly women, causing morbidity, possibly mortality, and societal economic burden. Many hypothesize that this disease is a result of coronary microvascular dysfunction (CMD). In patients with stable coronary artery disease the novel anti-anginal medication, ranolazine, has been shown to increase exercise duration and reduce angina frequency. The effect of ranolazine on patients with CMD is unclear; however, preliminary data suggest that it may decrease angina and improve myocardial perfusion.

Previous studies testing the efficacy of ranolazine as an antianginal therapy have relied on validated patient questionnaires, such as the Seattle Angina Questionnaire (SAQ), and stress-testing. These outcome measures are subjective and limited in scope as they provide only an isolated measurement. A more comprehensive evaluation of the effectiveness of anti-ischemic pharmacologic therapy would capture activity during the entire study period. Wireless accelerometers have been validated and allow for this assessment. Cook et al, has demonstrated the feasibility of using Fitbit, a commercially available accelerometer, as a research tool. To our knowledge, Fitbit has not been utilized to measure the effectiveness of anti-ischemic pharmacologic therapy.

The purpose of our study is to measure the effectiveness of ranolazine to increase daily activity levels in patients with demonstrated angina and CMD. We hypothesize that treatment with ranolazine will increase daily activity compared to placebo.

SPECIFIC AIMSAim 1 – To evaluate the difference in daily activity (total, average, and maximum step count, distance

traveled (miles), and calories) in subjects treated with ranolazine 1000 mg BID compared to placebo over a 2 week treatment period

Aim 2 – To evaluate the relationship between daily activity (total, average, and maximum step count, distance traveled (miles) and calories) and angina as measured by Seattle Angina Questionnaire (SAQ) and patient diary logs of angina episodes

Aim 3 – To evaluate the relationship between daily activity (total, average, and maximum step count, distance traveled (miles), and calories) and quality of life as measured by DASI and SF-36

Aim 4 – To evaluate the relationship between daily activity (total, average, and maximum step count, distance traveled (miles), and calories) and markers of ischemia (CMRI perfusion) and cardiac function (diastolic function and BNP)

By performing this clinical trial we will be the first research group to utilize wireless activity monitors to investigate pharmacologic treatment of a cardiovascular condition. This accomplishment will allow us to partner with research groups at Cedars Sinai to investigate cardiovascular interventions (procedures, devices, pharmacologic therapies) by offering a methodology that is inexpensive, objective, and relevant to real-life experience. We will leverage our expertise to answer clinical questions and to translate emerging biofeedback or quantified self-movement technologies to clinical practice.

RESEARCH PLANBACKGROUND: Disabling chronic angina is an increasingly common symptom that limits functionality and

quality of life (Olson M 2003). In fact, the number, frequency and severity of angina episodes are directly correlated to decreases in social and psychological well-being as well as functional impairment as determined by ability to perform daily activities (Olson M 2003). Many of these patients are found to have classic coronary artery disease and develop angina due to obstructed myocardial blood flow (Phan A 2009). However, a unique

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subset has no evidence of blood flow obstruction as measured by traditional coronary angiography despite evidence of myocardial ischemia during exertion measured by stress testing and cardiac MRI (Mehta 2011, Kothawade K 2011). This syndrome has been named Coronary Microvascular Dysfunction (CMD).

Coronary circulation is made up of arteries, pre-arterioles, arterioles, and capillaries which serve to oxygenate the myocardium (Camici PG 2007). CMD refers to dysfunction at the microcirculatory level from the prearterioles to the capillaries which results in a decreased ability to meet oxygen demand, commonly referred to as ischemia (Kothawade K 2011, Kansra U 2001).

CMD is traditionally detected with invasive coronary reactivity testing (CRT) by excluding obstructive coronary artery disease and identifying reduced coronary flow reserve as an index of the coronary microvascular function (Kothawade K 2011). Coronary flow reserve represents the ratio comparing the blood flow after administration of vasodilators (ie adenosine, dypridamole) compared to blood flow at rest (Camici PG 2007, Reis SE 2001). Non-invasive and less time consuming diagnostic techniques such as thermodilution, positron emission tomography (PET), and cardiac magnetic resonance imaging (CMRI), have also been utilized (Kuruvilla S 2013, Mehta 2011). In fact, CMRI measurement of ischemic abnormalities has been shown to correlate well with CRT and is used as a diagnostic tool to measure CMD (Mehta 2011).

CMD is estimated to affect at least 2-3 million people, most commonly women, and has been found to increase the risk of death or cardiovascular events, including heart failure (diastolic dysfunction), myocardial infarction, and stroke (Kothawade K 2011, Pepine 2010, Kaul 2008). Although the exact pathophysiological mechanism of CMD is not fully understood, it is treated with conventional anti-ischemic pharmacologic therapies such as beta-blockers, calcium channel blockers, and nitrates (Kothawade K 2011). Unfortunately, these traditional therapies have not produced a consistent therapeutic response and many patients continue to suffer from symptoms with no readily available therapy (Kothawade K 2011).

Ranolazine is a novel anti-ischemic pharmacologic therapy which was approved in January 2006 by the FDA for use in patients with chronic angina who are symptomatic on nitrates, beta-blockers, or calcium antagonists. Subsequent approval in 2009 extended use to primary anti-anginal therapy. The mechanism of action is not fully understood, but most recent evidence suggests that ranolazine reduces calcium overload in the ischemic myocyte through inhibition of the late sodium current (Chaitman 2006). Clinical trials such as MARISA, CARISA, ERICA, and MERLIN-TIMI 36, have clearly defined the role of ranolizine in the treatment of angina due to coronary artery disease. However, none of these clinical trials specifically evaluated the efficacy and safety of ranolazine in the treatment of CMD (Chaitman B 2004, Chaitman B 2004, Stone P 2006, Morrow D 2007, Wilson 2009).

Mehta et al performed a pilot randomized, 1 month cross-over pilot trial of ranolazine 1,000 mg by mouth twice daily versus placebo in 20 women with CMD (Mehta 2011). The findings demonstrated significant improvement in quality of life (QOL), specifically a decrease in physical limitation (a measure of how much a patient’s condition is hampering their ability to be physically active) and increased angina stability scores (measures whether a patient’s symptoms are changing over time), but did not improve angina frequency (a measure of how often a patient is having symptoms). These improvements were measured using the Seattle Angina Questionnaire (SAQ), a self-administered, disease specific measure for patients with CAD.

This pilot study has led to an ongoing clinical trial which is evaluating ranolazine in 134 subjects with CMD by measuring the impact of 2 weeks of ranolazine 1000mg by mouth twice daily compared to placebo on: angina stability and angina frequency (measured by SAQ), angina frequency (measured by diary), ischemia (measured by CMR perfusion), and QOL (Mehta P www.clinicaltrials.gov NCT01342029).

The hypothesis of the clinical trial is that ranolazine, by improving myocardial perfusion, will reduce angina symptoms and therefore increase daily activity. This is based on two important factors: (1) patients with CMD subjectively report limitation in functionality due to angina and (2) as mentioned previously, a pilot study, Mehta et al, demonstrated that treatment of CMD with ranolazine improves quality of life and decreases physical limitations (Mehta 2011, Olson M 2003). However, despite these findings, many factors related to our

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understanding of CMD and how it responds to treatment remain unknown. These factors include (1) The impact of CMD on daily activity, (2) The relationship between patient reported symptoms of angina and daily activity, and (3) The effect of anti-anginal therapy on daily activity. The reason why this information isn’t well known is because the methods that have been utilized to evaluate CMD have been largely based on questionnaires.

Multiple questionnaires are available to assess functional limitation caused by angina. The three we will

highlight are the Duke Activity Status Index (DASI), the Short Form 36 (SF36), and the Seattle Angina Questionnaire (SAQ). DASI is a 12-item, self-administered questionnaire that assesses functional capacity by determining the patient’s ability to perform a range of specific daily activities such as housework, walking, yard work, recreational activities, and strenuous sports (Blatky M 1989). The SF36 is a broad measure of functional status that uses eight scaled scores which measure vitality, physical functioning, general health functioning perceptions, physical role functioning, emotional role functioning, and mental health (Ware J 1992). The SAQ is a validated 19-item self-administered questionnaire that measures five dimensions of coronary artery disease: physical limitation, angina stability, angina frequency, treatment satisfaction and disease perception (Spertus JA 1995).

Together, these questionnaires quantify patient reported activity and quality of life. The benefit of questionnaires from an investigative perspective is that they are reproducible, responsive to clinical change, and have been validated in clinical trials. In clinical trials, these questionnaires have been shown to correlate with exercise stress testing (Spertus JA 1995). However, these measures are limited in that they are subjective and isolated point-in-time measurements resulting in non-continuous data. In fact, previous studies have shown that questionnaires fail to accurately correlate with activity as measured by activity tracking devices (Bassett D 2000). These limitations contribute to current gaps in our understanding of CMD and therefore present an area of investigational opportunity.

The purpose of this application is to rigorously, and objectively, measure effects of anti-ischemic therapy, specifically ranolazine, on daily activity in patients with CMD using Fitbit. Fitbit is a wearable accelerometer that continuously measures the quantity and intensity of daily activity, which includes walking, running, or stair-climbing (http://www.fitbit.com). Data is measured over an average period of 5-10 days and generates a downloadable report of steps, distance covered (miles), and calories burned (http://www.fitbit.com). Fitbit is easy to use for patients and investigators which allow reliable activity monitoring which can be electronically downloaded and analyzed. In addition, it has a reported accuracy of 97.5% in measuring steps based on validated direct observation and other activity monitors used in scientific investigation (Mammen G 2012, http://www.fitbit.com). This tool will improve upon existing methods for the evaluation of CMD by comprehensively and objectively measuring parameters that relate to physical activity.

RESEARCH OBJECTIVES: We hypothesize that treatment with ranolazine will increase daily activity in patients with CMD. To evaluate this hypothesis, we will investigate (1) how effective ranolazine is at increasing physical activity, (2) how daily activity correlates with angina (3) if objective reporting of daily activity correlates with previously validated questionnaires (SAQ, DASI, SF-36) and (4) how daily activity correlates with markers of ischemia (CMRI perfusion) and cardiac function (diastolic function and BNP).

STUDY DESIGN: Randomized, placebo-controlled cross-over clinical trial

METHODOLOGYSUBJECT RECRUITMENT: Subjects will be recruited from the ongoing RWISE Clinical Trial at Cedars

Sinai Medical Center which aims to enroll 134 subjects over 2 years who have signs or symptoms of myocardial ischemia with no evidence of obstructive coronary disease and CMD as measured by cardiac catheterization or cardiac MRI (APPENDIX I). Eligibility criteria are as follows:

INCLUSION CRITERIA EXCLUSION CRITERIA• men or women age >18 yrs from diverse racial/ethnic groups• competent to give informed consent• chronic angina or its equivalent

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• coronary angiogram revealing CMD with no obstructive CAD (epicardial coronary stenosis <50% luminal diameter stenosis)

• left ventricular ejection fraction > or = 45%• objective evidence of ischemia by noninvasive methods such as exercise stress test stress Echo or

SPECT• patients with an invasive measured CFR < 2.5 or ACH response of no dilation or constriction

determined by local site read or patients with cardiac MRI of an MPRI ≤ 1.8• patients must have withdrawn from ranolazine at least 2 weeks prior to study entry• qualifying WISE or clinical cardiac MRI scan must be completed within 2.5 years +/- 1 month of study

participation• qualifying angiograms must be within 2.5 years +/- 1 month of study participation • acute coronary

syndrome (defined by WHO)• cardiogenic shock or requiring inotropic or intra-aortic balloon support• planned percutaneous coronary intervention or CABG or established obstructive CAD with ischemia

eligible for revascularization• acute MI• prior non-cardiac illness with an estimated life expectancy <4 years• unable to give informed consent• allergy or contra-indication to CMRI testing, including renal failure, claustrophobia, and asthma• uncontrolled moderate hypertension (sitting blood pressure >160/95mmHg with measurements

recorded on at least 2 occasions)• conditions likely to influence outcomes: Severe lung, creatinine >1.8 or CrCl ≤ 50ml/min) or hepatic

disease, surgically uncorrected significant congenital or valvular heart disease and other disease likely to be fatal or require frequent hospitalization within the next six months

• adherence or retention reasons• unwilling to complete follow-up evaluation including repeat testing• documented obstructive hypertrophic cardiomyopathy• aortic stenosis (valve area <1.5cm)• LV dysfunction (ejection fraction <45%)• history of significant cocaine or amphetamine abuse• taking potent CYP3A4 inhibitors (ketoconazole, itraconazole, nefazodone, troleandomycin,

clarithromycin, ritonavir, nelfinavir)• women who are pregnant• immobility• physically inability to wear wrist band (ie amputation)• data collected <50% of study periodFollowing informed consent, subjects meeting inclusion criteria will undergo baseline testing and then be

randomized into a clinical cross-over trial of stepped dosing of ranolazine or placebo 1,000 mg po bid for 2 weeks with exit testing which includes cardiac MRI, SAQ and angina diary, DASI and SF-36, BNP, and Fitbit removal and data downloading followed by cross-over to the alternate ranolazine or placebo and repeat exit testing. Ranolazine will be used as first-line anti-anginal therapy; however, subjects will be maintained on existing medical therapy as needed, serving as their own controls with symptomatic angina. Dosing for ranalozine or placebo will be 1 pill twice a day (500 mg bid) for 1 week, and then 2 pills twice a day (1000 mg bid) as tolerated until exit testing at 2 weeks for both the ranolazine and placebo periods. Study subjects have four clinic visits at Baseline 0 week, 2 weeks, 4 weeks, Exit 6 week. An ECG will be performed at weeks 0, 2, and 6 for safety monitoring.

The Fitbit consists of a flexible wristband made of durable elastomer material that contains an insertable accelerometer chip. During baseline testing each subject will have a unique Fitbit account set up that is password protected, encoded, and accessible only by research coordinators. In addition, prior to each cross over period, they will be given a Fitbit accelerometer, Fitbit wristband, and a wall charger. Subjects will be instructed in clinic on the Fitbit placement and monitoring protocol. In addition, Fitbit utilization and data collection will be conducted according to the data collection protocol. Subjects will receive a reminder telephone call from a research coordinator to place the Fitbit on their non-dominant wrist for continuous

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monitoring of activity as measured by step-count for a period of 7 days during the second week of each 2 week cross-over period. After 7 days of continuous monitoring, the Fitbit equipment will be returned to the research coordinator for data collection. Fitbit data, including daily step count, daily distance traveled (miles), and daily calories burned will be collected by the research coordinator by connecting the device to a secure laptop and accessing the unique Fitbit password protected encoded account for downloading. All data during the monitoring period will be manually entered into a secure database by the research coordinator for analysis. Fitbit data will be made available to subjects after completion of the clinical trial.

To assure subject safety and proper handling of the Fitbit equipment, subjects will be instructed on exposure to liquids, battery charging, device cleaning, device connection, daily activity, nightly activity, and allergic reaction.

ANTICIPATED RESULTS: A national pedometer study in healthy adults (average functionality) showed that the average person walks 5,000 steps per day (BASSETT D 2010). In a representative, cross-section, of middle-aged African American males (average functionality), only 31% of participants achieved greater than 7,000 steps per day, with a maximum of 7,499 (NEWTON RL 2012). Steps per day are reduced to less than 1,000 immediately after cardiac surgery (extremely low functionality) and are as a low as 2,500 in patients with congestive heart failure (low functionality) (COOK 2013, KAZUHIRO IP 2011, JEHN 2011). When considering these findings in the context of the previously discussed functional limitations patients with CMD experience, we anticipate our population will experience average to below average daily activity and that this will be increased by 20% with ranolazine treatment. Therefore, we expect the following: (1) ranolazine will increase steps per day from 5,000 to 6,000, (2) ranolazine will decrease angina symptoms (angina diary and SAQ) and this will positively correlate with increased daily activity (steps per day, distance covered, calories burned), (3) ranolazine will decrease angina symptoms and therefore increase questionnaire reported activity and quality of life, this will positively correlate with increased daily activity (steps per day, distance covered, calories burned), (4) ranolazine will decrease ischemia (CMRI perfusion) and improve cardiac function (CMRI diastolic dysfunction, elevated BNP) which will positively correlate with increased daily activity (steps per day, distance covered, calories burned).

SAMPLE SIZE AND POWER ANALYSIS: A sample size of 12 achieves 82% power to detect a mean of paired differences of 1,000 between the null hypothesis that both ranolazine and placebo means are 6,000 and the alternative hypothesis that the mean of placebo is 5,000 with an estimated standard deviation of differences being of 1,100.0 and with a significance level (alpha) of 0.05000 using a two-sided paired t-test. To account for 40% dropout, 18 subjects will be enrolled to have 12 completed subjects for evaluation. Specific to our study, we anticipate that the possibility of ranolazine intolerance, incomplete data, uncharged device, or device failure may contribute to the overall dropout rate.

DATA ANALYSIS: Quantifying daily activity with Fitbit will allow us to draw conclusions about the relationship between daily activity and the clinical endpoints outlined in our aims. Specifically, we will perform statistical analysis to demonstrate the following: (1) if a patient has CMD and they are treated with ranolazine, they will have an objective increase in daily activity, (2) increased daily activity will occur because of the anti-ischemic effects of ranolazine which reduces symptoms of angina and therefore patients who experience decreased angina will experience increased daily activity, (3) as angina decreases, quality of life increases, therefore patients who experience increased quality of life will also experience increased daily activity, and finally (4) if a patient has CMD and they are treated with ranolazine, their markers of ischemia (CMRI perfusion) and cardiac function (diastolic function and BNP) are expected to improve and this will also correspond with increased daily activity. In summary, these findings will provide supportive evidence regarding (1) the underlying pathyophysiologic mechanism of ischemia as a driving force behind the functional limitation observed in patients with CMD and (2) the proposed pharmacologic mechanism of ranolazine and its effectiveness in mitigating angina.

TIMELINE: The anticipated timeline for this clinical trial is 12 months (range 9-15 months), with ongoing, rolling recruitment into the RWISE randomized clinical trial. On average 2-5 subjects are recruited monthly. Data collection and management will be ongoing and updated throughout the duration of the clinical trial.

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POTENTIAL PITFALLS AND CHALLENGES: We anticipate three primary pitfalls or challenges: (1) patient drop out and lost or damaged Fitbit which will result in loss of data, (2) incomplete data recorded by Fitbit, (3) lack of control for heterogeneity in baseline anti-ischemic therapies. To address these challenges, we will (1) enroll sufficient patients to allow for a 20% drop-out. (2) We will exclude patients from our analysis if less than 3 days of activity are recorded. We will report maximum activity and average activity achieved, which are less affected by incomplete data (less than 7 days, but at least 3 days) than total activity achieved. We will also perform a sub-group analysis to evaluate our specific aims in patients who we have collected at least 3 days of data (total, average, maximum of best 3 days) and analyze whether there is an interaction between 3 days of data and 7 days of data. (3) By including patients who have symptomatic ischemia we anticipate that they will serve as their own control despite differences in baseline anti-ischemic therapy.

SIGNIFICANCE: The potential impact of this application is important. If ranolazine is found to be effective, it will be the first time a treatment for CMD has been shown to increase daily activity. In order to make treatment of CMD with ranolazine standard of care we will need to perform a large randomized clinical trial for which we would apply our established wireless activity monitoring methodology. In addition, our application will generate robust data which will allow for the most comprehensive evaluation of the relationship between daily activity and CMD performed to date. This new information will inform future investigation of CMD and potentially therapeutic target development. Finally, because we will have developed a proven methodology and expertise in utilizing wireless activity monitoring in a clinical trial we foresee opportunity at Cedars-Sinai Medical Center to seek extramural grant support to fund partnerships with investigative groups in the evaluation of cardiovascular conditions and interventions including procedures, devices, or pharmacologic therapies.

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Patient Instructions

1. Insert your device into the charging cable.  Line up the device with the charging cable (Pic 1), putting the rounded end of the device into the charging cable at a slight

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Thank you for participating in the R-WISE activity monitoring study

The purpose of this study is to measure activity during your participation in the R-WISE Clinical Trial protocol

Activity will be evaluated by measuring step count with the Fitbit activity monitor

Please continue to pursue normal activities throughout the duration of the study

The Fitbit activity monitor is registered to Cedars Sinai Medical Center

You will not be able to access your activity data during the study. At the completion of the study you will be provided a complete record of your data.

If the Fitbit activity monitor is lost or damaged contact the research coordinator at (310) 423-9666.

angle (Pic 2). Use your thumb to push the device in and down into the charging cable until you hear a click (Pic 3). (This step will likely be already done for you in the clinic)

2. Insert the charging cable into a USB port wall charger

3. Continue to charge the device for one week. After 1 week, you will be contacted by a research coordinator.

The research coordinator will instruct you to remove the device from the wall charger and insert the device into the housing compartment on the device wristband. Hold the tracker in your hand with the grey arrow facing up. Insert this end into the wristband, with the arrow pointing toward the holes in the wristband.

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Pic 3Pic 1 Pic 2

1. Place device wristband on non-dominant arm so the window of lights are closest to the outside of your wrist and facing you.

2. Align both ends of the wristband so they are directly overlapping each other with the clasp over the two holes that best fit your wrist. Squeeze both the clasp and the wristband between your thumb and forefinger until you hear a click.

3. Wear device on non-dominant arm for one week4. After 1 week, you will be contacted by a research coordinator and asked to

remove the device and wristband5. Return the device and supplies to the research coordinator after 1 week

Frequently Asked Questions

1. Can I take a shower or go swimming with my device?

Although the device is water resistant, we advise that you remove your device prior to showering or swimming and place the device on your non-dominant arm after thoroughly drying your wrist area where you will place the device.

2. Can I develop an allergic reaction to my device?

Your wristband is made of flexible, durable elastamor material similar to that used for commercial sports watches. If rash, itching or redness occurs, remove the device immediately and call a research coordinator.

3. After charging, how long will my device battery last?

In general, your device will remain charged for 5-10 days. You do not need to monitor your device battery life status.

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4. Do I need to clean my device?

No you do not need to clean your device. Do not submerge your device in water or use abrasive cleaners. If your device becomes dirty, contact a research coordinator for instruction.

5. Do I need to connect my device to a smartphone, tablet, or computer?

It is not possible for you to connect your device to smartphone, tablet, or computer. All devices are registered to Cedars Sinai Medical Center and are incapable of syncing with your personal device. You will be provided all of your personal data upon completion of the study.

6. Can I wear my device while I am sleeping?

Yes, we expect that the device is worn continuously until you are instructed otherwise by a research coordinator.

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