Myocardial Protection in Patients With Post-acute Inflammatory Cardiac Involvement Due to COVID-19

Patients with documented COVID-19 infection, experiencing new cardiac symptoms in the aftermath of COVID-19 infection, fulfilling predefined CMR criteria for PostCOVID myocardial involvement and no previously known or demonstrable cardiovascular disease will be randomised to 16-week treatment with Losartan/Prednisolon or placebo. All imaging is conducted with fidelity to standardised imaging protocol. All images are analysed in a dedicated core-lab to confirm eligibility for inclusion. Investigators and participants remain blinded to group allocation and imaging results.

The primary outcome is a change in LVEF from the baseline to 16 weeks measured by MRI.

Secondary outcomes include changes in clinical symptom scores, imaging parameters, CPET (VO2max), as well as outcomes after 1 years time.

Inclusion criteria

• Patients ≥ 18 years
• Patients with documented recent COVID19 infection (>4 weeks)
• PASC Syndrome, defined by persistence or new symptoms, not present prior to the infection.
• CMR evidence of inflammatory cardiac involvement at BL by any of the following criteria:
• Increased native T1≥ 1130 ms at 3.0 Tesla (or 1030 ms at 1.5 Tesla) and/or;
• Increased native T2 ≥39.5 ms at 3.0 Tesla (or 49.5 at 1.5 Tesla) and/or
• present non-ischaemic myopericardial LGE and/or;
• LVEF ≥45 - ≤50%.
• Willingness to comply with the study procedures and study protocol

Exclusion criteria

• Severe acute COVID illness requiring hospitalisation
• Known allergy to or intolerance of the study medications
• Symptomatic hypotension (systolic blood pressure less than 90 mm Hg), not reversible with oral hydration
• Any previous or current use of ACE inhibitors, AR Blockers
• Any previous oral prednisolone, or any other immunosuppressive or biological treatment (within prior 10 weeks)
• History or CMR evidence of pre-existing significant heart disease, including:

• Known cardiac impairment with LVEF ≤44%
• Congestive heart failure (NYHA III-IV)
• Active heart failure treatment
• Established ischaemic heart disease, peripheral arterial disease and/or cerebrovascular disease
• Persistent or permanent atrial fibrillation or significant heart rhythm abnormalities
• Congenital or clinically relevant valvular heart disease (moderate or severe)
• Specific cardiomyopathy (hypertrophic, hypertensive heart disease, amyloidosis, previous myocarditis, non-ischaemic dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, non-compaction cardiomyopathy, etc).
• Known significant concomitant diseases that are likely to interfere with the evaluation of the patient's safety and of the study outcome (e.g. diabetes, lung or hepatic disease, epilepsy, psychiatric disorders, renal disease with a current estimated GFR <30 mL/min/1.73 m² using MDRD formula, chronic systemic infection or immunocompromise)
• Exceeding scanner bore and table-holding capacity: Weight >125 kg, BMI > 35 kg/m2
• Contraindications to contrast-enhanced CMR imaging, e.g.

• MR-unsafe implantable device
• known allergy to gadolinium-based contrast agent (CBGA)
• For female participants:

• Pregnant or breastfeeding women
• Persons of childbearing potential not willing to use effective contraception (defined as PEARL index <1 - e.g. contraceptive pill, IUD)
• Known alcohol, drug or chemical abuse
• Patients currently participating in an investigational study or for whom participation is planned.
• Unable to provide written informed consent

Patients with CMR evidence of structural heart disease or incidental heart rhythm abnormalities will be advised to see their own doctor for further investigation.