Inhaled Sodium Nitrite on Heart Failure With Preserved Ejection Fraction

Patients referred to the cardiac catheterization laboratory for invasive exercise stress
testing will be prospectively recruited. Standard right heart catheterization using high
fidelity micromanometers (Millar Instruments) will be performed at rest and during supine
exercise with simultaneous expired gas analysis (Medgraphics) as is the investigator's
current practice. The protocol is rest—passive leg elevation--20 Watts exercise x 5 minutes,
and then graded workload increases in 10Watt increments (3 minute stages) to exhaustion.
Hemodynamic, arterial and mixed venous blood gas and expired gas data are acquired at rest,
during each exercise stage and at peak exercise. Venous blood samples will be obtained at
rest and at peak exercise. Perceived symptoms of dyspnea and fatigue will be quantified
using the Borg dyspnea and effort scores at each stage of exercise.

After the initial exercise study and hemodynamics have returned to baseline, previously
prepared study drug (normal saline placebo or Sodium Nitrite Inhalation Solution (AIR001)
90mg placed into the medication chamber) will be nebulized utilizing the Aerogen
Solo-Idehaler over 10-15 minutes. After a 15 minute observation period post completion of
nebulization, resting hemodynamic and expired gas data will be acquired exactly as in the
initial run. Subjects will then repeat the leg elevation-20 Watt x 5 minutes exercise phase.
Blood samples will be again obtained at rest and with exercise. Subjects will repeat
exercise only at the 20 Watt stage, rather repeating the entire study. This is done to
increase the feasibility and shorten the time of the case. The investigators have previously
observed that the vast majority (>85%) of the elevation in cardiac filling pressures and
reduction in venous oxygen content in people with HFpEF occurs at the low 20 Watt workload,
so repeating exercise hemodynamic assessment at this load should be sufficient to detect any
clinically meaningful treatment effect.

Inclusion Criteria:

- HFpEF is defined by clinical symptoms of dyspnea and fatigue

- Normal left ventricular ejection fraction (>/=50%)

- And elevated Left Ventricular (LV) filling pressure at cardiac catheterization
(defined as resting Pulmonary Capillary Wedge Pressure (PCWP)>15 mmHg and/or PCWP
>/=25 mmHg during exercise).

Exclusion Criteria:

- Systolic Blood Pressure <120 mmHg (during catheterization)

- Prior nitrate therapy (within previous 2 weeks)

- G6PD-deficiency

- Other "non-HFpEF" specific causes of heart failure such as significant valvular
disease (>moderate left-sided regurgitation, >mild stenosis)

- Severe pulmonary disease

- Unstable coronary disease or coronary spasm

- Primary renal or hepatic disease (end stage renal failure/on dialysis or clinical
diagnosis of hepatitis or hepatic cirrhosis)

- Constrictive pericarditis, or infiltrative, restrictive, or hypertrophic
cardiomyopathies

- Pregnant