HDL-cholesterol versus apoA-I and Atherosclerosis Regression Prof. Erik Stroes Academic Medical Centre Amsterdam, The Netherlands

HDL-c decreases CV-risk via ‘Reverse cholesterol transport’ 4.0 3.0 2.0 1.0 0.65 1.17 1.68 HDL-c (mmol/L) Kannel WB AJC 52, 1983 – Framingham Study Risk INTESTINE LIVER PERIPHERAL TISSUES HDL VLDL LDL Chylo-microns Exogenous cholesterol Bile excretion MACROPHAGE

HDL-c concentration and CV-risk No association ‘genetic’ HDL-c increase and risk Epidemiology OR / 0.03 mmol/L HDLc increase Genetics OR / 0.03 mmol/L HDLc increase Cohort Atherosclerosis Risk in Communities Study Copenhagen City Heart Study Malmo Diet and Cancer Study, Cardiovascular Cohort Framingham Heart Study Heart Professionals Follow up Study Danish Diet, Cancer, and Health Study Meta-analysis of cohort studies Per 0.03 mmol/L (1 mg/dL) increase in plasma HDL-c Per 0.39 mmol/L (15 mg/dL) increase in plasma HDL-c 0.97 (0.96-0.98) 0.98 (0.98-0.99) 0.96 (0.94-0.98) - 0.98 (0.97-0.98) 0.70 (0.66-0.74) 7x10-18 6x10-13 1x10-6 4x10-6 - 4x10-36 0.96 (0.86-1.07) 1.09 (0.95-1.26) 0.82 (0.66-1.01) 1.17 (1.00-1.37) 1.84 (0.39-8.62) 1.05 (0.79-1.41) 1.02 (0.95-1.09) 1.28 (0.46-3.61) 0.44 0.21 0.06 0.16 0.71 0.64 Voight, Lancet 2012

HDL-c concentration and CV-risk No association ‘drug-induced’ HDL-c increase and risk ILLUMINATE Torcetrapib: HDLc  +72% : CV-death OR +1.25 DALOUTCOMES Dalcetrapib: HDLc  +35% : CV-events no change HPS2-THRIVE Nicotinic acid: HDLc  +15-25% : CV-events no change Meta-analysis Briel et al HDLc  +2-15% : CV-events no change HDL-c change no longer valid as surrogate for future CV-risk. Barter, New Engl J Med 2007; Schwartz GG, New Engl J Med 2012 Eur Heart J 2013; Briel, BMJ 2009

HDL-c and Reverse cholesterol transport No association between HDLc and fecal chol. excretion HDL-c concentration no longer valid as surrogate for RCT capacity. Broussea, ATvB 2005

Is apoA-I/HDL involved in RCT?

Decreased ‘Tissue cholesterol efflux’ in apoA-I/L178P heterozygotes Holleboom, Stroes J Lipid res 2013

Increased ‘Vessel-wall thickening’ in ABCA1 & LCAT- heterozygotes ABCAI heterozygotes LCAT heterozygotes Mean wall area outer wall area Duivenvoorden, Stroes, JACC 2010; Bochem, Stroes, J Lip Res 2013

Number of HDL particles more relevant than HDL-c concentration Mackey et al., JACC 2012

DO APOA-I - INCREASING STRATEGIES WORK?

apoA-I increase and RCT effect of rHDL particle infusion (≈ 45mg/kg) After Infusion 35% peak Increase Before Infusion Bile Acids 400 Neutral Sterols HDL-C (mg/dl) 41±7 300 Intestinal Excretion mg/day 200 100 0.0 SG GG LM IN Eriksson, Circ 1999

apoA-I increase and Plaque regression effect of rHDL particle infusion (40mg/kg) on peripheral atheroma Shaw, Circ Res 2008

apoA-I and Plaque regression Effect of ApoAI milano on coronary atheroma REVERSAL ASTEROID APOA-1 Milano 4 4 2.7* 2 Median change in TAV (%) -0.3† -0.8 -4.2 Prava 40 mg 18 months Atorva 80 mg 18 months -2 Rosuva 40 mg 24 months -4 ApoA-1 Milano 5 weeks Progression From no change to regression Nissen SE et al. JAMA. 2003 and 2004 Reference 1. Nissen SE, et al. JAMA. 2004;291:1071-80.

apoA-I and Plaque regression rHDL& delipidated HDL and coronary atheroma Reconstituted HDL (CSL-111) Delipidated HDL (LS-001) Tardiff, JAMA 2007; Waksman, JACC 2010

New apoA-I therapies CER-001 CER-001: recombinant human apoA-I preB HDL particle composed of recombinant human Apolipoprotein A-I and phospholipid containing Sphingomyelin and dipalmitoyl phosphatidylglycerol reconstituted charged pre-beta High Density Lipoprotein, mimicking biological properties of natural HDL

Preliminary results SAMBA study CER-001 infusion in Subjects with Familial HDL-C deficiency Trial design: Baseline Evaluations Lipoprotein profile Cholesterol Flux MRI Initial Dosing Period CER-001 Day 1 Lipoprotein profile PK and PD Cholesterol Flux Induction Period CER-001 q3 days Day 8 through Day 29 Lipoprotein profile PK and PD MRI Day 29 Maintenance Period CER-001 q2 weeks Week 6 through Week 24 Final Dosing Period CER-001 Week 26 Lipoprotein profile PK and PD MRI Study Drug Dosing First dose CER-001 8mg/kg Infusions every 3 days CER-001 8mg/kg, Day 1 to Day 29, 9 doses total Infusions every 2 weeks CER001 8mg/kg, 10 doses Final dose Methods: Safety & lipid profiles Cholesterol flux: 2H4-sitostanol (oral) 13C2-cholesterol (iv) Vessel wall dimension: 3T-carotid & aorta MRI

Summary Both HDL-chol & apoAI are inversely related to CVD-risk Recent drug trials & genetic studies challenged the protective role of HDL Novel concept: HDL particle number better predictor of CV risk? CER-001, a recombinant human ApoA-I particle: Promotes plasma efflux capacity Promotes fecal cholesterol excretion Reduces carotid wall thickness in patients with genetic low-HDLc levels Ongoing clinical trials with HDL-c & apoAI elevators will help us determine the value of HDL vs. ApoA-I therapy