Rationale for Targeting HDL Steven E. Nissen MD Disclosure Clinical Trials: AstraZeneca, Eli Lilly, Novartis, Takeda, Resverlogix, Orexigen, Vivus, and Pfizer. Companies are directed to pay any honoraria, speaking or consulting fees directly to charity so that neither income nor a tax deduction is received.

Steven E. Nissen, MD Clinical Trials: AstraZeneca, Eli Lilly, Novartis, Takeda, Resverlogix, Orexigen, Vivus, and Pfizer. Companies are directed to pay any honoraria, speaking or consulting fees directly to charity so that neither income nor a tax deduction is received.

Acknowledgements H. Bryan Brewer, Jr, MD MedStar Research Institute Washington, DC Philip Barter The Heart Research Institute Sydney, Australia Stephen J. Nicholls South Australian Health and Medical Research Institute Prof. of Cardiology, University of Adelaide, Australia

Residual Clinical Risk in Statin Trials

HDL as a Therapeutic Target Surface Monolayer of Phospholipids and Free Cholesterol apoA-I apoA-II Hydrophobic Core of Triglyceride and Cholesteryl Esters Rye Atherosclerosis 1999

Heterogeneity of Circulating HDL Particles Apolipoprotein Composition Particle Shape Discoidal Spherical (A-I)HDL (A-I/A-II)HDL (A-II)HDL Particle Size Lipid-poor/Lipid-free apoA-I HDL2b HDL2a HDL3a HDL3b HDL3c

Potential Targets to Modify HDL Increase apolipoprotein A1 (apo A1) production Increase anti-inflammatory effect of high-density lipoprotein (HDL) Infuse apo A1 phospholipid complexes PPAR alpha, delta and gamma LXR agonists Upregulate ABCA1 or ABCG1 Enhance LCAT activity Inhibit CETP Modify hepatic holoparticle uptake of HDL (niacin receptor agonist) Potential targets to modify HDL There are several potential targets to modify reverse cholesterol transport (RCT). Based on animal models and genetic disorders, increases in apo A1 production would most likely result in the most favorable improvement in RCT. Synthetic forms of HDL, HDL mimetics, reconstituted HDL, and reinfusing delipidated HDL are all potential therapeutic approaches in human clinical trials. LXR is the nuclear receptor that protects cells from cholesterol toxicity. Oxysterols are ligands for LXR, and if elevated, they upregulate LXR, resulting in the cellular transduction of the ATP-binding cassette sterol transporters, such as ABCA1 and ABCG1, that efflux free cholesterol into either nascent HDL (ABCA1) or mature HDL (ABCG1). Enhancing LCAT activity will increase the esterification of cholesterol in HDL, resulting in HDL maturation. Inhibiting CETP will increase HDL particle size and delay catabolism of HDL. Modifying the holoparticle uptake of HDL (a possible medication of niacin) will also delay catabolism by allowing the HDL particle to continue circulating and potentially increase RCT. HDL=high-density lipoprotein LXR=liver X receptor ABCA1=ATP-binding cassette transporter A1 ABCG1=ATP-binding cassette transporter G1 LCAT=lecithin cholesterol acyltransferase CETP=cholesteryl ester transfer protein

Why should we believe that HDL therapy will improve outcomes?

Framingham Heart Study CAD Risk in Relation to Levels of LDL-C and HDL-C in Men (Ages 50 to 70 Years) Framingham Heart Study mmol/L mg/dL CAD Relative Risk CAD risk as a function of LDL-C and HDL-C in men (ages 50 to 70 years old): Framingham Heart Study The lower the high-density lipoprotein cholesterol (HDL-C) level, the greater is the likelihood of developing coronary artery disease (CAD). This relationship of risk is gradually enhanced as low-density lipoprotein cholesterol (LDL-C) levels are increased. The risk nearly reaches 3-fold when LDL-C is 220mg/dL and HDL-C is 25mg/dL. HDL-C remains an important risk factor even in patients with a low LDL-C level. For example, a patient with an LDL-C of 100mg/dL and an HDL-C of 25mg/dL has a similar risk of coronary heart disease as a patient with an LDL-C of 220mg/dL and an HDL-C of 45mg/dL. Reference: Castelli WP. Cholesterol and lipids in the risk of coronary artery disease—the Framingham Heart Study. Can J Cardiol .1988;4:5A-10A. 25 0.65 45 1.16 65 1.68 HDL Cholesterol 85 2.2 220 160 100 mg/dL 5.69 4.14 2.58 mmol/L LDL Cholesterol Reprinted from Castelli WP. Can J Cardiol. 1988;4:5A–10A,

MACE Rates vs. On-treatment HDL-C and LDL-C Outcomes in the Treating to New Targets (TNT) Trial Atorvastatin 10 mg Atorvastatin 80 mg Mean LDL-C 99 mg/dL Mean LDL-C 73 mg/dL Percentage of Patients Major cardiovascular events according to on-treatment HDL-C: Treating to New Targets (TNT) trial The Treating to New Targets (TNT) trial demonstrated that atorvastatin 80 mg with an on-treatment low-density lipoprotein cholesterol (LDL-C) of 73 mg/dL decreased coronary events in a coronary heart disease patient population more than atorvastatin 10 mg with an on-treatment LDL-C of 99mg/dL. Low high-density lipoprotein cholesterol (HDL-C) (i.e., HDL-C <40 mg/dL) was associated with a higher residual risk even in patients with a low LDL-C. References: Barter PJ, Kastelein JJ. Targeting cholesteryl ester transfer protein for the prevention and management of cardiovascular disease. J Am Coll Cardiol. 2006;47:492-499. Waters DD, LaRosa JC, Barter P, et al. Effects of high-dose atorvastatin on cerebrovascular events in patients with stable coronary disease in the TNT (treating to new targets) study. J Am Coll Cardiol. 2006;48:1793-1799. On-treatment HDL-C (mg/dL) Barter PJ, Kastelein JJ. J Am Coll Cardiol. 2006;47:492–499. | Waters DD, et al. J Am Coll Cardiol. 2006;48:1793–1799.

ApoA1 Milano: Change in Atheroma Volume -2.9 mm3 P = 0.97 -12.6 mm3 -14.1 mm3 -15.1 mm3 P = 0.007 P < 0.001 P = 0.02 Placebo Low Dose High Dose Combined

Does the 3-15% increase in HDL make a difference? Statins and HDL Does the 3-15% increase in HDL make a difference?

Impact of LDL-C Lowering on Plaque Progression Pooled results from 6 major IVUS outcomes trials 4 5 6 7 8 9 1 - 2 L D C u r i n g T e a t m , / d Change in PAV (%) Nicholls S. et al. JAMA. 2007;297:499-508.

Impact of HDL-C Raising on Plaque Progression Pooled results from 6 major IVUS outcomes trials - 2 1 Increase in HDL (%) 10 20 30 40 Change in PAV (%) Nicholls S. et al. JAMA. 2007;297:499-508.

Total Atheroma Volume: LDL-C and HDL-C 2.1 mm3 0.2 mm3 -2.8 mm3 P < 0.001 Median LDL-C - 87.5 mg/dL Median HDL-C change - 7.5% -8.8 mm3 LDL-C worse HDL-C worse LDL-C worse HDL-C better LDL-C better HDL-C worse LDL-C better HDL-C better

Other Potential Functions of HDL Anti-inflammatory Promote NO Anti-oxidant Anti-thrombotic

Lipid Filled Macrophage in Arteries Current Working Model of HDL Metabolism Liver Intestine LDLr CETP CE TG LDL CD36 SR-A SR-BI ABCG1 A-I αHDL LCAT ABCA1 Lipid Filled Macrophage in Arteries A-I αHDL A-I Preβ-HDL

CETP Inhibitors with Human Studies Torcetrapib Dalcetrapib Anacetrapib Evacetrapib CF3 F3C N O S O HN O F3C N F CF3 Cao et al. J Lipid Res 2011; 52:2169 19

ILLUMINATE: Primary Endpoint: Time to First MACE: Kaplan-Meier Plot 100 Hazard Ratio 1.25 P=0.001 98 96 Event Free (%) 94 92 Atorvastatin events = 373 Torcetrapib/Atorvastatin events = 464 90 90 180 270 360 450 540 630 720 810 Days from Randomization Barter et al, NEJM 2007;357:2109

Off Target Toxicity of Torcetrapib Increase in BP even in animals that do not express CETP Electrolyte changes consistent with RAAS activation Increase adrenal synthesis of aldosterone and cortisol Less nitric oxide synthase and greater endothelin expression associate with endothelial dysfunction

Illustrate Trial: Torcetrapib Change in Percent Atheroma Volume This slide shows the results for the primary efficacy parameter, percent atheroma volume. After 24 months, the change was nearly identical in the two treatment groups, 0.19% in the atorvastatin monotherapy group and 0.12% in the torcetrapib-atorvastatin group, p = 0.72. Thus, for the primary efficacy parameter, torcetrapib, despite a 61% relative increase in HDL-cholesterol and 20% relative decrease in LDL cholesterol, did not slow progression of coronary atherosclerosis. Atorvastatin monotherapy Torcetrapib- atorvastatin

Torcetrapib Results: Levels of HDL-C Achieved Percent Atheroma Volume Primary Efficacy Parameter 0.70% 0.30% 0.18% P < 0.001 -0.69% Quartile 1 <56 mg/dL Quartile 2 56 to 69 mg/dL Quartile 3 69 to 86 mg/dL Quartile 4 >86 mg/dL

Dalcetrapib-OUTCOMES Trial It was announced in early May 2012 that the dal-OUTCOMES trial had been terminated on the basis of futility. http://www.roche.com/media_releases/med-cor-2012-05-07.htm

Why Did Dalcetrapib Fail to Reduce CV Events? Inhibiting CETP with a relatively weak inhibitor such as dalcetrapib may not be sufficient to have a favorable impact on CV events: Only a 30% increase in HDL-C No effect on LDL-C However, we must acknowledge that CETP inhibition may not yield HDL-C particles with a favorable effect on CV morbidity and mortality.

Evacetrapib: Lipid Effects in Phase II Trial Change in HDL-C Change in LDL-C Plac 30 mg 100 mg 500 mg

Resverlogix: ApoA-I Induction in CAD Patients Parameter Placebo (n=74) RVX-208 P Value 100 mg (n=76) 200 mg (n=75) 300 mg (n=74) ApoA-I 0.9 0.1 3.8 5.6 0.02 HDL-C 3.2 6.3* 8.3** Large HDL -0.5 11.1 20.2** 21.1*** 0.003 Small HDL 2.6 -0.4 -2.6 -4.0 0.07 α1 HDL -2.3 3.7 8.0* 8.8* 0.12 * P<0.05, ** P<0.01 and *** P<0.001compared with placebo Nicholls JACC 2010; 57:1111-9