Presenter Disclosure Information The ASCOT Trial: Morbidity and Mortality Outcomes From Lipid Lowering in a Hypertensive Patient Population. The following relationships exist related to this presentation: Name Research Grants Consultancies Peter S. Sever Pfizer, Servier, AstraZeneca Björn Dahlöf Pfizer, Merck, AstraZeneca, Servier Pfizer, Merck, Boehringer Neil R. Poulter Pfizer, Servier Pfizer, AstraZeneca, Merck/Schering Plough Hans Wedel Pfizer, AstraZeneca Pfizer, AstraZeneca, Merck, Medtronic Inc Gareth Beevers Merck Mark Caulfield AstraZeneca Rory Collins Merck, AstraZeneca Sverre E. Kjeldsen Merck, AstraZeneca, Pfizer Arni Kristinsson Gordon T. McInnes Pfizer, Merck, Aventis, AstraZeneca AstraZeneca, Boehringer, Merck, Servier, Merck/Schering Plough Jesper Mehlsen Pfizer Markku Nieminen Pfizer, Merck Pfizer, Merck, AstraZeneca Eoin O’Brien Jan Östergren Aventis, Merck, AstraZeneca

On behalf of the ASCOT Investigators ASCOT-LLA REVISITED: INTERACTION OF ANTIHYPERTENSIVE AND LIPID-LOWERING THERAPY P Sever (Co-chair), B Dahlöf (Co-chair), N Poulter (Secretary), H Wedel (Statistician), G Beevers, M Caulfield, R Collins, SE Kjeldsen, A Kristinsson, J Mehlsen, G McInnes, M Nieminen, E O’Brien, J Östergren On behalf of the ASCOT Investigators

ASCOT-BPLA and LLA Primary Objectives To compare the effect on non-fatal myocardial infarction (MI) and fatal CHD of : a standard antihypertensive regimen (-blocker +/- diuretic) with a more contemporary regimen (CCB +/- ACE inhibitor) and atorvastatin with placebo in those with total cholesterol < 6.5 mmol/L(250mg/dl)

Investigator-led, multinational randomised controlled trial Study design 19,257 hypertensive patients ASCOT-BPLA atenolol ± bendroflumethiazide PROBE design amlodipine ± perindopril Investigator-led, multinational randomised controlled trial placebo atorvastatin 10 mg Double-blind ASCOT-LLA 10,305 patients TC ≤ 6.5 mmol/L (250 mg/dL)

ASCOT-LLA Summary of all end points Area of squares is proportional to the amount of statistical information 0.5 1.0 1.5 Atorvastatin better Placebo better Primary End Points Nonfatal MI (incl silent) + fatal CHD Secondary End Points Total CV events and procedures Total coronary events Nonfatal MI (excl silent) + fatal CHD All-cause mortality Cardiovascular mortality Fatal and nonfatal stroke Fatal and nonfatal heart failure Tertiary End Points Silent MI Unstable angina Chronic stable angina Peripheral arterial disease Development of diabetes mellitus Development of renal impairment Risk Ratio Hazard Ratio 0.64 (0.50-0.83) 0.79 (0.69-0.90) 0.71 (0.59-0.86) 0.62 (0.47-0.81) 0.87 (0.71-1.06) 0.90 (0.66-1.23) 0.73 (0.56-0.96) 1.13 (0.73-1.78) 0.82 (0.40-1.66) 0.87 (0.49-1.57) 0.59 (0.38-0.90) 1.02 (0.66-1.57) 1.15 (0.91-1.44) 1.29 (0.76-2.19) There was a significant reduction in the primary end point and also in four of the seven secondary end points, some of which were incorporated the primary end point. Sever PS, Dahlöf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet. 2003;361:1149-58

Study design 19,257 hypertensive patients ASCOT-BPLA atenolol ± bendroflumethiazide PROBE design amlodipine ± perindopril placebo atorvastatin 10 mg Double-blind ASCOT-LLA 10,305 patients TC ≤ 6.5 mmol/L (250 mg/dL)

ASCOT-BPLA :summary of all end points Unadjusted Hazard ratio (95% CI) 0.90 (0.79-1.02) 0.87 (0.76-1.00) 0.87 (0.79-0.96) 0.84 (0.78-0.90) 0.89 (0.81-0.99) 0.76 (0.65-0.90) 0.77 (0.66-0.89) 0.84 (0.66-1.05) 1.27 (0.80-2.00) 0.68 (0.51-0.92) 0.98 (0.81-1.19) 0.65 (0.52-0.81) 1.07 (0.62-1.85) 0.70 (0.63-.078) 0.85 (0.75-0.97) 0.86 (0.77-0.96) 0.84 (0.76-0.92) Primary Non-fatal MI (incl silent) + fatal CHD Secondary Non-fatal MI (exc. Silent) +fatal CHD Total coronary end point Total CV event and procedures All-cause mortality Cardiovascular mortality Fatal and non-fatal stroke Fatal and non-fatal heart failure Tertiary Silent MI Unstable angina Chronic stable angina Peripheral arterial disease Life-threatening arrhythmias New-onset diabetes mellitus New-onset renal impairment Post hoc Primary end point + coronary revasc procs CV death + MI + stroke 0.50 0.70 1.00 1.45 2.00 Amlodipine  perindopril better Atenolol  thiazide better The area of the blue square is proportional to the amount of statistical information

Additional objectives include: Secondary end points Total stroke All coronary events Primary end point minus silent MI Total cardiovascular (CV) events and procedures CV mortality All-cause mortality Heart failure Tertiary end points Development of diabetes Impairment of renal function Pre-specified end points in pre-specified subgroups Life-threatening arrhythmias Other objectives Interaction between statins and antihypertensive treatment on the primary endpoint and total CV events and procedures Health economic analyses

Primary endpoint: Non-fatal MI and fatal CHD ASCOT-LLA Primary endpoint: Non-fatal MI and fatal CHD Amlodipine-based treatment Atenolol-based treatment 4.0 4.0 Atorvastatin Placebo Atorvastatin Placebo 3.0 3.0 16% 53% Cumulative incidence (%) 2.0 Cumulative incidence (%) 2.0 1.0 1.0 HR=0.47 (0.32 - 0.69) p<0.001 HR=0.84 (0.60 - 1.17) p=0.30 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Years Years

Primary endpoint: Non-fatal MI and fatal CHD ASCOT-LLA Primary endpoint: Non-fatal MI and fatal CHD Amlodipine-based treatment Atenolol-based treatment 4.0 4.0 Atorvastatin Placebo Atorvastatin Placebo 3.0 3.0 16% 53% Cumulative incidence (%) 2.0 Cumulative incidence (%) 2.0 1.0 1.0 HR=0.47 (0.32 - 0.69) p<0.001 HR=0.84 (0.60 - 1.17) p=0.30 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Years Years

Amlodipine-based treatment Atenolol-based treatment 4.0 4.0 Atorvastatin Placebo Atorvastatin Placebo 3.0 3.0 16% 53% 2.0 Cumulative incidence (%) Cumulative incidence (%) 2.0 1.0 1.0 HR=0.47 (0.32 - 0.69) p<0.001 HR=0.84 (0.60 - 1.17) p=0.30 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Years Years

Total cardiovascular events and procedures ASCOT-LLA Total cardiovascular events and procedures Amlodipine-based treatment Atenolol-based treatment 12.0 12.0 10.0 Atorvastatin Placebo 10.0 Atorvastatin Placebo 15% 27% 8.0 8.0 Cumulative incidence (%) 6.0 Cumulative incidence (%) 6.0 4.0 4.0 2.0 2.0 HR=0.73 (0.60 - 0.88) p=0.001 HR=0.85 (0.71 - 1.02) p=0.08 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Years Years

Fatal and non-fatal stroke ASCOT-LLA Fatal and non-fatal stroke Amlodipine-based treatment Atenolol-based treatment 3.0 3.0 24% Atorvastatin Placebo Atorvastatin Placebo 2.0 2.0 31% Cumulative incidence (%) Cumulative incidence (%) 1.0 1.0 HR=0.69 (0.45 - 1.06) p=0.09 HR=0.76 (0.63 - 1.08) p=0.013 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Years Years

Fatal CHD + non-fatal MI n.s. n.s. p<0.0001 p=0.015 Events/1000 patient years Interaction p=0.025

Total CV events and procedures n.s. p=0.08 p=0.001 p=0.021 Events/1000 patient years Interaction p=0.25

Stroke n.s. p=0.06 p=0.09 p=0.04 Interaction p=0.73 Events/1000 patient years Interaction p=0.73

Fatal CHD + Non-fatal MI Fatal CHD + non-fatal MI On-treatment Fatal CHD + Non-fatal MI Fatal CHD + non-fatal MI Primary + Revascularisation n.s. n.s. n.s. p<0.0001 n.s. n.s. n.s. p<0.0001 p=0.003 p=0.015 p=0.015 p=0.019 Events/1000 patient years Interaction p=0.025 Interaction p=0.043 Interaction p=0.043

CHD events * Per 1000 patient years Events ( Rate)* Censoring Time HR Atorva Placebo Censoring Time Hazard Ratios (95% CI) 30 days 90 days 180 days 1 Year 2 Years End of Study 0.17(0.02-1.38) 1 (2.4) 6 (14.2) 0.33(0.14-0.78 7 (5.5) 21 (16.6) 0.52(0.30-0.91) 19 (7.5) 36 (14.3) 0.55(0.36-0.84) 34 (6.6) 61 (12.0) 0.62(0.45-0.85) 60 (5.9) 96 (9.5) 0.64(0.50-0.83) 100 (6.0) 154 (9.4) * Per 1000 patient years Atorvastatin better Placebo better

Rates and hazard ratios at various timepoints for non-fatal MI (incl silent) + fatal CHD amongst patients in the Amlodipine arm CHD Event (Rate*) HR (95% CI) Atorvastatin Placebo 0.33 (0.03-3.17) 1 (4.9) 3 (14.8) 0.27 (0.08-0.97) 3 (4.8) 11 (17.7) 0.40 (0.19-0.88) 9 (7.1) 22 (17.7) 0.46 (0.26-0.84) 16 (6.2) 34 (13.5) 0.39 (0.23-0.65) 20 (3.9) 51 (10.2) 0.47 (0.32-0.69) 38 (4.6) 80 (9.8) Censoring Time Hazard Ratios (95% CI) 3.17 30 days 90 days 180 days 1 year 2 years End of study // 0.0 0.5 1.0 1.5 Atorvastatin better Placebo better * Per 1000 patient years

Summary Benefits of atorvastatin on coronary end points greater in those allocated amlodipine compared with atenolol-based treatment. A formal test for interaction between lipid-lowering and blood pressure-lowering treatment was of borderline significance for this endpoint. No significant interaction was evident for two other endpoints (total CV events and procedures and fatal and non-fatal stroke) Whilst these observations could be a chance finding, there is a plausible biological explanation for a synergistic effect of atorvastatin and amlodipine-based treatment on acute coronary events.

LDL Monocytes Vascular endothelium Smooth muscle cells Expression of adhesion molecules Vascular endothelium Uptake of LDL Foam cell Monocyte Macrophage Oxidised LDL Smooth muscle cells

SMC dedifferentiation To synthetic phenotype Macrophage Foam cells Cytokine release SMC migration and proliferation

Formation of fibrous cap

Apoptosis MMPs Destruction of inter-cellular matrix Lipid-laden macrophage

Plaque rupture

SMC DEDIFFERENTIATION Contractile phenotype Synthetic phenotype Loss of Functionality of L-type VOC • CCBs ineffective CCB Ca2+ Presence of statins leads to growth arrest and re-expression of functioning L-type VOCs L-type VOC • CCBs effective

An additional mechanism?

SMC: reversion to a more differentiated phenotype

Hypothesis Electrochemical bonding of atorvastatin and amlodipine in the lipid bilayer of vascular smooth muscle cell membranes (Mason) Restoration of functionality of L-type calcium channels in vsm cells which is lost during migration and proliferation( de-differentiation) due to an action of atorvastatin inducing growth arrest of cells ,and restoration of responsiveness of vsm to CCBs Return of vsm cells to more differentiated phenotype Stabilisation of plaque possibly due to reduced destruction and apoptosis of vsm cells, a reduction in release of MMPs and preservation of intercellular matrix.