1. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Ronald M. Krauss, MD Children’s Hospital Oakland Research Institute UC Berkeley and UCSF Raising HDL With Drugs – Does it Work?

2. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Coronary Heart Disease (CHD) Risk: HDL Cholesterol vs. LDL Cholesterol as Predictors* Adapted from Castelli WP Can J Cardiol 1988;4(SupplA):5A-10A Relative risk of CHD after 4 years LDL cholesterol (mg/dl) 85 65 45 25 HDL cholesterol (mg/dl) *Data represent men aged 50 – 70 from the Framingham Heart Study

3. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Statin Therapy Does Not Eliminate Cardiovascular Disease (CVD) Risk Associated With Low HDL Cholesterol Adapted from HPS Collaborative Group Lancet 2002; 360: 7-22 and Sacks FM et al. Circulation 2000; 102: 1893-900 CVD event rate (%) CARE: Cholesterol And Recurrent Events HPS: Heart Protection Study LIPID: Long-Term Intervention with Pravastatin in Ischaemic Disease High HDL cholesterol + statin Low HDL cholesterol + statin

4. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org On-Treatment HDL Cholesterol and LDL Cholesterol vs. Cardiovascular Events: Treating to New Targets (TNT) Study % Mean LDL cholesterol 73 mg/dl (1.89 mmol/l) Mean LDL cholesterol 99 mg/dl (2.56 mmol/l) Adapted from Barter P et al. J Am Coll Cardiol 2006; 47: 298A (abstract 914-203) On treatment HDL cholesterol (mg/dl) <40 >40-50 >50-60 >60

5. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Pleiotropic Anti-Atherogenic Properties of HDL  Cholesterol efflux and reverse cholesterol transport  Anti-oxidant and anti-inflammatory effects  Anti-apoptotic properties  Vasodilation (increased eNOS activity)  HDL proteomics: anti-thrombotic, complement activation eNOS: endothelial nitric oxide synthase

6. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Role of HDL in Reverse Cholesterol Transport Adapted from Tall AR et al. J Clin Invest 2001; 108: 1273-5 PLFC LCAT CE CETP PLTP FC Apolipoprotein AI LDL receptor ABCA1: ATP-binding cassette transporter A1 CE: cholesteryl ester CETP: cholesteryl ester transfer protein FC: free cholesterol LCAT: lecithin-cholesterol acyltransferase PC: phosphatidylcholine PL: phospholipids PLTP: phospholipid transfer protein SR-B1: scavenger receptor B1 PL, FC CE PL CE, FC FC, PC FC, CE Cholesterol synthesis Other peripheral cells Macrophage Liver HDL VLDL/LDL HDL FC CE

7. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Apolipoprotein AI ABCA1: ATP-binding cassette transporter A1 ABCG1: ATP-binding cassette transporter G1 CE: cholesteryl ester FC: free cholesterol LCAT: lecithin-cholesterol acyltransferase LXR/RXR: liver X receptor / retinoid X receptor FC CE FC CE Role of ABCA1 and ABCG1 in Macrophage Cholesterol Efflux Mature HDL Nascent HDL Modified lipoproteins Scavenger receptors LXR/RXR Oxysterols LCAT Macrophage

8. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org HDL Therapy Adapted from Linsel-Nitschke P and Tall AR. Nat Rev Drug Discov 2005; 4: 193-205 Reprinted by permission from Macmillan Publishers Ltd: Nature Reviews Drug Discovery, Copyright © 2005 ABCA1: ATP-binding cassette transporter A ABCG1: ATP-binding cassette transporter G1 ABCG4: ATP-binding cassette transporter G4 Apo AI: apolipoprotein AI CETP: cholesteryl ester transfer protein LUVs: large unilamellar phopholipid vesicles LXR: liver X receptor PPAR-  : peroxisome proliferator activated receptor-  RXR: retinoid X receptor RAR  : retinoid acid receptor-  SR-B1: scavenger receptor B1 CETP Apo AI synthesis increased by fibrates Infusion of apo AI Cholesterol phospholipids Cholesterol Upregulation of ABCA1 by LXR- agonists, apo AI, RAR  /RXR Upregulation of ABCG1/ABCG4 by LXR-agonists, PPAR-  agonists Infusion of apo AI/ phospholipid complexes, LUVs Niacin decreases HDL catabolism by unknown mechanism CETP inhibitors Bile Apo AI synthesis Apo AI preβHDL HDL 3 HDL 2 VLDLLDL Macrophage Liver

9. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Atherogenic Dyslipidemia in Obesity, Insulin Resistance, and Metabolic Syndrome  High triglyceride (TG) levels –TG-rich remnant lipoproteins (VLDL)  Commonly, absolute levels of LDL cholesterol are not significantly increased,  number of LDL particles –Predominantly small, dense LDL particles  Low levels of HDL cholesterol Adapted from Haffner SM Diabetes Care 2003; 26: S83-6 and Garvey WT et al. Diabetes 2003; 52: 453-62

10. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Metabolic Basis for Atherogenic Dyslipidemia: Concordant Increase in VLDL, Small LDL and Reduction of HDL Smaller LDL HL Apo AI Renal clearance LPL Remnants LPL/HL VLDL TG CETP Cholesterol HDL TG LDL Apo AI: apolipoprotein AI CETP: cholesteryl ester transfer protein HL: hepatic lipase LPL: lipoprotein lipase TG: triglycerides TG Smaller HDL

11. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Relation of HDL Cholesterol to Aortic Atherosclerosis in Apo E-Deficient Mice Transgenic for Human Apo AI (Model for Increased Apo AI Transport) Adapted from Plump AS et al. Proc Natl Acad Sci USA 1994; 27: 9607-11 Copyright © 1994 National Academy of Sciences, U.S.A. 0 250000 500000 750000 501001500 Mean lesion area (µm 2 ) HDL cholesterol (mg/dl) r=0.88, p<0.0001 Apo AI expression None Low High Apo: apolipoprotein

12. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org  Statin ± cholesterol absorption inhibitor  Niacin  Fibrate  Thiazolidinedione (type 2 diabetes)  Combination therapy (statin + niacin/fibrate) Current Options for Pharmacologic Management of Patients With Low HDL Cholesterol

13. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Niacin Extended-Release + Statins: Extended-Release Lovastatin/Niacin Adapted from Hunninghake DB et al. Clin Cardiol 2003; 26: 112-8 LDL cholesterolHDL cholesterolTriglycerides Lovastatin/niacin 40 mg/2,000 mg, week 28 Lovastatin 40 mg, week 28 Change from baseline (%) * * * *p<0.05 vs. lovastatin 40 mg

14. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org SAFARI: Combination Therapy in Patients With Combined Hyperlipidemia Reprinted from The American Journal of Cardiology, Vol 95, Grundy SM et al. Effectiveness and tolerability of simvastatin plus fenofibrate for combined hyperlipidemia (the SAFARI trial), 462-8, Copyright © 2005, with permission from Elsevier * * * * Simvastatin 20 mg Simvastatin 20 mg + Fenofibrate 160 mg n=618 *p<0.001 vs. simvastatin

15. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Gemfibrozil, Niacin, and Cholestyramine in Men With Low HDL Cholesterol and Coronary Heart Disease Triglycerides Adapted from Whitney EJ et al. Ann Intern Med 2005; 142: 95-104 Drug treatment + lifestyle modification Lifestyle modification only Change from baseline (%) * * * LDL cholesterolHDL cholesterol *p<0.001 vs. lifestyle only

16. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Cardiovascular Disease Outcomes in Trials of HDL- Raising Drug Therapies

17. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Niacin Therapy: Angiographic and Outcomes Trials TG: triglycerides No. of subjectsLipid changes (treatment group) Trial Treatment (mean dose) TreatmentPlacebo Total cholesterol TG LDL cholesterol HDL cholesterol Findings Stockholm Ischaemic Heart Disease Secondary Prevention Study Niacin (4.5 g/d) + clofibrate (1.5 g/d) 279276-13%-19%---  36% ischemic heart disease mort. (p<0.01)  26% total mortality (p<0.05) Coronary Drug Project Niacin (3 g/d)11192789-10%-26%---  27% nonfatal myocardial infarction  11% total mortality (p=0.0004) Cholesterol Lowering Atherosclerosis Study Niacin (4.3 g/d) + colestipol (30 g/d) 8082-26%-21%-43%+37%angiographic regression no difference in clinical events Familial Atherosclerosis Treatment Study Niacin (4 g/d) + colestipol (30 g/d) 4852-23%-29%-32%+43%angiographic regression  80% clinical events (p<0.01) HDL- Atherosclerosis Treatment Study Niacin (2.4 g/d) + simvastatin (13 mg/d) 73 -29%-34%-40%+18%angiographic regression  60% clinical events (p=0.02)

18. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Analysis of the HDL-Atherosclerosis Treatment Study (HATS): Angiographic and Clinical Endpoints After 3 Years – Simvastatin + Niacin vs. Placebo Adapted from Brown BG et al. N Engl J Med 2001; 345: 1583-92 Placebo Mean change in stenosis (%) *p<0.001 vs. placebo ‡ p=0.04 vs. placebo Coronary death, myocardial infarction, stroke or revascularization Simvastatin + Niacin Composite event rate (%) 3.9 23.7 -0.4 2.6 * ‡ 89% reduction -0.5 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Nine proximal lesions 25 20 15 10 5 0

19. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org ARBITER 2: Statin + Placebo vs. Statin + Extended-Release Niacin 1,000 mg/d Primary Endpoint – Carotid Intima-Media Thickness (CIMT) Change Statin + Placebo (n=71) Statin + Extended release niacin (n=78) Baseline CIMT (mm) Adapted from Taylor AJ et al. Circulation 2004; 110: 3512-7 Change in CIMT (mm) Statin + Extended release niacin (n=78) p=0.23* Statin + Placebo (n=71) p<0.001* *Within-group comparisons Baseline  CIMT after 1 year

20. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org AIM-HIGH: Study Overview Vascular disease Age >45 years Atherogenic dyslipidemia (HDL<40♂ or 50♀ mg/dl; TG>149 mg/dl; LDL<160 mg/dl) Simvastatin Simvastatin + Niaspan 3-5 years 3,300 patients from 60 sites (U.S. and Canada)  Cardiovascular death  Nonfatal myocardial infarction  Stroke  Acute coronary syndrome LDL cholesterol target <80 mg/dl both groups (may add ezetimibe if needed) Hypothesis - 30% event rate with simvastatin - 23% event rate with simvastatin + niacin - 50% relative reduction based on ~46% placebo rate 2-year enrollment TG: Triglycerides

21. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org VA-HIT: Gemfibrozil Effect on Primary Endpoint - Lipids Adapted from Rubins HB et al. N Engl J Med 1999; 341: 410-8 LDL cholesterol TG HDL cholesterol Primary endpoint occurrence* † Change from baseline (%) % Placebo Gemfibrozil TG: Triglycerides *Nonfatal myocardial infarction or death from coronary causes † 22% relative risk reduction (95% CI: 7%–35%, p=0.006)

22. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org VA-HIT: LDL and HDL Particle Subclasses Adapted from Otvos JD et al. Circulation 2006; 113: 1556-63 IDL: intermediate-density lipoprotein B: baseline IDLLarge HDL Large LDLMedium HDL Small LDLSmall HDL PlaceboFibrate 5% reduction 1364 1463 1352 1290* LDL particle number (nmol/l) B7 monthsB 20% decrease 36% increase * * HDL particle number (  mol/l) 25.2 25.1 26.6 27.6* PlaceboFibrate B7 monthsB 21% increase * * 10% increase *p≤0.0005 vs. placebo at 7 months

23. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Relative odds ratio † LDL particle number HDL particle number VA-HIT: LDL and HDL Particle Numbers in Prediction of New Coronary Heart Disease Events Adapted from Otvos JD et al. Circulation 2006; 113: 1556-63 * * * * † Calculated for a 1-SD increment of each lipoprotein particle in separate logistic regression models adjusted for treatment group, age, hypertension, smoking, body mass index, and diabetes *p<0.01 Baseline 7 Months

24. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org FIELD: End of Study Lipid Results Adapted from Keech A et al. Lancet 2005; 366: 1849-61 Placebo (P) Fenofibrate (F) 113 LDL cholesterol HDL cholesterol Triglycerides Baseline (mg/dl) 11743 164167 119 LDL cholesterol HDL cholesterol Triglycerides Baseline (mg/dl) 11943 171173 128 LDL cholesterol HDL cholesterol Baseline (mg/dl) 1254240184197 Triglycerides Did not start other lipid-lowering therapy n= 3,124 (P) 3,951 (F) Total population Started other lipid-lowering therapy n= 1,776 (P) 944 (F)

25. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Change from baseline at 24 weeks (mg/dl) Lipid Effects of Pioglitazone and Rosiglitazone Adapted from Goldberg RB et al. Diabetes Care 2005; 28: 1547-54 † † † ‡ -12 15 4 19 16 23 15 8 TriglyceridesHDL cholesterol Non-HDL cholesterol LDL cholesterol Pioglitazone Rosiglitazone † Between-group comparison for change from baseline: p<0.001 (mg/dl, %) ‡ Between-group comparison for change from baseline: p<0.001 (mg/dl), p=0.002 (%) Values in bars = percent change from baseline at 24-week endpoint

26. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Age-Adjusted 6-Year Coronary Heart Disease (CHD) Rates for Elderly Japanese American Men With and Without CETP Mutations Adapted from Curb JD et al. J Lipid Res 2004; 45: 948-53 Reproduced with permission CETP: cholesteryl ester transfer protein CHD incidence (rate/1,000 person-years) HDL cholesterol <60 mg/dl HDL cholesterol  60 mg/dl 171/1,713* 31/509 † 5/76 2/42 *Number of CHD events/men at risk † Significantly lower risk compared to men with HDL cholesterol <60 mg/dl (1.55 mmol/l) and without a CETP mutation (p<0.05) CETP mutation Absent Present

27. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Raising HDL Cholesterol With CETP Inhibition LCAT CE TG CETP Apo B Apolipoprotein AI ABCA1: ATP-binding cassette transporter A1 Apo B: apolipoprotein B CE: cholesteryl ester CETP: cholesteryl ester transfer protein FC: free cholesterol LCAT: lecithin-cholesterol acyltransferase LDLR: low-density lipoprotein receptor SR-B1: scavenger receptor B1 TG: triglycerides CE FC CE FC Bile Macrophage Liver CE FC Mature HDL Nascent HDL FC VLDL/LDL

28. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Torcetrapib Slows Apolipoprotein AI Turnover Rate Adapted from Brousseau ME et al. Arterioscler Thromb Vasc Biol 2005; 25: 1057-64 Atorvastatin+Torcetrapib Torcetrapib 120 mg bid Torcetrapib 120 mg qd % change vs. placebo * (n=19) *p<0.01 vs. placebo

29. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org 446 atorvastatin patients464 torcetrapib patients 24-month follow-up intravascular ultrasound of originally imaged “target” vessel (n=910) 4 to 10-week run-in atorvastatin 10-80 mg to achieve LDL cholesterol of 100±15 mg/dl Intravascular ultrasound with 40 MHz transducer Motorized pullback at 0.5 mm/sec through >40 mm segment 1,188 patients from 137 centres in North America and Europe Symptomatic coronary artery disease, coronary angiography with >20% stenosis Atorvastatin monotherapy Torcetrapib 60 mg+ atorvastatin 24-month treatment 135 patients withdrew140 patients withdrew ILLUSTRATE Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16

30. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Time Course: Change in HDL Cholesterol Levels Adapted from Barter et al. New Engl J Med 2007; 357, 2109-22 20 30 40 50 60 70 80 90 013691215182124 Time (months) HDL cholesterol level (mg/dl) Difference 60.8% Atorvastatin monotherapy Torcetrapib+Atorvastatin

31. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Change in percent atheroma volume* ILLUSTRATE: Primary Efficacy Parameter Change in Percent Atheroma Volume Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16 † p value from ANCOVA *LS mean change p=0.72 †

32. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org ILLUSTRATE: Secondary Intravascular Ultrasound Efficacy Parameters Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16 p=0.023 † p=0.12 † Change in normalized atheroma volume (mm 3 )* Change in 10 mm most diseased segment (mm 3 )* † p value from ANCOVA *LS mean change Atorvastatin +Torcetrapib

33. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Blood Pressure Related Adverse Events Blood pressure >140/90 mmHg Systolic blood pressure increase >15 mmHg Atorvastatin Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16 +Torcetrapib

34. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org ILLUSTRATE Adverse Events: Safety Population Atorvastatin monotherapy (n=597) Torcetrapib + Atorvastatin (n=591) Death6 (1.0%)8 (1.4%) Coronary heart disease (CHD) death1 (0.2%) Nonfatal myocardial infarction (MI)16 (2.7 %)13 (2.2%) Fatal or nonfatal stroke8 (1.3%)2 (0.3%) Hospitalization for unstable angina34 (5.7%)47 (8.0%) Coronary revascularization95 (15.9%)114 (19.3%) Peripheral vascular disease13 (2.2%)10 (1.7%) Hospitalization for congestive heart failure4 (0.7%)9 (1.5%) Composite: CHD death, MI, stroke, and unstable angina 57 (9.5%)62 (10.5%) Composite: CHD death, MI, stroke, unstable angina, and revascularization 117 (19.6%)124 (21.0%) Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16

35. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org RADIANCE 1: Heterozygous Familial Hypercholesterolemia Adapted from Kastelein JJ et al. N Engl J Med 2007; 356: 1620-30 Copyright © 2007 Massachusetts Medical Society. All rights reserved 0.0 0.5 1.0 1.5 2.0 Treatment period (months) Slope (mm/year) 95% CI p value -0.0006 (-0.0084, 0.0072) 0.8737 Maximum carotid intima-media thickness (mm) Baseline 6 121824 Torcetrapib+ Atorvastatin (T/A) Atorvastatin (A) 1.1261.1321.1331.1481.134 1.1631.1491.1621.1501.152 T/A vs. A

36. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org RADIANCE 2: Mixed Dyslipidemia Reprinted from The Lancet, Vol 370, Bots ML et al. Torcetrapib and carotid intima- media thickness in mixed dyslipidaemia (RADIANCE 2 study): a randomised, double-blind trial, 153-60, Copyright © 2007, with permission from Elsevier 1.32101.35921.31501.36341.3260 1.36801.33191.34691.30791.3002 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Slope (mm/year) 95% CI p value -0.0049 (-0.0180, 0.0082) 0.4621 Treatment period (months) Maximum carotid intima-media thickness (mm) Baseline6121824 T/A vs. A Torcetrapib+ Atorvastatin (T/A) Atorvastatin (A)

37. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org ILLUSTRATE and RADIANCE  No change in atherosclerotic burden in coronary or carotid beds  Secondary endpoints suggest modest regression of atheroma in coronaries and progression in carotids  Imaging studies do not parallel clinical outcomes and do not explain toxicity  Carotids more sensitive to blood pressure (BP) related toxicity than coronaries  If other cholesteryl ester transfer protein inhibitors have not caused an increased BP, should they be evaluated in further clinical studies?

38. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Recombinant Apo AI Milano: Change in Atheroma Volume as Measured by Intravascular Ultrasound Adapted from Nissen SE et al. JAMA 2003; 290: 2292-300 Placebo (n=11) p=0.97 ETC-216 15 mg/kg (n=21) p=0.03 ETC-216 45 mg/kg (n=15) p=0.45 Combined treatment group* (n=36) p=0.02 Mean % change from baseline *Primary efficacy endpoint ETC-216: intravenous recombinant Apo AI Milano/phospholipid complexes

39. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org ERASE: CSL-111 (Reconstituted HDL) Group Change in atheroma volume (%) p vs. placebop vs. baseline Placebo (n=47) -1.62—0.07 CSL-111 (n=89) -3.410.48<0.001 Adapted from Tardif JC et al. JAMA 2007; 297: 1675-82 Intravascular ultrasound results

40. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org Conclusions/Discussion Raising HDL: Does it Work?  Multiple mechanisms for raising HDL  No conclusive evidence as yet in humans for independent benefit of HDL increase on cardiovascular disease  Best evidence to date, from animals and to a limited extent in humans, is for reduced atherosclerosis severity with increased apolipoprotein AI transport

41. Source: International Chair on Cardiometabolic Risk www.cardiometabolic-risk.org  www.cardiometabolic-risk.org www.cardiometabolic-risk.org