1. HDL Therapy: Hype or the Future Blockbuster Treatment for CVD Patients – Combination Therapy
EJ Schaefer, MD
Distinguished University Professor, Lipid Metabolism Laboratory, Tufts University School of Medicine, Boston, MA USA
February 23rd, 2010

2. Ernst J. Schaefer, MD DISCLOSURES Consulting Fees Honoraria
Merck & Co., Inc
Honoraria
Arisaph Pharmaceuticals, Inc., Unilever, Vatera Capital LLC, Roche
Grants/Contracted Research
Abbott Vascular, Resverlogix Corporation, Roche
Ownership Interest (Stocks, Stock Options or Other Ownership Interest)
Boston Heart Lab

3. Conflicts – Past 12 Months
Consultant – Abbott, AstraZeneca, Merck-Schering, Unilever
Grants – Abbott, Arisaph, DuPont, Unilever
Speaker – Schering –Merck (Japan -Overseas)
Medical Director – Boston Heart Laboratory, Framingham, MA (Advanced Lipid Testing, sdLDL-C, Lp(a), HDL Mapping, Plasma Sterols, Genotyping, Multiple Other Tests – insulin, CRP, LpPLA2, NT-proBNP)

4. HDL-C as CHD Risk Factor: Framingham Heart Study*
Relative Risk
HDL-C (mg/dl) Men Women
< ** **
 ** **
** p < 0.05 multivariate analysis, 2489 men, 2856 women, years of age, 12 year followup, 383 men and 227 women developed CHD. *Wilson et al., Circulation 97: 1837, 1998.

5. Events in the Major Prevention Trials
# Events Control
# Events Statin
% Risk
Reduction
% Events not Avoided
4S/CARE/WOS/AFCAPS/LIPID
30,817
2,074
1,537 26 74
HPS
20,536
1,212
898
PROSPER
5,804
356
292 19 81
ALLHAT
10,355
421
380 9 91
ASCOT
10,305
154
100 36 64
Total
77,817
4,217
3,207 24 76
Despite the significant reduction in the incidence of CAD with LDL-C lowering, there is clearly a need for improvement.

6. Residual Cardiovascular Risk in Major Statin Trials
CHD events occur in patients treated with statins
28.0
Patients Experiencing
Major CHD Events, %
19.4
15.9
12.3
13.2
10.2
11.8
10.9
8.7
7.9
6.8
5.5
Residual Cardiovascular Risk in Major Statin Trials.
In all of these major statin trials,1-6 significant residual cardiovascular risk remains even after reducing LDL-C. According to Libby, in the best of circumstances, the decrease in cardiovascular events due to statin treatment still allows two-thirds of cardiovascular events to occur. Libby concludes, “To address the majority of cardiovascular events that still occur despite our most powerful existing therapies, we must combine lifestyle change and evaluate new pharmacological strategies that will move us toward the goal of eradicating cardiovascular disease in the future.”7
Reference
4S Group. Lancet. 1994;344:
LIPID Study Group. N Engl J Med. 1998;339:
Sacks FM, et al. N Engl J Med. 1996;335:
HPS Collaborative Group. Lancet. 2002;360:7-22.
Shepherd J, et al. N Engl J Med. 1995;333:
Downs JR, et al. JAMA. 1998;279:
Libby PJ, et al. J Am Coll Cardiol, 2005:46:
4S1
LIPID2
CARE3
HPS4
WOSCOPS5
AFCAPS/
TexCAPS6 N
4444
9014
4159
20 536
6595
6605
 LDL-C
-35%
-25%
-28%
-29%
-26%
-25%
Secondary
High Risk
Primary
1 4S Group. Lancet. 1994;344:
2 LIPID Study Group. N Engl J Med. 1998;339:
3 Sacks FM, et al. N Engl J Med. 1996;335:
4 HPS Collaborative Group. Lancet. 2002;360:7-22.
5 Shepherd J, et al. N Engl J Med. 1995;333:
6 Downs JR, et al. JAMA. 1998;279:

7. Residual CVD Risk in Patients Treated With Intensive Statin Therapy
Standard statin therapy
26.3
Intensive high-dose statin therapy
22.4
Patients Experiencing
Major CVD Events, %
13.7
12.0
10.9
8.7
LDL-C,*
mg/dL 95 62
104 81
101 77
Residual CVD Risk in Diabetic Patients Treated With Statins.
A closer look at 3 trials investigating intensive LDL-lowering with statin therapy in patients with CHD revealed that residual CVD risk remains in these patients even after aggressive LDL-cholesterol lowering therapy. All 3 trials compared the standard degree of LDL-cholesterol lowering to ~100 mg/dL with more intensive LDL-cholesterol lowering to ~70 mg/dL as a means of preventing major CVD events in patients with a history of CHD or acute coronary syndromes.
In the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) study (N = 4162), pravastatin 40 mg reduced LDL-C to 95 mg/dL and pravastatin 80 mg reduced LDL-C to 62 mg/dL in patients who had been hospitalized for an acute coronary syndrome. After 2 years, 22.4% of patients treated with intensive statin therapy (pravastatin 80 mg/dL) suffered a major CVD event.1
In the Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) study (N = 8888), simvastatin 20 mg reduced LDL-C to 104 mg/dL and atorvastatin 80 mg reduced LDL-C to 81 mg/dL in patients with a history of acute myocardial infarction. After 4.8 years, 12.0% of patients experienced a major CVD event even after intensive LDL-C lowering with statin therapy (atorvastatin 80 mg).2
Finally, in the Treating to New Targets (TNT) study (N = ), 10 mg atorvastatin reduced LDL-C to 101 mg/dL and 80 mg atorvastatin reduced LDL-C to 77 mg/dL in patients with stable CHD. After 4.9 years, a major CVD event occurred in 8.7% of patients receiving intensive statin therapy (80 mg atorvastatin).3
These 3 trials reveal that significant residual CVD risk remains in patients even after intensive statin treatment to lower LDL-C below 100 mg/dL. According to H. Robert Superko, although the reduction in PROVE IT was statistically significant, it was not clinically profound.4 Superko suggests that “this statistically significant but clinically inadequate control of CHD risk is, in part, due to a lipid treatment focus on LDL-C alone with a resultant neglect of other important aspects of lipoprotein metabolism.”4
References
Cannon CP, et al. N Engl J Med. 2004;350:
Pedersen TR, et al. JAMA. 2005;294:
LaRosa JC, et al. N Engl J Med. 2005;352:
Superko HR. Br J Cardiol. 2006;13:
PROVE IT-TIMI 222
IDEAL3
TNT4 N
4162
8888
10 001
1 Superko HR. Br J Cardiol. 2006;13:
2 Cannon CP, et al. N Engl J Med. 2004;350:
3 Pedersen TR, et al. JAMA. 2005;294:
4 LaRosa JC, et al. N Engl J Med. 2005;352:
*Mean or median LDL-C after treatment

8. Statins and Cholesterol Metabolism
In a subset of 868 patients from the 4S Study, the investigators documented that those with low baseline markers of cholesterol synthesis and elevated markers of cholesterol absorption got no significant benefit from simvastatin in CHD risk reduction; relative risk increased from to 1.166, while those with elevated synthesis markers and decreased absorption markers got very substantial reduction in CHD (>50%), also greater LDL –C reduction
Miettinen T et al , BMJ 1998; 316:

9. Changes of Total Cholesterol and LDL-C among Statin Treatment Groups
-100
-80
-60
-40
-20 20 40
LDL cholesterol change (%) R A
-55%, p<0.001
-53%, p<0.001
p treatment = 0.333
-70
-60
-50
-40
-30
-20
-10 10
Total cholesterol change (%)
-40%, p<0.001
-40%, p<0.001
p treatment = 0.684

10. Changes of Lathosterol (Synthesis) among Statin Treatment Groups60
-120
-100
-80
-60
-40
-20 20 40
Lathosterol changes (%)
-78%, p<0.001
-81%, p<0.001
p treatment = 0.102
-64%, p<0.001
-68%, p<0.001 40 20
-20
Lathosterol/C ratio changes (%)
-40
-60
-80
-100
p treatment = 0.253

11. Changes of Campesterol (Absorption) among Statin Treatment Groups
-100
-50 50
100
150
200
Campesterol/C ratio changes (%)
-100
-80
-60
-40
-20 20 40 60 80
100
Campesterol changes (%)
+52%, p<0.001
+72%, p<0.001
-2%, p = 0.002
+5%, p = 0.477
p treatment <0.001
p treatment = 0.001

12. Overview of Major Studies on the Effects of Statins on Changes in Lathosterol and Campesterol
Author
Year
Statin N
Duration
ΔTotal C %
Δ Latho/C
ΔCamp/C
Uusitupa, et al.
1992
Lovastatin
(80 mg/d) 62
18 weeks
-34%
-43%
+33%
Van Himbergen et
2008
Rosuvastatin
40 mg/day
Atorvastatin
80 mg/day
138
139
6 weeks
-40%
-64%
-68%
+52%
+72%
Miettinen, et al.
2002
Simvastatin
(20m//d)
319
1 year
-30%
-36%
+48%
(40 mg/d)
115
-27%
-35%
+46%
2003
(29 mg/d)
102
-52%
+74%
(34 mg/d)
105
-33%
Assmann, et al.
(10-80 mg/d)
160
12 weeks
-59%
+58%
232
-42%
+35%

13. Conclusions
Patients with physterolemia have markedly increased CHD risk and have ABCG5/8 mutations
Synthesis and absorption markers are major determinants of LDL-C levels in the Framingham Offspring Study (Matthan et al JLR 2009 epub).
Hyper-responders to statins in terms of cholesterol lowering have the greatest reduction in synthesis markers and the least increase in absorption markers, with the converse also being true. Responsiveness relates to ABCG5/8, NPC1L1 and apoE genotype (multiple papers including van Himbergen et al 2009; 50:730-9)
Ezetimibe decreases cholesterol absorption, but increases synthesis (Sudhop et al Circulation 2004)
The statin-ezetimibe combination is ideal for lowering LDL-C and small dense LDL-C levels – and in my view will lower CHD risk more than statin alone, requires a study of sufficient power – IMPROVE-IT 2012

14. JAMA 2001; 285:2486, *Circulation 2004;110:227-39
National Cholesterol Education Program Adult Treatment Panel III Goals of Therapy
LDL C < 160 mg/dl or non HDL C < 190 mg/dl in all patients (low risk < 10% CHD risk over 10 yrs)
LDL C < 130 mg/dl or non HDL C < 160 mg/dl with 10-20% 10 yr CHD risk (Framingham) or 2 or more risk factors, optional < 100 mg/dl
LDL C < 100 mg/dl or non HDL C < 130 mg/dl with CHD or other vascular disease, diabetes, or > 20% 10 yr CHD risk, < 70 mg/dl or non HDL C < 100 mg/dl optional in CHD and high risk patients*
Canadian and European guidelines also recommend getting the TC/HDL C ratio < 4.0 in CHD patients
JAMA 2001; 285:2486, *Circulation 2004;110:227-39

15. Effects of LDL-C and HDL-C Change in Lipid Drug Classes on 1-Year Clinical Trial Outcome
% Event s = (%HDL-C) (%LDL-C) R2=0.93; P<.0001
Reduction During Trial in 1yr CV Event Rate vs Placebo
% HDL-C minus % LDL-C in Rx (%) placebo-adjusted
Brown BG, et al. Curr Opin Lipidol 2006;17:

16. Analysis of Lipoprotein Changes and Alterations in Atheroma as Assessed by IVUS-Cleveland Clinic Data Base
Analysis of 1455 patients with CHD who underwent IVUS at baseline and 18 to 24 months later.
On multivariate analysis mean levels of on treatment LDL C (beta coeff 0.11) and increases in HDL C (beta coeff -0.26) remained independent predictors of atheroma regression (p<0.001)
Substantial regression was observed if LDL C was < 87.5 mg/dl and HDL C increased by > 7.5% (both p<0.001)
Nicholls SJ et al JAMA 2007; 297:

17. Cholesterol-Carrying Lipoproteins
VLDL
Chylomicron
0.95
Chylomicron
VLDL
VLDL
VLDL
Remnants
1.006
IDL
Chylomicron
Remnants
Particle
Density, g/mL
1.02
LDL
Patients with Heart Disease often have elevated remnants, LDL (increased small dense LDL), and Lp(a), and decreased HDL (decreased large alpha 1 HDL), increased insulin and decreased adiponectin levels – with M Ai, B Asztalos, S Otokozawa & K Nakajima
1.06
Key Point:
Several different atherogenic lipoproteins can carry cholesterol.
HDL2
1.10
Lp(a)
HDL3
1.20 5 10 20 40 60 80
1000
Particle Size - Diameter, nm
Genest et al Circulation 1992;85:2025 Campos et al, ATVB 1992; 12:187, Schaefer et al JAMA 1994;59:32, McNamara et al Atherosclerosis 2001;154:229 Genest et al Circulation 1992;85:2025, Asztalos et al ATVB 2004;24:2181

18. CHD Patients Have Low Large ApoA-I Containing HDL
[nm]
17.0
9.51
8.16
7.10
4.66
pre
pre 
ApoA-I-Containing HDL Subpopulation Profiles of a Control (a) a CHD Patient (b), and a Schematic Diagram of 2D Gel System Based on Size (Vertical) and Charge (Horizontal) for HDL Particle Seperation – CHD Patients Have Decreases in Large Alpha 1 and Alpha 2 HDL and Increases in Pre-Beta 1 HDL. These particle patterns are significantly superior to HDL-C in predicting future CHD events in both the Framingham Offspring
Study and the Veterans Affairs HDL Intervention Trial.
Asztalos et al. Arterioscler Thromb Vasc Biol. 2003;23: ; 2004; 24: , 2005; 25: , HATS Trial, Framingham Offspring Study, and the Veterans Affairs HDL Intervention Trial

19. Apolipoprotein A-I Immunoblotting in Various Disorders of HDL Metabolism

21. Observations on HDL Particles – Population Studies
Patients with CHD have decreased HDL due to decreases in alpha 1 (-39%) and increases in alpha 3 HDL (+29%), and pre-beta 1 HDL (+16%) versus controls. (Asztalos et al ATVB 2000; 20:2670, ATVB 2004;24:2181)
In the Framingham Offspring Study in men free of CHD (n=1277) and men with CHD (n=169) for every 1 mg/dl increase in apoA-I in alpha 1 HDL there was a 26% decrease in risk of CHD (p<0.001), and HDL particles were significantly better CHD predictors then HDL C values (Asztalos et al ATVB 2004; 24:2181)
In the Veterans Affairs HDL Intervention Study low levels of alpha 1 and alpha 2 HDL predicted recurrent CHD events (n=398) versus no recurrence (n=1097) in men selected for low HDL C (<40 mg/dl) and CHD. Low alpha 1 HDL was the most significant parameter predicting recurrence (p<0.001) (Asztalos et al ATVB 2005; 25:2185)

22. Effect of Simvastatin-Niacin Treatment on HDL Subpopulation After 2 Years
Off Medication, mg/dL
On Medication, mg/dL
% (On/Off)
HDL-C
apoA-I
apoA-II 1 2 3
pre1
pre2
pre3
34  7
111  16
29  4
9.2  4.8
29.7  6.6
44.7  5.8
2.8  2.3
4.4  2.0
4.0  1.2
41  11*
118  17†
27  4†
17.6  10.1*
37.2  8.5*
36.9  9.9*
6.0  4.0*
6.7  2.4*
4.3  1.8
20  20
7  10
-7  14
115  123
27  25
-17  23
311  555
77  85
20  69
Asztalos BF, et al. Arteriosclerosis Thromb Vasc Biol. 2003;23(5):
*P<0.001, †P<0.01

23. Conclusions – Niacin
Niacin has been shown to reduce CHD risk in the Coronary Drug Project
Niacin plus simvastatin will regress coronary atherosclerosis if LDL C < 90 mg/dl and apoA-I levels in large alpha 1 HDL is > 20 mg/dl Asztalos et al ATVB 2003; 23:847-52
Niaspan (2 grams/day) will lower TG 21%, raise HDL –C 35% and large alpha 1 HDL 105% - associated with enhanced clearance of TRL apoB-100 and apoB-48 and increased apoA-I production, with no effect on clearance, Niaspan will also increase adiponectin 100%, a powerful anti-inflammatory substance made in fat Lamon-Fava et al ATVB 2008; 28:1672-8
Hamster and Monkey Studies that we have recently completed indicate that niacin increases liver mRNA for apoA-I 40% and for ABCA1 100%, and also 100% for adiponectin mRNA in fat Lamon-Fava et al (unpublished observations)
Ongoing studies will document that the statin-niacin combination is superior to statin alone in CHD risk reduction

24. Effects of Medications on HDL Particles and Metabolism
Fibrates increase HDL C 6%, alpha 3 HDL, mainly increase apoA-II, have little effect on apoA-I concentration, increase gene expression of AI, AII, LPL, but enhance AI FCR, and increase alpha 3 HDL Saki, Kashyap et al JCI 1995, Watts et al Diabetes Care 2005, Asztalos et al Metabolism 2007
Rosuvastatin increases HDL C by 10%, alpha 1 HDL by 24%, while atorvastatin increases these values by 2% and 12%. Both agents decrease pre-beta 1 HDL by 40%, associated with decreased CETP activity, but little effect on apoA-I kinetics. Statins enhance the clearance of all apoB containing lipoproteins Asztalos et al Am J Cardiol 2007 , Lamon-Fava et al JLR 2007

25. Cholesterol Ester Transfer Protein (CETP) Inhibition
CETP - 75 angstrom tube structure which shuttles between HDL and TRL to transfer hydrophobic core TG and CE between lipoproteins (Qi et al Nature Phys Chem 2006)
CETP inhibition (torcetrapib) markedly increases alpha 1 HDL by 150%, associated with delayed apoA-I clearance, but no effect on fecal cholesterol excretion, and enhances FCR of TRL apoB, apoE (Brousseau et al NEJM, 2004, ATVB 2005, 2009, Clark, ATVB 2004, Millar et al ATVB 2006, JLR 2008)
Torcetrapib raises systolic blood pressure (increased aldosterone, decreased K)- increased death, off target effects – apparently not shared by other CETP inhibitors, dalcetrapib and anacetrapib – (Barter et al NEJM 2007)

27. Human Apolipoprotein (Apo) Metabolism
Synthetic Sites
Catabolic Sites
FFA
Chylomicron ApoB-48 other Apos Lipids
LPL, HL, LCAT
Chylomicron Remnant ApoB-48, ApoE Lipids
5 hours
Liver 4 6 1
Lipids Apolipoproteins A-I, A-II, A-IV C-I, C-II, C-III, E Transfer Proteins HL
2 mg/kg/d 8
MTP
4.5 days
Kidney
Intestine
HDL ApoA-I other Apos Lipids
12 mg/kg/d 3
Scavenger Cells
Liver
An overview of human apolipoprotein (apo) metabolism as assessed by endogenous labeling with a primed constant infusion of deuterated leucine in the fed state. CETP, cholesterol ester transfer protein (transfers cholesterol ester from LDL and HDL to remnants of triacylglycerol-rich lipoproteins); FFA, free fatty acid; HL, hepatic lipase (cleaves fatty acids from both phospholipid and triacylglycerol); LCAT, lecithin cholesterol acyltransferase (phosphatidylcholine-sterol O-acyltransferase; transfers fatty acid from phosphotidyl choline or lecithin to cholesterol to form cholesterol ester); LPL, lipoprotein lipase (cleaves fatty acids from glycerol backbone on triacylglycerol); MTP, microsomal transfer protein (joins lipid with apo B). Open arrows indicate secretion pathways (with secretion rates). Closed arrows indicate catabolic pathways (with mean residence times for apo B-48, apo A-I, and apo B-100, respectively).
Schaefer EJ. Am J Clin Nutr. 2002;75:
Lipids Apolipoproteins C-I, C-II, C-III, E Transfer Proteins
MTP
LCAT 9
20 mg/kg/d 2
VLDL ApoB-100 other Apos Lipids
12 mg//kg/d
LDL ApoB-100 Lipids
Peripheral Cells
LPL, HL, LCAT 5
3.5 days 7
FFA
4 hours
Schaefer & Levy New Engl J Med 1985; 312:1300, Cohn JS et al J Clin Invest 1990: 85:804, Schaefer EJ. Am J Clin Nutr. 2002;75:191

28. HDL ApoA-I Particle Metabolism
Liver cell #7
SR-B1 cycle
SR-B1
Apos PL FC
LCAT, LPL CE CE #3
CELL
LCAT, LPL
LCAT, LPL HL
-2
-1
ABC-G1
-3
-4 #4 #5 PL FC #8
CETP cycle #2 #6
Pre-1
EL and sPLA2
CETP
ABC-A1
HDL Particle Metabolism: Apolipoprotein (apo) A-I is synthesized in the liver and intestine, and picks up some phospholipid (PL) to become discoidal pre-beta 1 HDL. This particle picks up free cholesterol (FC)
from cell membranes via the ATP Binding Cassette – A1 (ABC-A1) transporter to become discoidal alpha 4 HDL. This particle picks up more FC from cells via the ABC-G1 transporter, and the
FC is converted to cholesteryl ester (CE) by the action of lecithin cholesterol acyltransferase (LCAT, adds a fatty acid from PL to FC) to form spherical alpha 3 HDL which contains both apoA-I and apoA-II.
Via the action of lipoprotein lipase on triglyceride-rich lipoproteins (TRL), surface apolipoproteins (A-I, A-IV, and C apolipoproteins) are transferred to HDL and via the action of cholesteryl ester
transfer protein (CETP) TG is transferred to HDL in exchange for CE to form alpha 2 HDL, which is further enlarged to alpha 1 HDL by the same mechanisms. Alpha 1 HDL does not contain apoA-II. Via
action of hepatic lipase, PL can be removed from alpha 1 HDL and apoA-II added to form alpha 2 HDL. Alternatively alpha 1 and 2 particles can serve as dones for CE to TRL and the apoA-I can be recycled
back to pre-beta 1 HDL, which can either cleared by the kidney or serve as an acceptor for more FC. This latter process is faciltated by endothelial lipase (EL) and secretory phospholipase A2 (sPLA2).
Alpha 1 and apha 2 HDL can also donate CE to the liver via scavenger receptor – B1 (SR-B1), and the apoA-I can recycle back to apha 4 HDL. #1 #9 PL
CE TG
Catabolism
Free ApoA-I
#10
Kidney
TRL
Liver Intestine
Schaefer EJ, Asztalos BF. Curr Opin Lipidol. 2006, Curr Opin Cardiology 2007, Am J Cardiol 2008

29. HDL Raising Rx – Bright Future
Low HDL C levels < 40 mg/dl associated with decreased large alpha 1 HDL - powerful CVD predictor
Raising HDL-C and large alpha 1 HDL associated with regression of CAD
Exercise and weight loss are lifestyle strategies for HDL raising
CETP inhibition is the most powerful modality for HDL raising and we will have more outcomes data in 2013 which in my view will be positive – prevents CE from getting onto remnant particles
Niacin is the next most powerful HDL raising agent and more outcomes data will be available in 2012 – enhances clearance of TRL and increases reverse cholesterol transport by upregulation of ABCA1 -Combination with statins is currently the most powerful modality we have for regression of atherosclerosis

30. Thank you