1. Delipidation for ACS Patients HDL Therapy Via Plasmapheresis
Ron Waksman, MD
Washington Hospital Center

2. Ron Waksman, MD DISCLOSURES Consulting Fees Grants/Contracted Research
Abbott Vascular, Biotronik, Medtronic CardioVascular, Inc, Boston Scientific Corporation
Grants/Contracted Research
Abbott Vascular, Biotronik, Boston Scientific Corporation, The Medicines Company, GlaxoSmithKline, Schering-Plough, sanofi-aventis U.S. LLC

3. WHY HDL ???
Low high-density lipoprotein (HDL) cholesterol is associated with increased risk of CHD.
HDL also protects low-density lipoproteins (LDL) from oxidation and inhibits expression of adhesion molecules in endothelial cells, preventing monocyte movement into the vessel wall
HDL removes and transports excess cholesterol from peripheral cells to the liver for removal from the body
Current drug options for increasing HDL– Cholesterol levels include the statins, fibrates, and niacin 3

4. Mechanism by Which HDL protects against CVD
HDL-mediated efflux of cholesterol from cholesterol-loaded macrophages is one of the most extensively studied anti-atherogenic functions of HDL.
The major pathway for cholesterol efflux from macrophages to HDL is by interaction of HDL with the ABCA1 transporter.
The preferred acceptor for the ABCA1 transporter-mediated cholesterol efflux is poorly lipidated apoA-I or preβ-HDL. 4

5. Use of cholesteryl ester transfer protein inhibitors. CETP
Strategies in development for increasing the function of HDL or apolipoprotein A-I and thereby reducing atherosclerotic progression
Use of agents to upregulate the adenosine triphosphate-binding cassette transporter in vessel wall macrophages to increase cholesterol efflux from these cells
Use of agents to stimulate endogenous apoA-I synthesis; administration of apoA-I, apoA-I Milano, apoA-I-mimetic peptides.
Use of cholesteryl ester transfer protein inhibitors. CETP
Delipidated HDL by apheresis.
Infusion of HDL in the form of apoA-I/phospholipids complexes was associated with regression of atherosclerosis in cholesterol-fed rabbits 5

6. How Does HDL Therapy Work? Delipidated HDL Enhances
Reverse Cholesterol Transport
The major pathway for cholesterol efflux from macrophages to HDL is by interaction of HDL with the ABCA1 transporter.
Liver
Modification C A - I
Pre-Beta HDL “Empty Dump Truck”
Alpha HDL “Full Dump Truck”
LDL
LDL “Bad Cholesterol”
Cholesterol
LCAT
HDL Therapy Infusion of Delipidated HDL.
α HDL transports
Excess Cholesterol
to the liver
αHDL 6 6

7. Plasma from African Gree monkeys underwnet selective HDL delipidation
Selective delipidation of plasma HDL enhances reverse cholesterol transport in vivo
Plasma from African Gree monkeys underwnet selective HDL delipidation
The delipidated plasma was reinfused into five monkeys.
Pre β-1-like HDL had a plasma residence of 8+6 h.
Small α-HDL was converted entirely to large α-HDL
Treatment with delipidated plasma tended to reduce diet –induced aortic atherosclerotic in monkeys measured by intravascular ultrasound.
These findings link the conversion of small to large HDL, in vivo, to improvement in atherosclerosis
Sacks, et al. J Lipid Res :

8. Effect of Selective HDL delipidation on aortic atheroma in monkeys
Total atheroma Volume
Pre
treatment
Post treatment
% Change
Mean
5.63
5.25
-6.9% SD
1.27
1.41
11.1%
Percent atheroma Volume
Pre
treatment
Post treatment
% Change
Mean
31.78
30.26
-4.4% SD
4.41
5.61
14.8%
Sacks, et al. J Lipid Res :

9. HDL Selective Delipidation
“Energized HDL”
“Full Dump
Truck”
~95%
“Empty Dump
~5%
~80%
~20% 9 9

10. LIPID SCIENCE 01 TRIAL Key Trial Personnel and organization
Principal Dr. Ron Waksman
Investigator Associate Director of Cardiology
MedStar Research Institute
IVUS Dr. Neil Weissman Dr. Peter Fitzgerald
Laboratories Director, IVUS Core Laboratory Director, IVUS Core Laboratory
MedStar Research Institute Stanford School of Medicine
ECG Core Laboratory Dr. Joseph Lindsay
Director, ECG Core Laboratory
MedStar Research Institute
Data Safety Dr. William Wientraub
Monitoring Board DSMB, Chairman
Director, Christiana Center for Outcomes Research,
Christiana Care Health Services
Clinical Event Dr. David Cohen
Committee CEC, Chairman
St. Luke’s Mid American Heart Institute
Data Coordinating David Hellinga
Center Director, Data Center
Cardiovascular Research Institute
Central Laboratory Dr. Jason Umans
Director, Penn Laboratories
MedStar Research Institute
Waksman et al. In Press in JACC 2010 10 10

11. Objectives
The primary aim of this study was to test the safety and feasibility of autologous delipidated HDL infusions in acute coronary syndrome (ACS) patients.
An exploratory aim of this study was to assess the impact on plaque volume assessed by IVUS measurements. 11 11

12. HDL Selective Delipidation Trial Design
Patients with ACS scheduled for cardiac cath with non obstructive atheroma were randomized to HDL delipidation or control and subjected to apheresis/ reinfusion. Patients had 7 sessions each 1 week apart. IVUS performed up to 14 days from last procedure to assess atheroma volume indices. 12 12

13. HDL Delipidation Process
Schematic Overview of the Methodology for the Selective Delipidation of HDL in Plasma
Plasma
Delipidated
HDL Delipidation Process
NOT Patient connected
Uses patient’s own HDL
Cholesterol removed from α-HDL to yield pre-β-HDL
Delipidated plasma is reinfused into patient 13 13

14. Major Inclusion Criteria
≥ 18 Years And ≤ 85 Years Of Age
ACS Diagnosis within the preceeding 14 days
Suitable For Plasmapheresis
HDL ≥ 32 mg/dL And ApoA-I Level ≥ 95 mg/dL
Triglycerides < 300 mg/dL
CHD In A “Target Artery” With ≥ 20% But ≤ 50% Reduction In Lumen Diameter By Visual Angiography
Waksman et al. In Press in JACC 2010 14 14

15. Major Exclusion Criteria
Elevated ST Segment MI ≤ 72 Hours Of Screening
Ejection Fraction (LVEF) < 40%
Hemodynamically Unstable
Pregnant Or Lactating ≤ 6 Months Prior To Screening
Active Liver Disease Or Hepatic Dysfunction
Renal Dialysis Or Presence Of Renal Dysfunction
Active Cholecystitis, Gallbladder Symptoms, or Hepatobiliary Abnormalities
Insulin Dependent Diabetes
Unstable Or Uncontrolled Hypertension
Unstable Hypotension
Cardiac Insufficiency
Currently Taking Coumadin
Waksman et al. In Press in JACC 2010 15 15

16. Study Design
Patient presents with ACS with non-obstructive atheroma in ≥ 1 native coronary artery
FDA Approval: 01/27/06
Trial Launch: 05/31/06
Trial Conclusion: 01/29/08
Undergo IVUS of target non-obstructive atheroma native coronary artery (n=28)
Randomized (1:1)
Single-Blind
Control n=14
7 apheresis/reinfusion (1 week apart)
HDL delipidation n=14
7 apheresis/reinfusion (1 week apart)
2 control subjects discontinued after sessions 1 & 6
Undergo repeat IVUS of target atheroma (n=26)
Within 14 days after final reinfusion 16

17. Baseline Characteristics
Variable, n (%) or median (range)
Evaluated at Screening
Delipidation Group
n=14
Control Group
Age (years)
55 (44-68)
55 (37-74)
Male
10 (71.4)
12 (85.7)
Diabetes
6 (42.9)
2 (14.3)
History of HTN
13 (92.9)
History of Hyperlipidemia
Current Smokers
5 (35.7)
Prior PCI
4 (28.6)
Prior CABG
1 (7.4)
Weight (kg)
88 (68-108)
88 (58-117)
Statin Use at Randomization
Non-Statin Cholesterol Lowering Medication at Randomization
Waksman et al. In Press in JACC 2010 17

18. Delipidation Group (n=14)
Lipid Profile
Delipidation Group (n=14)
Control Group (n=12)
P value*
Pre
Final Visit
Total Cholesterol
148.5 ( )
147 (90-203)
148 ( )
148.5 (99-221)
0.643
HDL-C
47 (33-65)
44 (34-59)
41.5 (32-82)
44 (27-86)
0.395
LDL-C
75 (45-133)
67.5 (35-120)
78 (43-113)
70.5 (40-131)
0.268
VLDL-C
20.5 ( )
27.5 ( )
24.2 (3-54.1)
28.3 ( )
0.662
ApoB
82.5 (55-123)
74 (46-105)
71 (57-100)
73 (46-116)
0.099
ApoA-1
139.1 ( )
129.1 ( )
126.4 ( )
124.5 ( )
0.554
Triglycerides
138.0 (65-446)
146.5 (66-360)
187.5 (65-505)
161.5 (64-440)
0.700
*Wilcoxon Rank Sum Test (change between groups) 18

19. Safety Laboratory Values
Delipidation Group (n=14)
Control Group (n=12)
P value*
Pre
Final Visit
Hemaglobin
14.1 ( )
13.8 ( )
14.1 ( )
13.6 ( )
0.315
Hematocrit
41.5 ( )
39.7 ( )
41.9 ( )
40.5 ( )
0.396
AST
27.5 (19-69)
28.5 (21-51)
24.5 (16-82)
23.5 (16-66)
0.367
ALT
38.5 (28-101)
36 (28-71)
40.5 (25-98)
35.5 (21-52)
0.777
Alkaline Phos
86 (61-132)
91 (62-129)
88 (65-163)
92.5 (60-135)
0.156
LDH
497.5 ( )
468.5 ( )
502.5 ( )
476.5 ( )
0.738
Total CPK
96.5 (31-233)
106 (40-288)
101.0 (20-314)
81.5 ( #)
0.625
Potassium
4.5 ( )
4.4 ( )
4.2 ( )
4.3 ( )
0.093
*Wilcoxon Rank Sum Test (change between groups); #One patient was a body builder – CK-MB and Trops were <2xULN for this patient at final visit 19

20. Major Adverse Cardiac Events
Variable, n (%) - ITT
Delipidation Group
n=14
Control Group
Death
Re-infarction
Target Lesion Revascularization
Non-Target Lesion Revascularization
1 (7.2)
2 (11.8)
Unanticipated Adverse Device Effects
Waksman et al. In Press in JACC 2010 20

21. Quantitative 2-D Gel Electrophoresis & Pre-β HDL (ELISA) Following Delipidation
Waksman et al. In Press in JACC 2010 21 21

22. Results
All reinfusion sessions were well tolerated by the patients with no adverse clinical effects.
The levels of pre-β HDL in the delipidated plasma are dramatically increased as compared to the undelipidated, control plasma in a subset analysis.
Associated with the pre-β HDL increase was a 5X rise in the cholesterol efflux for the delipidated plasma versus the control.
Corrected 80.8% to 79.1% and 19.2% to 20.9%. (Recent correction of primary data.)
Put sentence about IVUS data as its own bullet.
Waksman et al. In Press in JACC 2010 22

23. Change in IVUS parameters, post delipidation treatments minus baseline ACS presentation
Variable (mean ± SD)
Delipidated Group
n=14
Control Group
n=12
Change in Total Atheroma
Volume (mm3)
± 36.75
2.80 ± 21.25
Change in Plaque Burden (%)
-1.0 ± 4.0
0.0 ± 4.0
Change in 10 mm Most Diseased Subsegment – Atheroma Volume (mm3)
-6.24 ± 17.94
-1.73 ± 11.21
Change in 10 mm Least Diseased Subsegment – Atheroma Volume (mm3)
-1.10 ± 11.35
1.53 ± 11.70
Changed heading title from “Change in Atheroma Volume” to “Change in Total Atheroma Volume”
Changed heading title from “Change in Most Diseased 10 mm – Atheroma Volume” to “Change in 10 mm Most Diseased Subsegment (mm3)”
Changed heading title from “Change in Least Diseased 10 mm – Atheroma Volume” to “Change in 10 mm Least Diseased Subsegment (mm3)”
Waksman et al. In Press in JACC 2010 23

24. IVUS Data
Waksman et al. In Press in JACC 2010 24

25. Rapid Regression of Human Coronary Plaque after 5 Weekly Intravenous Injections of Recombinant rApo A-Imilano (ETC-216)
*Nissen et al JAMA 2003: 290,

26. Comparison of the Changes in IVUS Parameters in Lipid Sciences Selective Delipidation Trial and ApoA-I Milano Trial
Variable (mean ±SD)
LS-001 Trial
N=14
ApoA-I Milano Trial
N=36*
Change in Total Atheroma Volume (mm3)
± 36.75
± 39.50
Change in % Atheroma Volume (Plaque Burden)
-1.0% ± 4.0%
-1.1% ± 3.2%
Change in Most Diseased 10 mm Subsegment, Atheroma Volume (mm3)
-6.24 ± 17.94
-7.20 ± 12.60
*Nissen et al JAMA 2003: 290, 26

27. Summary
Pre-clinical studies have demonstrated that pre-β HDL is a key component in reverse cholesterol transport
Safety and feasibility of delipidation were demonstrated
Infusions are well tolerated by patients
Patient compliance is excellent
The PDS-2 consistently, reliably, and dramatically
converts αHDL to pre-β HDL
IVUS data demonstrates a numeric trend towards reduction in atheroma volumes 27 27

28. Conclusions
In patients with ACS, serial autologous infusions of HDL delipidated plasma are well tolerated by patients, and are clinically feasible and safe.
This therapy may offer a novel adjunct treatment for patients presenting with ACS, and may ultimately stabilize and regress atherosclerotic plaques.
Thank You 28