Slide 1

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 2

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 3

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 4

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 5

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 6

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 7

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 8

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 9

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 10

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 11

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 12

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 13

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 14

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 15

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 16

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 17

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 18

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 19

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 20

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 21

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 22

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 23

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 24

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 25

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 26

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 27

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 28

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 29

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 30

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 31

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 32

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 33

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 34

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 35

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 36

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 37

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 38

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 39

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 40

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 41

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 42

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 43

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 44

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 45

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 46

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 47

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 48

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 49

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 50

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 51

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 52

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 53

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 54

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 55

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 56

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 57

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 58

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 59

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 60

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 61

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 62

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 63

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 64

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 65

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 66

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 67

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 68

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 69

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 70

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial


Slide 71

Secretory Phospholipase A2: A New
Risk Factor and Soon a New Target of
Therapy
Rabih R. Azar, MD, MSc, FACC
Associate Professor of Medicine
Division of Cardiology
Hotel Dieu de France
Saint Joseph University

Risk of CAD according to LDL
and HDL

Is Very Low LDL the Answer to Better Prevention?
Relationship between LDL-C and CV Event Rate
30

- Primary prevention

4S - Pl

- Secondary prevention

25

Rx - Statin therapy

Event rate (%)

Pl - Placebo

20

4S - Rx
LIPID - Pl

15
LIPID - Rx

10

CARE - Rx
PROSPER - Rx
HPS - Rx
ALLHAT - Rx

5
ASCOT - Rx

0
70 (1.8)

90 (2.3)

CARE - Pl
PROSPER - Pl
HPS - Pl

WOSCOPS - Rx
AFCAPS/TexCAPS - Pl

AFCAPS/TexCAPS
- Rx
110 (2.8)

WOSCOPS - Pl

ALLHAT - Pl

ASCOT - Pl

130 (3.4)

150 (3.9)

170 (4.4)

190 (5.0)

210 (5.4)

LDL-C achieved mg/dL (mmol/L)
Adapted from Ballantyne CM et al. Am J Cardiol 1998;82:3Q–12Q.

NCEP ATP III: LDL
-C Goals
LDL-C
(2004 proposed modifications)

190 -

High Risk

Moderately
High Risk

Moderate
Risk

Lower
Risk

CHD or CHD risk
equivalents

≥ 2 risk
factors

≥ 2 risk
factors

< 2 risk
factors

(10-yr risk
>20%)

(10-yr risk
10-20%)

(10-yr risk
<10%)

goal

160

LDL-C level

mg/dL

160 -

goal

goal

mg/dL

mg/dL

130

130 -

goal

100

mg/dL

130

or
optional

100

mg/dL*

100 -

or
optional

70

mg/dL*

Existing LDL-C goals
Proposed LDL-C goals

70 *Therapeutic option
70 mg/dL =1.8 mmol/L; 100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160
mg/dL = 4.1 mmol/L

Grundy SM et al. Circulation 2004;110:227-239.

High Residual Risk in ACS Despite Early
Statin Use
PROVE-IT
30%
Pravastatin 40 mg

Placebo

15

Atorvastatin 80 mg

10

5

Death, MI, ACS, stroke,
revascularization

Death, non-fatal MI, or recurrent USA

MIRACL

20%
Atorvastatin 80 mg

10%

RRR 16%
p=.005

RRR 16%
p=.048

0

0%
0

1

2

Months

3

4

0

12

24

30

Months
5

Schwartz et al., JAMA 2001;285:1411; Cannon et al. N Engl J Med. 2004;350:1495.

IS LDL CHOLESTEROL
THE “ONLY” PLAYER IN
ATHEROSCLEROSIS?

Cholesterol distribution in CHD
and non-CHD populations
In spite of major
advances made in the
screening, detection,
and management of
heart disease, a major
need exists for more
accurate ways to predict
CV risk
– Approximately 50% of
individuals diagnosed
with coronary artery
disease do not have
high blood cholesterol
levels
– Therefore, other
factors must be
involved

Framingham Heart Study — 26-year follow-up
35% of CHD occurs
in people with
TC considered optimal
(<200mg/dL)

No CHD

CHD

150

200

250

300

Total cholesterol (mg/dL)
Adapted from Castelli W. Atherosclerosis 1996

Prevalence of major risk
factors in men with CHD
• Traditional risk factors

4 major risk
factors
3 major risk
0.9%
factors
2 major risk
factors

8.9%

are a useful first step
in determining who
could be at risk for a
coronary event

0 major risk
factors

19.4%
62.4%
0 to 1
major
risk
factor

27.8%

43.0%
1 major risk
factor

N=87,869
4 Major modifiable risk factors:
hypertension, smoking,
hypercholesterolemia, diabetes

• Exposure to one or

more CHD risk factors
is also highly
prevalent in
individuals who do not
develop clinical CHD

• Less than 10% of

patients have 3 or 4
major risk factors

• Secondary testing can

be used to further
stratify individuals for
CHD risk
Khot, et al. JAMA. 2003

Stages of Atherosclerosis
LUMEN

LDL

INTIMA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Adhesion
molecules
Oxidized LDL
sPLA2

INTIMA
Lyso-PC
OxFA

MEDIA

Stages of Atherosclerosis
LUMEN

Monocytes
Cytokines
Adhesion
molecules

Plaque
formation

Oxidized LDL
sPLA2

Foam cell
INTIMA

Macrophage
Lyso-PC
OxFA

MEDIA

What is sPLA2?
• Family of Ca2+ dependent proteins
• Exact physiologic role in humans is not clearly known
• Type IIA is an acute phase protein secreted from liver in response
to inflammatory cytokines
• Groups IIA, V, X have each been implicated in CVD
• All types cleave phospholipids at sn-2 position
• By generating intermediates acts as mediator between proximal
and distal effectors of inflammation

13

Role of sPLA2
Phosphatidylcholine (PC)

Oxidation

Oxidatively-modified PC

sPLA2

+
Oxidized fatty acid (oxFA)

Lysophosphatidylcholine (Lyso-PC)
Tselepis AD, et al. Atheroscler Suppl. 2002

Pro-atherogenic activities of
lysophosphatidylcholine (Lyso-PC)
lyso-PC

Expression
of adhesion
molecules

Upregulation
of cytokines
and CD40
ligand

Cytotoxic to
vascular smooth
muscle cells

Stimulation
of
macrophage
proliferation

Chemoattractant
for macrophage
and T-cells

1. Dada N, et al. Expert Rev Mol Diagn. 2002
2. Quinn MT, et al. Proc Natl Acad Sci USA. 1988

Induction
of MCP-1

Inhibition of
endothelial-derived
nitric oxide

3. Macphee CH, et al. Biochem J. 1999
4. Carpenter KL, et al. FEBS Lett. 2001

sPLA2-IIA overexpression induces
atherosclerosis in mice
Transgenic overexpression of human sPLA2-IIA gene in mice induces
atherosclerosis:
• Spontaneous atherosclerosis lesions development, even in the
absence of hyperlipidemia.

• Elevated plasma lysoPC levels.
C57BL/6

sPLA2-IIA Tg

Ivandic et al. ATVB 1999,19:1284

17

Varespladib Decreases Atherosclerosis;
Synergistic with Statins in ApoE -/- Mice

% Plaque Area
(of Aortic Surface Area)

20%
n=20

Monotherapy
(Percent Plaque
Area)

10%

n=18

*

7

% En Face Lesions

15%

Combination Therapy: A-002 + Statin
(Percent Plaque Area)*

n=17

*

5%

6
5

*

4
3

**, †
2
1

0%

0
Vehicle

30 mg/kg

90 mg/kg

* p< 0.10 vs. placebo
** p< 0.05 vs. placebo
† p< 0.05 vs. A-002 low dose

Fraser H et al, J Cardiovasc Pharmacol 2009;53

Shaposhnik Z et al, J Lipid Res 2009;50

**
**

sPLA2 levels increased with atherosclerotic
development in human plaques

19

The extent of sPLA2s expression increased with atherosclerosis development.

Kimura-Matsumoto et al., Atherosclerosis, 196 (2008) 81–91

sPLA2 family plays a causal role in atherosclerosis

20

•

•

RCT of trandolapril in 3738 patients
with stable CAD and EF >40%
Mean follow-up of 4.8 years

•

Secondary events: cardiovascular
death, stroke or MI.

•

Reference: O’Donoghue M et al,
American Heart Association 2009
Meeting, P1131

Adjusted Hazard Ratio

sPLA2 Activity in stable CAD Patients
PEACE Study
CVD, MI or stroke at 5 years
(P trend <0.001) Adj HR 1.56
Adj HR 1.19 Adj HR 1.26
(0.80-1.66) (0.90-1.76)

(1.14-2.15)

Referent

Q1

Q2
Q3
sPLA2 Activity Quartile

Q4

Matched for age, sex, HTN, DM, smoking, prior MI, prior coronary
revascularisation, apoB, apoA, eGFR, current lipid-lowering Rx.

sPLA2 activity allows clinicians to predict fatal and
non-fatal recurrent events after a first event

21

sPLA2 Activity in acute MI Patients
FAST-MI Study

•
•

1036 patients with Acute Myocardial
Infarction
86 cases after 6 months follow-up.
Reference: Simon T et al, European
Society of Cardiology 2008 Meeting,
P1317

sPLA2 activity allows clinicians
to better monitor patients with
MI by increasing prediction of
recurrent event

Death, MI or stroke at 6 months
(p trend < 0.01) Adj OR 2.29
(1.28-4.12)

sPLA2 Activity

Adjusted Odd Ratio

•

Lp-PLA2
Adj OR 1.39
(0.73-2.65)
1.09

Referent
0.82

T2
T3
T1
sPLA2 Activity and Lp-PLA2 Tertiles
Matched for sex, age, time, traditional CV risk factors, CRP
and treatments including statins.

sPLA2 Activity in ACS Patients
GRACE Study
•

446 Acute Coronary Syndrome patients (38.5
% with ST elevation MI, 52.5% with Non-ST
elevation MI and 9% with UA).

•

One year cumulative incidence of death or MI:
9.63%.

•

Reference: Mallat Z et al, J Am Coll Cardiol.
2005 Oct 4;46(7):1249-57.

ACS Patients with high sPLA2 activity have a 4-fold risk
increase of death and new or recurrent myocardial infarction

22

sPLA2 Activity in Asymptomatic Patients
EPIC-Norfolk Study
2797 subjects (991 apparently healthy
subjects with development of fatal or non-fatal
coronary artery disease, 1806 matched
controls).

•

6 years median follow-up

•

Reference: Mallat Z et al, Arterioscler Thromb
Vasc Biol. 2007, May;27(5):1177-83.

Adjusted Odd Ratio

•

Incident CAD at 6 years
Adj OR 1.70
(1.32-2.19)
Adj OR 1.41 Adj OR 1.38
(1.10-1.83) (1.07-1.78)
Referent

Q1

Q2
Q3
Q4
sPLA2 Activity Qartiles

Matched for sex, age, enrollment time, and adjusted
for diabetes, smoking, body mass index, systolic
blood pressure, LDL-C, and HDL-C.

After adjustment for components of the Framingham Risk
Score, sPLA2 Activity allows prediction of the risk of
incident CAD in asymptomatic patients on top of FRS

23

24

A very high level of proof
5 studies already published (8200 patients)
sPLA2 activity: the first independent biomarker to allow a 2- to 4fold CV risk increase prediction in different population types.
3738 stable CHD patients
PEACE study (1)
Secondary
prevention

sPLA2 Activity

1.6

1206 CHD patients
KAROLA study (2)

1.7

1036 Acute Coronary Events patients
FAST-MI study (3-4)

2.3
3.1

446 Acute CAD patients
GRACE study (5)
Primary
prevention

1.7

2797 asymptomatic patients
EPIC-Norfolk study (6-7)
0

1- O’Donoghue M et al, American Heart Association Meeting, 2009, P1131
2- Koenig W et al, Eur Heart J. 2009 Nov;30(22):2742-8.
3- Simon T et al, European Society of Cardiology Meeting, 2008, P1317
4- Simon T et al, European Society of Cardiology Meeting, 2009, P5109
5- Mallat Z et al, J Am Coll Cardiol. 2005 Oct 4;46(7):1249-57
6- Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83
7- Tsimikas S et al, American Heart Association Meeting, 2008, P4998

1

2

3

4

5

Relative Risk of Cardiovascular Events
(adjusted odd ratio, first quartile/tertile
vs last quartile/tertile)
Adjusted for traditional risk factors, treatments and
biomarkers when available

Multimarker Approach in Asymptomic Patients
EPIC-Norfolk Study
OR=2.89
(1.78-4.68)

2
2

3

4

1

sPLA2 Activity
Both matched for sex, age, enrollment time,
adjusted for diabetes, smoking, BMI, SBP, LDL-C
and HDL-C

Adjusted Odd Ratio

Adjusted Odd Ratio

3
1

OR=3.67
(2.38-5.65)

4

4

25

3.5
3
2.5
2
1.5
1

3

0.5

2

0

1

2
3
sPLA2 Activity

1

In asymptomatic patients, sPLA2 activity allows a
increased prediction of CV risk:
• 3-fold higher risk combined with CRP
Mallat Z et al, Arterioscler Thromb Vasc Biol. 2007, May;27(5):1177-83.
• 4-fold higher risk combined with oxPL/apoB100
Tsimikas S et al, American Heart Association 2008 Meeting, P4998.

Effect of Ezetimibe/Atorvastatin
Combination on sPLA2 in Patients With
CAD or CAD Equivallent
Mireille Azar, Emmanuel Valentin, Georges
Badaoui, Roland Kassab, Antoine Sarkis, and
Rabih Azar
• Am J Cardiol May 2011 (manuscript)
• Sponsored by Pharmaline

OBJECTIVE
TO EVALUATE THE EFFECT OF
ATORVASTATIN 40 mg and of
ATORVASTATIN 40 mg +
EZETIMIBE ON sPLA2

Exogenous

Endogenous

Cholesterol Absorption Inhibition for Broader Lipid Control

VLDL

IDL

LDL

Statins
synthesis

BILIARY
SECRETION

Absorption
Cholesterol
Absorption
Inhibition

INTESTINE

DIETARY
CHOLESTEROL

Excretion
Slide 28

Doubling a Statin Dose Yields Only
a 6% Incremental Drop in LDL-C

Reduction of LDL-C, %

Statin Rule of 6

6% drop
6% drop

6% drop

0

10

20

30

40

50

60

70

80

Statin, mg
Adapted from Knopp RH. N Engl J Med. 1999;341:498–511; Stein EA. Am J Cardiol. 2002;89(suppl):50C–57C.
Slide 29

CHANGE OF SYNTHESIS
AND ABSORPTION MARKERS1

MEAN LDL-C LOWERING2,3

Inhibition of
absorption

Inhibition of
synthesis

Ezetimibe alone

Statin alone

absorption
synthesis

10%

LDL-C

synthesis

40%
50%

Ezetimibe/Statin

synthesis absorption
absorption

LDL-C

20%
30%

Dual Inhibition

LDL-C

STATIN

20%
30-45%

+

EZETIMIBE
As high as

60%

1. Assmann G, et al. J Am Coll Cardiol 2004;43(5, Suppl. 2):A445-A446; 2. Goldberg AC, et al. Mayo Clin Proc. 2004 May;79(5):620-9.;
3. Davidson M et al. J Am Coll Cardiol 2002; 40:2125-34.

Slide 30

Effect of Ezetimibe/Atorvastatin Combination on
sPLA2 in Patients With CAD or CAD Equivallent
- Prospective, randomized, double-blind, placebocontrolled trial
- Inclusion criteria:
- Patients with CAD
- > 50% stenosis on angiography
- MI
- PCI or CABG

- Patients with CAD equivalent
- Diabetes requiring medications
- Peripheral vascular disease
- Stroke

- Lipid levels were not entry criteria

Exclusion Criteria
• Therapy with a statin more potent than atorvastatin 20
mg/day (atorvastatin 40 or above, rosuvastatin any
dose)
• Therapy with ezetimibe, any other cholesterol absorption
inhibitor, niacine, fibrate within the last 3 months
• MI, CABG, PCI within the last 3 months
• Age > 80 years
• EF < 35% or CHF with NYHA class > 2
• Creatinin clearance < 30 mL/min
• CPK or SGPT > 2 times upper normal

Study Protocol

• The statin taken by the patient was
stopped and replaced by atorvastatin 40
mg/day
• Patients were then randomized to
ezetimibe 10 mg/day vs. placebo
• Duration of treatment 8 weeks

MEASURMENTS
• Standard lipid profile (Total cholesterol,
VLDL, LDL, HDL)
• High sensitivity CRP
• Secretory phospholipase A2

• CPK, SGPT

End-Points
• Primary end-point
• Change in sPLA2

• Secondary end-points
• Change in hs-CRP

• Safety end-points
• Elevation of CPK or SGPT more than twice
upper normal

Inclusion Criteria
Ezetimibe
n = 50
Stenosis > 50% 19 (38%)
Prior MI
18 (36%)
PCI
23 (46%)
CABG
26 (52%)
Diabetes
18 (36%)
Stroke
1 (2%)
PVD
6 (12%)

Placebo
n = 50
23 (46%)
12 (24%)
15 (30%)
21 (42%)
21 (42%)
1 (2%)
5 (10%)

The number of inclusion criteria is superior to 100% because each
patient may have more than 1 criterion that defines CAD

Baseline Characteristics

Age (year)
Male
Smoking
Hyperlipidemia
Hypertension
Fam. Hist. CAD
BMI (kg/m2)

Ezetimibe
n = 50

Placebo
n = 50

64
44
14
47
35
21
27

65
41
12
43
38
14
28

+8
(88%)
(28%)
(94%)
(70%)
(42%)
+3

+ 11
(82%)
(24%)
(86%)
(76%)
(28%)
+4

Concomitant Medications

Aspirin
Clopidogrel
ACE inhb. or ARB
Beta-blockers
CCB
Nitrates
Diuretics
OAD
Insulin

* P = 0.02

Ezetemibe
n = 50

Placebo
n = 50

45 (90%)
11 (22%)
41 (82%)
37 (74%)
8 (16%)
10 (20%)
6 (12%)
15 (30%)
6 (12%)

43 (86%)
11 (22%)
34 (68%)
35 (70%)
18 (36%)*
11 (22%)
6 (12%)
17 (34%)
6 (12%)

Statin Use at Baseline
• 90% of patients were using a statin prior
to randomization
• Simvastatin

53%

• Atorvastatin

30%

• Fluva or pravastatin 7%
• None

10%

Change in LDL
P < 0.001

10% additional
reduction

P < 0.001

20% additional
reduction

Final LDL levels were lower in ezetimibe vs. placebo; p < 0.001

Change in VLDL
P = 0.07

P < 0.001

P = ns

P = ns

Change in Hs-CRP
p = 0.014

37% reduction

p < 0.001

Effect of Atorvastatin-Placebo on sPLA2
P = NS

No Change

Reduction of sPLA2 by
atorvastatin/ezetimibe combination
P = 0.001

10% reduction

Correlation between change in sPLA2 and
changes in hs-CRP

p = 0.007

p < 0.001

Correlation between the change in sPLA2 and in
LDL

p = 0.005

p = NS

Variables independently associated with
change in sPLA2

-

Variable

Beta coef

P

Change in CRP
Baseline LDL
BMI
Diabetes
Ezet/atorva

0.53
-0.26
-0.24
0.16
-0.15

< 0.001
0.001
0.003
0.04
0.05

(Linear Regression Model)

Safety End-Point
There was no elevation of CPK
or SGPT in any patient of the 2
groups

Major Findings of the Study
• First to demonstrate a reduction in sPLA2 with
lipid lowering therapy
• Effect was weak: 10% reduction
• Low LDL level at baseline. If LDL was higher,
reduction might have been more potent

• Cannot exclude that statins do not decrease
sPLA2, because 90% of our patients were on
statin at baseline and because statins decrease
both LDL and hs-CRP

Summary of Results: Effects of
Atorvastatin and Ezetimibe on Various
Lipid Parameters

LDL

Large
LDL

Small
dense
LDL

Particl
e size

HDL

VLDL

OxLDL

sPLA2

More
potent
statin

Ezetimb
e

The changes induced by statin are quantitative and qualitative
The Changes induced by ezetimibe are only quantitative

Enhance-Study

Kastelein et al., NEJM 2008, 358: 1431-43

LDL-cholesterol
10

Percentage change from baseline

0
10
20
30
40
50
60
70 0

Simva

Baseline
(mg/dL)
318 ± 66

24 months
(mg/dL)
193 ± 60

Eze-Simva

319 ± 65

141 ± 53

P<0.01

-16.5 %
incremental
reduction

6

12

Months
Kastelein JP et al N Engl J Med 2008;358:1431-43.
ENHANCE

18

24

Simva
Eze-Simva

Mean cIMT during 24 months of therapy
Longitudinal, repeated measures analysis
0.80

Mean IMT (mm)

0.75

P=0.88

0.70

0.65

0.60

6

12

ENHANCE
Kastelein JP et al N Engl J Med 2008;358:1431-43.

Months

18

24

Simva
Eze-Simva

Slide 55

SANDS-Study

Fleg et al., JACC 2008; 52

Slide 56

SANDS
Trial
Design*

499 men and women
with diabetes and no CVD
40 yrs old
SBP>130, LDL>100

Standard Targets
LDL-C <100; SBP <130
non-HDL-C <130
N=247

Aggressive Targets
LDL-C <70; SBP <115
non-HDL-C <100
N=252

Measure CVD using carotid
and cardiac ECHO at baseline
18 months and after 3 yrs intervention
Primary outcome—change in CIMT
*JAMA 2008; 299:1678-89

Slide 57

Change in IMT by Ezetimibe +/0.04
0.03
0.02
0.01
mm

Aggressive
Standard

0
-0.01
-0.02
-0.03

E+ (N=69)

E- (N=154)

* p<0.001 for both E + and E- compared to Standard
Slide 58

The results of the Study of Heart and
Renal Protection (SHARP)
Colin Baigent, Martin Landray
on behalf of the SHARP Investigators

Disclosure: SHARP was sponsored, designed, run, and analysed by the University of
Oxford. Funding was received from Merck, the UK MRC, British Heart Foundation, and
Australian NHMRC.

Slide 59

SHARP: Eligibility
• History of chronic kidney disease
– not on dialysis: elevated creatinine on 2 occasions
• Men: ≥1.7 mg/dL (150 µmol/L)
• Women: ≥1.5 mg/dL (130 µmol/L)
– on dialysis: haemodialysis or peritoneal dialysis
• Age ≥40 years
• No history of myocardial infarction or coronary
revascularization
• Uncertainty: LDL-lowering treatment not definitely
indicated or contraindicated

Slide 60

SHARP: Assessment of LDLlowering

Slide 61

SHARP: Major Atherosclerotic Events

Proportion suffering event (%)

25

Risk ratio 0.83 (0.74 – 0.94)
Logrank 2P=0.0022

20

Placebo
15

Eze/simv
10

5

0
0

1

2

3

Years of follow-up

4

5
Slide 62

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%
More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

20
40
10
30
Mean LDL cholesterol difference
between treatment groups (mg/dL)

Slide 63

CTT: Effects on Major Atherosclerotic Events

Proportional reduction in
atherosclerotic event rate (95% CI)

30%

Statin vs control
(21 trials)

25%
20%

SHARP
17% risk
reduction

More vs Less
(5 trials)

15%

SHARP
32 mg/dL

10%
5%
0%
0

10

20

30

Mean LDL cholesterol difference
between treatment groups (mg/dL)

40
Slide 64

Varespladib: a New and Potent sPLA2
Inhibitor

PLASMA II
• 135 patients with stable CHD randomized to 8 weeks of therapy
with placebo, varespladib 250 or 500 mg/day

• primary endpoint was change in sPLA2-IIA concentration
between placebo and varespladib groups
• The 2 doses of varespladib lowered sPLA2 by 73% and 84%
respectively (p<0.0001)
• compared with placebo, varespladib 500 mg reduced LDL-C by
15% (p<0.001), non-HDL-C by 15% (p<0.001), total VLDL
particle concentration by 14% (p=0.022), and small VLDL
particle concentration by 24% (p=0.030)
Rosenson RS et al, Eur Heart J 2010, epub Nov.16

PLASMA II: Results
-73%

-84%
-15%

-15%

Rosenson RS et al, Eur Heart J 2010, Epub Nov.16

-14%

FRANCIS-ACS Trial: Safety and Efficacy of
Varespladib in Acute Coronary Syndromes

625 Patients
•
•
•

•

Men/Women
Unstable Angina,
NSTEMI or STEMI
Any one of
• Diabetes
• CRP ≥2 mg/L
• Met. syndrome
Randomized within
96 hours of event

Primary End Point at 8 wks
 LDL-C
 hs-CRP
 sPLA2 concentration

Varespladib 500mg QD
+ Atorvastatin 80mg QD
Placebo
+ Atorvastatin 80mg QD
6 Month Minimum Treatment
Period

Secondary End Points
 Occurrence of MACEs for treatmentrelated trends at study completion.

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

69

FRANCIS: Change in sPLA2, LDL-C, and hs-CRP

4

8

12

16

0
-20

20

24

Varespladib
Placebo

-50
-60
-70

P<0.0001

P<0.0001

-80
-90

P<0.0001

P<0.0001

P<0.0001

Median % Change From
Base Line hs-CRP

Median % Change From
Base Line sPLA2

0

Weeks

0

4

8

Weeks
12

Mean % Change From
Base Line LDL-C

Weeks
0

4

8

12

16

20

24

0
Varespladib
Placebo

-10
-20
-30
-40

P=0.0011
P=0.0071

-50
P=0.0024

P=0.0269

P=0.0021

-60

16

20

24

0
-20

P=0.1791

Varespladib
Placebo

-40
-60
-80

P=0.3976

P=0.0913

P=0.0021

P=0.0185

70

FRANCIS: MACE at 16 Weeks
Varespladib 500 mg
+ Atorvastatin 80 mg

Placebo +
Atorvastatin 80 mg

313

311

Total MACE

14 (4.2%)

19 (6.1%)

UA hospitalization

5 (1.6%)

9 (2.9%)

Myocardial infarction

2 (0.6%)

4 (1.3%)

Stroke

1 (0.3%)

1 (0.3%)

Death

6 (1.9%)

5 (1.6%)

0 (0%)

0 (0%)

Patients

Revascularization >60
days

Rosenson RS et al, J Am Coll Cardiol 2010;56:1079-88

Vascular Inflammation Suppression to Treat
Acute Coronary Syndrome (VISTA-16)
Patient
Screening

Patient Randomization

Varespladib + Atorvastatin
Acute Coronary
Syndrome
Patient1

Interventional
procedures if
necessary

Primary

Survival
Status

Endpoint
MACE

(STEMI, NSTEMI,
UA)

Placebo + Atorvastatin
< 96 hours

1As

16 week
treatment

6 Months

per FDA Guidance Major Adverse Coronary Events (MACE) are defined as Cardiovascular Death,
Non-Fatal Myocardial Infarction, Non-Fatal Stroke, and Unstable Angina requiring urgent
hospitalization
72

Conclusions
• sPLA2 plays an important role in atherosclerosis and is an independent
marker of future cardiovascular events

• We demonstrated for the first time that combination of statin/ezetimibe
lowers sPLA2
• In patients with stable CAD, increasing the potency of statin to
atorvastatin 40 and adding ezetimibe is safe and results in effects that go
beyond LDL lowering: decrease in small dense LDL, decrease in oxidized
LDL, decrease in CRP and decrease in sPLA2
• Potent and specific inhibitors of sPLA2 are currently available
• Whether inhibiting sPLA2 is clinically beneficial is awaiting the result of
the on-going VISTA-16 trial