The document discusses the efficacy of raising HDL cholesterol through pharmacological interventions and its relationship with coronary heart disease risk, highlighting findings from various studies. It points out that statin therapy does not completely mitigate cardiovascular risks associated with low HDL cholesterol levels, and outlines multiple treatment options including niacin, fibrates, and combination therapies. Additionally, it presents the metabolic mechanisms of HDL and its roles in atherosclerosis, emphasizing the complexities involved in managing dyslipidemia in different patient populations.

1. Ronald M. Krauss, MD Children’s Hospital Oakland Research Institute UC Berkeley and UCSF Raising HDL With Drugs – Does it Work?

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

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

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

5. Pleiotropic Anti-Atherogenic Properties of HDL Cholesterol efflux and reverse cholesterol transport Anti-oxidant and anti-inflammatory effects Anti-apoptotic properties Vasodilation (increased eNOS activity) HDL proteomics: anti-thrombotic, complement activation eNOS: endothelial nitric oxide synthase

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

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

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

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

10. Metabolic Basis for Atherogenic Dyslipidemia: Concordant Increase in VLDL, Small LDL and Reduction of HDL Smaller LDL HL Apo AI Renal clearance LPL Remnants LPL/HL VLDL TG CETP Cholesterol HDL TG LDL Apo AI: apolipoprotein AI CETP: cholesteryl ester transfer protein HL: hepatic lipase LPL: lipoprotein lipase TG: triglycerides TG Smaller HDL

11. Relation of HDL Cholesterol to Aortic Atherosclerosis in Apo E-Deficient Mice Transgenic for Human Apo AI (Model for Increased Apo AI Transport) Adapted from Plump AS et al. Proc Natl Acad Sci USA 1994; 27: 9607-11 Copyright © 1994 National Academy of Sciences, U.S.A. 0 250000 500000 750000 50 100 150 0 Mean lesion area ( µm 2 ) HDL cholesterol (mg/dl) r=0.88, p<0.0001 Apo AI expression None Low High Apo: apolipoprotein

12. Current Options for Pharmacologic Management of Patients With Low HDL Cholesterol Statin ± cholesterol absorption inhibitor Niacin Fibrate Thiazolidinedione (type 2 diabetes) Combination therapy (statin + niacin/fibrate)

13. Niacin Extended-Release + Statins: Extended-Release Lovastatin/Niacin Adapted from Hunninghake DB et al. Clin Cardiol 2003; 26: 112-8 LDL cholesterol HDL cholesterol Triglycerides Lovastatin/niacin 40 mg/2,000 mg, week 28 Lovastatin 40 mg, week 28 Change from baseline (%) * * * *p<0.05 vs. lovastatin 40 mg

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

15. Gemfibrozil, Niacin, and Cholestyramine in Men With Low HDL Cholesterol and Coronary Heart Disease Triglycerides Adapted from Whitney EJ et al. Ann Intern Med 2005; 142: 95-104 Drug treatment + lifestyle modification Lifestyle modification only * * * LDL cholesterol HDL cholesterol *p<0.001 vs. lifestyle only

16. Cardiovascular Disease Outcomes in Trials of HDL-Raising Drug Therapies

17. Niacin Therapy: Angiographic and Outcomes Trials TG: triglycerides No. of subjects Lipid changes (treatment group) Trial Treatment (mean dose) Treatment Placebo Total cholesterol TG LDL cholesterol HDL cholesterol Findings Stockholm Ischaemic Heart Disease Secondary Prevention Study Niacin (4.5 g/d) + clofibrate (1.5 g/d) 279 276 -13% -19% --- ---  36% ischemic heart disease mort. (p<0.01)  26% total mortality (p<0.05) Coronary Drug Project Niacin (3 g/d) 1119 2789 -10% -26% --- ---  27% nonfatal myocardial infarction  11% total mortality (p=0.0004) Cholesterol Lowering Atherosclerosis Study Niacin (4.3 g/d) + colestipol (30 g/d) 80 82 -26% -21% -43% +37% angiographic regression no difference in clinical events Familial Atherosclerosis Treatment Study Niacin (4 g/d) + colestipol (30 g/d) 48 52 -23% -29% -32% +43% angiographic regression  80% clinical events (p<0.01) HDL-Atherosclerosis Treatment Study Niacin (2.4 g/d) + simvastatin (13 mg/d) 73 73 -29% -34% -40% +18% angiographic regression  60% clinical events (p=0.02)

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

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

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

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

22. VA-HIT: LDL and HDL Particle Subclasses Adapted from Otvos JD et al. Circulation 2006; 113: 1556-63 IDL: intermediate-density lipoprotein B: baseline IDL Large HDL Large LDL Medium HDL Small LDL Small HDL Placebo Fibrate 5% reduction 1364 1463 1352 1290* LDL particle number (nmol/l) B 7 months B 7 months 20% decrease 36% increase * * HDL particle number (  mol/l) 25.2 25.1 26.6 27.6* Placebo Fibrate B 7 months B 7 months 21% increase * * 10% increase *p ≤0.0005 vs. placebo at 7 months

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

24. FIELD: End of Study Lipid Results Adapted from Keech A et al. Lancet 2005; 366: 1849-61 Placebo (P) Fenofibrate (F) 113 LDL cholesterol HDL cholesterol Triglycerides Baseline (mg/dl) 117 43 43 164 167 119 LDL cholesterol HDL cholesterol Triglycerides Baseline (mg/dl) 119 43 43 171 173 128 LDL cholesterol HDL cholesterol Baseline (mg/dl) 125 42 40 184 197 Triglycerides Did not start other lipid-lowering therapy n= 3,124 (P) 3,951 (F) Total population Started other lipid-lowering therapy n= 1,776 (P) 944 (F)

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

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

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

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

29. ILLUSTRATE 446 atorvastatin patients 464 torcetrapib patients 24-month follow-up intravascular ultrasound of originally imaged “target” vessel (n=910) 4 to 10-week run-in atorvastatin 10-80 mg to achieve LDL cholesterol of 100±15 mg/dl Intravascular ultrasound with 40 MHz transducer Motorized pullback at 0.5 mm/sec through >40 mm segment 1,188 patients from 137 centres in North America and Europe Symptomatic coronary artery disease, coronary angiography with >20% stenosis Atorvastatin monotherapy Torcetrapib 60 mg+ atorvastatin 24-month treatment 135 patients withdrew 140 patients withdrew Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16

30. Time Course: Change in HDL Cholesterol Levels Adapted from Barter et al. New Engl J Med 2007; 357, 2109-22 20 30 40 50 60 70 80 90 0 1 3 6 9 12 15 18 21 24 Time (months) HDL cholesterol level (mg/dl) Difference 60.8% Atorvastatin monotherapy Torcetrapib+Atorvastatin

31. ILLUSTRATE: Primary Efficacy Parameter Change in Percent Atheroma Volume Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16 † p value from ANCOVA *LS mean change p=0.72 †

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

33. Blood Pressure Related Adverse Events Blood pressure >140/90 mmHg Systolic blood pressure increase >15 mmHg Atorvastatin Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16 +Torcetrapib

34. ILLUSTRATE Adverse Events: Safety Population Adapted from Nissen SE et al. N Engl J Med 2007; 356: 1304-16 Atorvastatin monotherapy (n=597) Torcetrapib + Atorvastatin (n=591) Death 6 (1.0%) 8 (1.4%) Coronary heart disease (CHD) death 1 (0.2%) 1 (0.2%) Nonfatal myocardial infarction (MI) 16 (2.7 %) 13 (2.2%) Fatal or nonfatal stroke 8 (1.3%) 2 (0.3%) Hospitalization for unstable angina 34 (5.7%) 47 (8.0%) Coronary revascularization 95 (15.9%) 114 (19.3%) Peripheral vascular disease 13 (2.2%) 10 (1.7%) Hospitalization for congestive heart failure 4 (0.7%) 9 (1.5%) Composite: CHD death, MI, stroke, and unstable angina 57 (9.5%) 62 (10.5%) Composite: CHD death, MI, stroke, unstable angina, and revascularization 117 (19.6%) 124 (21.0%)

35. RADIANCE 1: Heterozygous Familial Hypercholesterolemia Adapted from Kastelein JJ et al. N Engl J Med 2007; 356: 1620-30 Copyright © 2007 Massachusetts Medical Society. All rights reserved 0.0 0.5 1.0 1.5 2.0 Treatment period (months) Slope (mm/year) 95% CI p value -0.0006 (-0.0084, 0.0072) 0.8737 Baseline 6 12 18 24 Torcetrapib+ Atorvastatin (T/A) Atorvastatin (A) T/A vs. A 1.126 1.132 1.133 1.148 1.134 1.163 1.149 1.162 1.150 1.152

36. RADIANCE 2: Mixed Dyslipidemia Reprinted from The Lancet, Vol 370, Bots ML et al. Torcetrapib and carotid intima-media thickness in mixed dyslipidaemia (RADIANCE 2 study): a randomised, double-blind trial, 153-60, Copyright © 2007, with permission from Elsevier 0.60 0.80 1.00 1.20 1.40 1.60 1.80 Slope (mm/year) 95% CI p value -0.0049 (-0.0180, 0.0082) 0.4621 Treatment period (months) Baseline 6 12 18 24 T/A vs. A Torcetrapib+ Atorvastatin (T/A) Atorvastatin (A) 1.3210 1.3592 1.3150 1.3634 1.3260 1.3680 1.3319 1.3469 1.3079 1.3002

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

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

39. ERASE: CSL-111 (Reconstituted HDL) Adapted from Tardif JC et al. JAMA 2007; 297: 1675-82 Intravascular ultrasound results Group Change in atheroma volume (%) p vs. placebo p vs. baseline Placebo (n=47) -1.62 — 0.07 CSL-111 (n=89) -3.41 0.48 <0.001

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

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