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Lipids: Current practice and future targets:
HDL dysfunction and CETP inhibition?
Ulf Landmesser, MDCardiology, Cardiovascular Center,
University Hospital Zürich, Switzerland
Cardiology Update, February 10 – 15 2013, Davos
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Seite 1
HDL dysfunction and CETP inhibition ?
1. The HDL cholesterol hypothesis
2. HDL dysfunction
3. Novel therapeutic interventions - CETP inhibition ?
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Seite 2
LDL and HDL-Cholesterol and risk of coronary disease: Framingham Heart Study
Gordon T et al. Am J Med 1977;62:707-714
100 160 2200,0
1,0
2,0
3,0
2545
6585
LDL-C
mg/dl
mg/dl
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Seite 3
Low HDL as predictor of cardiovascular events in patients
with stable CAD and low LDL-C levels on statin therapy ?
N Engl J Med 2007; 357(13):1301-10
“HDL cholesterol levels were predictive of major cardiovascular events in patients
treated with statins.
This relationship was also observed among patients with LDL cholesterol levels
below 70 mg per deciliter.”
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Seite 4
N Engl J Med 2012, 367(22):2089-99
Association of baseline HDL cholesterol levels and risk of cardiovascular
events in patients with a recent acute coronary syndrome on statin therapy ?
There was no significant
association in either
group between the baseline
HDL cholesterol level
(i.e., the level measured at
randomization) and
the risk of the primary end point
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Seite 5
A-I
Bile
Nascent
HDL
A-I
FCCE
FCLCATMature
HDL
HDL
CETPVLDL/
LDLTG
CE
CEFC
PLTPLDL-R
SR-BI Macrophage
ABCA1
ABCG1
SR-BI ?
1. HDL-mediated promotion of RCT(reverse cholesterol transport)
HDL: proposed anti-atherogenic effects
2. Direct HDL-mediated endothelial-protective
potential anti-atherogenic effects
Endothelial NO
production
Endothelial anti-
apoptotic effects
Anti-inflammatory
effects
Promotion of
endothelial repair
Anti-thrombotic
effects
Besler C, Lüscher T, Landmesser U. EMBO Mol Med 2012; 4: 251-68
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Seite 6
Mechanisms of vasoprotective effects of HDL:
Endothelial cell nitric oxide (NO) production
Nofer et al.; J. Clin. Invest. 2004
Yuhanna IS et al.; Nat Med 2001
Oxy-
sterols
Terasaka N et al.; Arterioscler Thromb Vasc Biol. 2010
AMPK
Li D et al. Arterioscler Thromb Vasc Biol. 2010
Terasaka N et al.; J. Clin. Invest. 2008
Cave
olin
Mineo e al.; J Biol Chem. 2003
ABCG1 S1P3
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Seite 7
HDL - a therapeutic target in cardiovascular prevention ?
HDL
Should we raise the “good“ cholesterol ?
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Seite 8
CETP-Inhibition with Torcetrapib: lipid changes
Barter et al., N Engl J Med 2007; 357: 2109-2122
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Seite 9
CETP-Inhibitor - Torcetrapib -
Clinical Outcome Study: ILLUMINATE
Barter et al., N Engl J Med 2007; 357: 2109-2122
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Seite 10
Thomas H. Huxley
(1825 - 1895)
The deepest sin against
the human mind is to
believe things without
evidence.
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Seite 11
HDL dysfunction and CETP inhibition?
1. The HDL cholesterol hypothesis
2. HDL dysfunction
3. Novel therapeutic interventions - CETP inhibition ?
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Seite 12
Effect of HDL on endothelial cell nitric oxide
production in coronary disease ?
HDL from
Healthy subject
HDL from
CAD patient
30 minutes
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Seite 13
Vascular effects of HDL in
patients with stable coronary
disease or
acute coronary syndrome as
compared to healthy subjects ?
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Seite 14
Study design:
Endothelial effects of HDL - endothelial bioassays
Isolation of HDL2/3(by sequential ultracentrifugation)
ESR spectroscopy
Organ chamber
ESR spectroscopy
Patients with acute coronary syndrome (n=25)
Patients with stable coronary disease (n=25)
Healthy control subjects (n=25)
Vascular effects
Anti-inflammatory
effects
(Endothelial cell
inflammatory activation)
Monocyte adhesion VCAM-1 expression
Carotid artery injury model in nude mice
Anti-thromboticeffects
Tissue factor Arterial
thrombosis
Anti-oxidant
effects
(Endothelial cell
superoxide production)
Effects on Re-
Endothelialization
Endothelial Function
(Endothelial cell NO production and vasoreactivity)
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Seite 15
HDL –effects on endothelial cell nitric oxide
production in patients with CAD
-20
-10
0
10
20
30
25 m g/ml 50 m g/ml 100 m g/ml
HDL HDL HDL
Healthy
sCAD
ACS
P<0.025
DE
nd
oth
elia
l n
itric o
xid
e
pro
du
ctio
n
[in
% o
f b
uffe
r-tr
ea
ted
ce
lls]
Besler C et al. & Lüscher T, Landmesser U. J Clin Invest 2011;121(7):2693-708
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Seite 16
Effects of HDL on vascular inflammation: Monocyte adhesion on TNFα-stimulated endothelial cells
Baseline TNFαTNFα + HealthyHDL
TNFα +Stable CAD
HDL
TNFα +ACS
HDL
0
5
10
15
20
25
30
35
Nu
mb
er
of
GC
SF
-la
bele
d m
on
ocyte
s
per
hig
h p
ow
er
field
P < 0.05 P < 0.05
n.s.
P < 0.05
Besler C et al. & Lüscher T, Landmesser U. J Clin Invest 2011;121(7):2693-708
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Seite 17
HDL function
(vascular effects)
Which changes of HDL are
mediating differences in
HDL‘s vascular effects ?
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The complexity of the HDL-lipoprotein
Phospholipids
Triglycerids
Esterified cholesterol
Apo A1Free
cholesterol
> 1000 different lipids
(Phospholipid species, Cholesterol
Ester, Trigylcerides, …)
70 different proteins
(ApoA1, PON-1, ApoA2, ApoCIII,
ApoE, ApoH, ….)
Changes in composition and modification of both, lipids and proteins of HDL
in cardiovascular disease results in altered HDL „function“
Cholesterol
Ester
PON-1
HDL-bound
microRNAs,
small molecules
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Seite 19
Mechanisms leading to altered effects of HDL on
endothelial nitric oxide availability in CAD
Mineo C & Shaul PW. J Clin Invest 2011
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Seite 20
Effects of HDLHealthy, HDLsCAD or HDLACS
on endothelial apoptosis in vitro and in vivo
Riwanto M et al. & Lüscher T, Landmesser U. Circulation 2013 (in press)
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Seite 21
HDL proteome alterations in patients with coronary disease
0 0,1 0,2 0,3 0,4 0,5 0,6
Phosphatidylinositol-glycan-specific …
Endosialin OS=Homo sapiens GN=CD248
Aminopeptidase N OS=Homo sapiens …
Sonic hedgehog protein OS=Homo sapiens …
Beta-1A of Integrin beta-1 OS=Homo …
IGK@ protein OS=Homo sapiens GN=IGK@
Integrin alpha-2 OS=Homo sapiens …
Apolipoprotein F (APOF), mRNA OS=Homo …
Angiotensinogen OS=Homo sapiens GN=AGT
Serum paraoxonase/arylesterase 1 …
Serum paraoxonase/lactonase 3 OS=Homo …
Prenylcysteine oxidase 1 OS=Homo …
Apolipoprotein D OS=Homo sapiens …
Cathelicidin antimicrobial peptide …
Apolipoprotein A-II OS=Homo sapiens …
DPI of Desmoplakin OS=Homo sapiens …
Hemoglobin subunit alpha OS=Homo …
Antithrombin-III OS=Homo sapiens …
Apolipoprotein L1 OS=Homo sapiens …
Alpha-2-macroglobulin OS=Homo sapiens …
0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9
Pulmonary surfactant-associated protein B OS=Homo …
Heparin cofactor 2 OS=Homo sapiens GN=SERPIND1
Lipopolysaccharide-binding protein OS=Homo sapiens …
Serum amyloid A protein OS=Homo sapiens GN=SAA1
Haptoglobin OS=Homo sapiens GN=HP
Vitronectin OS=Homo sapiens GN=VTN
Alpha-2-HS-glycoprotein OS=Homo sapiens GN=AHSG
Alpha-1-antichymotrypsin OS=Homo sapiens …
Apolipoprotein C-IV OS=Homo sapiens GN=APOC4
Anthrax toxin receptor 1 OS=Homo sapiens GN=ANTXR1
Complement component C9 OS=Homo sapiens GN=C9
HLA class I histocompatibility antigen, A-24 alpha chain …
Haptoglobin-related protein OS=Homo sapiens GN=HPR
Anthrax toxin receptor 2 OS=Homo sapiens GN=ANTXR2
GTP-binding protein SAR1a OS=Homo sapiens GN=SAR1A
Inter-alpha-trypsin inhibitor heavy chain H4 OS=Homo …
Apolipoprotein A-IV OS=Homo sapiens GN=APOA4
Serum amyloid A-4 protein OS=Homo sapiens GN=SAA4Reduced in
CADpatients
Increased in CAD patients
ApoCIII
Clusterin
Riwanto M et al. & Lüscher T, Landmesser U. Circulation 2013 (in press)
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Seite 22
Summary of mechanisms leading to altered effects
of HDL on endothelial apoptosis in CAD
Riwanto M et al. & Lüscher T, Landmesser U. Circulation 2013 (in press)
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Seite 23
HDL from patients with chronic kidney disease (CKD)
promotes endothelial inflammatory activation
Speer T et al.& Deanfield J, Lüscher TF, Fliser D, Landmesser U. Immunity 2013 (in press)
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Seite 24
HDL dysfunction and CETP inhibition?
1. The HDL cholesterol hypothesis
2. HDL dysfunction
3. Novel therapeutic interventions - CETP inhibition ?
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Eur Heart J 2013 (in press)
AIM-HIGH trial
• Pre-randomisation phase with niacin
(1.5/2g) exclusion: 20.1 %
• Aiming to have similarly low LDL-C in both
treatment groups (simvastatin 40-80 mg)
LDL: - 5.5 %, HDL: + 13.2 %
Cave: More patients increased
statin dose and/or added
ezetimibe in control-group
• Randomization (n): 1718 vs. 1696 patients
• Mean FU - 3 years (556 events)
HPS2-THRIVE trial
• Pre-randomisation phase with ER-niacin (2g)/
laropiprant (40 mg) exclusion: 25.4 %
• No further adjustment of LDL-C levels after
randomization (simvastatin 40 mg)
LDL: -19.9 %; HDL + 16.9 %
Cave: Cardiovascular effects of
PGD2 receptor DP1 antagonist
laropiprant ?
• Randomization (n): 12838 vs. 12835 patients
• Mean FU - 4 years (? events)
Niacin (vitamin B3): clinical outcome studies in
combination with statin therapy
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• NPC1L1 (Ezetimibe*)
• CETP inhibition
(Anacetrapib*, Evacetrapib*)
• Reconstituted HDLs
• ApoA1 modulation
Further
LDL-C Combined
LDL-C
HDL-C
HDL-C
*Clinical outcome trials ongoing
• PCSK9 inhibition
(Monoclonal Ab*)
• ApoB-100 Antisense
oligonucleotides
Statin
therapy
Lipid-targeted Therapies - What should be added
to statins in patients with high vascular risk ?
Eur Heart J 2013 (in press)
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HDL metabolism – different targets regulating HDL-C
(1) apoA-I
(lipid-
free)
(4) SR-BI
inhibition
(3) CETP
inhibition
(2) ABCA-1
expression
Besler C, Lüscher T, Landmesser U. EMBO Mol Med 2012; 4: 251-68
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“Some genetic mechanisms that
raise plasma HDL cholesterol do
not seem to lower risk of
myocardial infarction.
These data challenge the concept
that raising of plasma HDL
cholesterol will uniformly
translate into reductions in risk of
myocardial infarction.
Association of LIPG Asn396Ser with myocardial infarction in 116 320 participants from 20 studies
Genetic link with increased HDL cholesterol (endothelial
lipase SNP), but not associated with myocardial infarction
Lancet 2012; 380: 572-80
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Endothelial lipase and reverse cholesterol transport
Circ J 2010;74: 2263–2270
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Odds Ratios for Coronary Disease for
3 CETP variants
Three CETP genotypes that are
associated with moderate inhibition of
CETP activity (and higher HDL-C
levels) show weakly inverse
associations
with coronary risk.
46 studies had data on 27,196 coronary cases and 55,338 controls
JAMA 2008; 299(23):2777-88
CETP – genetic association with coronary disease:
a meta-analysis
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CETP – genetic association with ischemic cardiovascular events
in Copenhagen City Heart Study
J Am Coll Cardiol. 2012; 60(20):2041-8
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Voight BF et al Lancet 2012; 380: 572–80
CETP – genetic association with
myocardial infarction ?
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CETP Valine homozygosity
occurred in
24.8% of centenarians
compared with
8.6% among controls
CETP – genetic association with
longevity and reduced dementia
Barzilai N et al. JAMA 2003 Oct 15;290(15):2030-40
Sanders AE et al., JAMA 2010; 303(2):150-8
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Incidence of the Primary Efficacy End Point.
N Engl J Med 2012
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Summary and conclusion
1. The HDL-cholesterol hypothesis is derived largely from epidemiological
studies in primary prevention and experimental studies using HDL from
healthy subjects.
2. Vascular effects of HDL are heterogenous and are altered in patients with
coronary disease (i.e. HDL dysfunction). One may speculate that this could
lead to divergent effects of HDL-C raising strategies in different patient
populations.
3. Therapeutic strategies leading to increased HDL cholesterol levels may have
anti- or pro-atherogenic effects. HDL cholesterol alone is therefore not a
reliable surrogate marker.
4. Whereas the ILLUMINATE and dal-HEART programm were halted, genetic
studies of CETP variants are promising. The results of the ongoing HPS3-
TIMI 55 (anacetrapib) and ACCELERATE (evacetrapib) study are expected.
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Acknowledgments
University of Zürich, Switzerland
Meliana Riwanto, BS
Timo Speer, MD
Sajoscha Sorrentino, MD
Christian Besler, MD
Carola Dörries, MD
Pavani Mocharla, BS
Sylvie Briand, PhD
Maja Müller, BS
Michaela Keel, BS
Thomas Lüscher, MD
Lucia Rohrer, PhD
Arnold von Eckardstein, MD
UCLA, USA
Alan Fogelman, MD
Diana Shih, PhD
Aldon Lusis, PhD
UCL, London, UK
John Deanfield, MD
Frank Neill, PhD
Marietta Charakida, MD
Seattle, USA
Clem Furlong, PhD
Cleveland Clinic, USA
Stan Hazen, MD, PhD
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Thank you
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Seite 38
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Seite 39
HDL-associated paraoxonase activity and content
Healthy
HDL
Stable CAD
HDL
ACS
HDL
0
0.1
0.2
0.3
0.4
0.5
0.6
Pa
rao
xo
na
se
-1 a
ctivity
(Un
its/5
0μ
g H
DL
)
n.s.
P < 0.05
Paraoxonase activity
Healthy
HDL
stable CAD
HDL
ACS
HDL
0
100
200
300
400
500
600
700
800
Pa
rao
xo
na
se
-1 c
on
ten
t
of is
ola
ted
HD
L (
in %
)
n.s.
P < 0.05
Paraoxonase-1 content
Besler C et al. & Landmesser U. J Clin Invest 2011;121(7):2693-708
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HDL from paraoxonase-1 deficient mice did not
stimulate endothelial NO production
-25
0
25
50
P<0.01
HDLWild type
HDLPON1 -/-D
Endoth
elia
l nitri
c o
xid
e
pro
ductio
n
[in
% o
f b
uffe
r-tr
ea
ted
ce
lls]
Besler C et al. & Landmesser U. J Clin Invest 2011;121(7):2693-708
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Seite 41
Paraoxonase gene polymorphisms, functional
activity and cardiovascular risk
Bhattacharyya T et al.; Jama 2008
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Seite 42
High endothelial cell turnover in atherosclerosis -
prone areas
Circulation. 2008;117(14):1856-63.
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Seite 43
Characteristics of Type-2 Diabetic Patients and
Healthy Subjects
Sorrentino SA et al. & Landmesser U. Circulation 2010;121:110-122
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Effects of HDL from patients with type-2 diabetes
on endothelial NO availability
HDL Healthy
En
do
thelial
NO
Prod
ucti
on
[%
of
bu
ffer-
treate
d c
ells]
PBS HDLDiabetics
0
50
100
150
200
P < 0.0001 P < 0.0001
Sorrentino SA et al. & Landmesser U. Circulation 2010;121:110-122
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Sorrentino SA et al. & Landmesser U. Circulation 2010;121:110-122
Effects of HDL from patients with type-2 diabetes
on endothelial oxidant stress
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Sorrentino SA et al. & Landmesser U. Circulation 2010;121:110-122
Lipid oxidation of HDL from patients with type-2
diabetes and healthy subjects
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HDLCKD increases arterial blood pressure in vivo
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Lancet 2008; 371:317-321
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HMG-CoA
Farnesyl-PP
Cholesterol
StatinHMG-CoA
Reduktase
GGPP
+ Iso.-PP
Mevalonat
NO
Sorrentino & Landmesser, Curr Treat Opt; 2005
Statins: pleioptropic endothelial effects
NADPH-oxidase
Nox
p47phox
Rac
p22
Rho
H4B
H4B
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Statins: pleioptropic effects on endothelial function
Simvastatin 10 mg group
Baseline 4 weeksBaseline 4 weeks
Flo
w d
ep
end
en
t d
ilati
on
(pe
rce
nt
chan
ge o
f d
iam
ete
r)
Flo
w d
epen
de
nt
dila
tio
n(p
erc
en
t ch
ange
of
dia
met
er)
P<0.01 P= n.s.
3
0
6
9
12
LDL-c reduction similar in both groups.
Simvastatin: 15.6 % Ezetimibe: 15.4%
Landmesser et al, Circulation 2005; 111(18): 2280-1
12
Ezetimibe 10 mg group
0
3
6
9
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9-14-77 9-16-77 10-20-77
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CASE EXAMPLE – Coronary disease
Acute coronary syndrome
Plaque in RCA Acute occlusion of RCA
2 Month later
We need to target the underlying
atherosclertic vascular disease
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Coronary atherosclerosis by OFDI imaging:
plaque characteristics
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Atherosclerotic plaque progression
Moore K, Tabas. Cell 2011, 145(3):341-55
Inflammatory
activation
Endothelial
integrity/function
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Speer T et al. (in revision)
titel
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“Some genetic mechanisms that
raise plasma HDL cholesterol do
not seem to lower risk of
myocardial infarction.
These data challenge the concept
that raising of plasma HDL
cholesterol will uniformly
translate into reductions in risk of
myocardial infarction.
Association of LIPG Asn396Ser with myocardial infarction in 116 320 participants from 20 studies
Genetic link with increased HDL cholesterol (endothelial
lipase SNP) not linked risk of myocardial infarction
Lancet 2012; 380: 572-80
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Voight BF et al Lancet 2012; 380: 572–80
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Voight BF et al Lancet 2012; 380: 572–80
From observational epidemiology, an increase of 1
SD in usual LDL cholesterol was associated with
raised risk of myocardial infarction (OR 1・54, 95%
CI 1・45–1・63; appendix p 22). In a mendelian
randomisation analysis, a 1 SD increase in LDL
cholesterol due to genetic score was also
associated with risk of myocardial infarction (OR 2
・13, 95% CI 1・69–2・69, p=2×10–1⁰; table 4).
From observational epidemiology, a 1 SD rise in
usual HDL cholesterol was associated with
lowered risk of myocardial infarction (OR 0・62,
95% CI 0・58–0・66; appendix p 22). However, in
mendelian randomisation analysis, a 1 SD
increase in HDL cholesterol due to genetic score
was not associated with risk of myocardial
infarction (OR 0・93, 95% CI 0・68–1・26, p=0・63;
table 4).
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Incidence of the Primary Efficacy End Point.Association between HDL Cholesterol Level
Dalcetrapib Placebo and Risk of the Primary End Point
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LDL-Cholesterol/HDL-Cholsterol and risk of
coronary disease
1% decrease
in LDL-C:
reduced CHD risk
by
1%
1% increase
in HDL-C:
reduced CHD risk
by
2-3%
Statin Therapy
Therapeutic Opportunity ?
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Endothelial NO production – anti-atherogenic
effects
Vascular smooth muscle cell
Monocyt
Inhibition of Leukocyte
adhesion und -infiltration
Inhibition of VSMC
proliferation
NO
Platelets
Inhibition of Thrombocyte
adhesion and -aggregation
Endothel
Landmesser et al. Circulation 2004; 109(21 Suppl 1):II27-33
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Experimental
Studies –
lesion initiation
>14 Clinical studies –
Advanced plaque
progression
Endothelial dysfunction in atherosclerosis
Summarized in:
Landmesser et al. Circulation 2004; 109(21 Suppl 1):II27-33
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High-Density Lipoprotein - vascular effects?
• Anti-atherogenic effects of HDL ?
• “HDL function“ in coronary disease
and diabetes ?
• HDL-targeted therapies ?
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Characteristics of the study population
Healthy subjects
(n=25)
Stable coronary
artery disease
(n=25)
Acute coronary syndrome
(n=25)
Age (years) 54±5 56±6 54±6
Sex (male/female) 19/6 19/6 18/7
Body mass index (kg/m2) 26±5 27±4 26±3
Total cholesterol (mmol/l) 5.3±1.0 5.4±0.9 5.1±0.7
HDL cholesterol (mmol/l) 1.4±0.4 1.2±0.3 1.2±0.3
LDL cholesterol (mmol/l) 2.9±0.9 2.7±1.0 2.8±0.6
Besler C et al. & Landmesser U. J Clin Invest 2011;121(7):2693-708
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HDL –effects on endothelial cell nitric oxide
production in patients with CAD
HDL
Healthy
Subjects
HDL
Patients with
stable CAD
HDL
DE
nd
oth
elia
l N
O
Pro
duction
[in
% o
f b
uffe
r-tr
ea
ted
ce
lls]
-30
-20
-10
0
10
20
30
40
P<0.01
P<0.001
Patients with an
acute coronary
syndrome
Besler C et al. & Landmesser U. J Clin Invest 2011;121(7):2693-708
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Carotid injury model to examine in vivo effect of HDL
on endothelial repair
4 mm
4 mm
Evans blue staining
Sorrentino SA et al.; Circulation 2007; 116(2):163-73
Sorrentino SA et al.; Circulation 2010; 121(1):110-22
Giannotti G et al.; Hypertension 2010; 55:1389-97
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Effects of HDL on endothelial repair in vivo after
arterial injury
PBS HDLHealthy
HDLStable CAD
HDLACS
0
5
10
15
20
25
30
Re
-en
do
thelia
lize
d a
rea
[in
%] P < 0.0001
P < 0.05
Quantification of re-endothelialized area 3 days after induction
of carotid injury by Evan`s blue staining
4 mm