Novel Biomarkers and CVD

NOVEL BIOMARKERS and NOVEL BIOMARKERS and CARDIOVASCULAR DISEASECARDIOVASCULAR DISEASE

Nathan D Wong, PhD, FACCNathan D Wong, PhD, FACCProfessor and DirectorProfessor and Director

Heart Disease Prevention ProgramHeart Disease Prevention ProgramUniversity of California, IrvineUniversity of California, Irvine

Beyond Cholesterol: Beyond Cholesterol: Predicting Predicting Cardiovascular Risk In the 21Cardiovascular Risk In the 21stst Century Century

Cardiovascular RiskCardiovascular RiskCardiovascular RiskCardiovascular Risk

LipidsLipidsHTNHTN

DiabetesDiabetes

LipidsLipidsHTNHTN

DiabetesDiabetesBehavioralBehavioralBehavioralBehavioral HemostaticHemostatic

ThromboticThromboticHemostaticHemostaticThromboticThrombotic InflammatoryInflammatoryInflammatoryInflammatory GeneticGeneticGeneticGenetic

Inflammation and AtherosclerosisInflammation and Atherosclerosis Inflammation may determine plaque stability

- Unstable plaques have increased leukocytic infiltrates

- T cells, macrophages predominate rupture sites

- Cytokines and metalloproteinases influence both stability and degradation of the fibrous cap

Lipid lowering may reduce plaque inflammation

- Decreased macrophage number

- Decreased expression of collagenolytic enzymes (MMP-1)

- Increased interstitial collagen

- Decreased expression of E-selectin

- Reduced calcium deposition

Libby P. Circulation 1995;91:2844-2850. Ross R. N Engl J Med 1999;340:115-126.

Is there clinical evidence that Is there clinical evidence that

inflammatory markers predict future inflammatory markers predict future

coronary events and provide additional coronary events and provide additional

predictive information beyond predictive information beyond

traditional risk factors?traditional risk factors?

Evaluating Novel Risk Factors for Evaluating Novel Risk Factors for CADCAD

Consistency of Consistency of prospective dataprospective data

Strength of associationStrength of association

Independence of Independence of associationassociation

Improve predictive Improve predictive valuevalue

Standardized measureStandardized measure

Low variability

High reproducibility

Biologic plausibility

Low cost

Modifiable

Thrombosis and Cardiovascular RiskThrombosis and Cardiovascular Risk

Thrombus formation is a crucial factor in the Thrombus formation is a crucial factor in the precipitation of unstable angina or myocardial precipitation of unstable angina or myocardial infarction, as well as occlusion during or following infarction, as well as occlusion during or following angioplasty.angioplasty.

Often preceded by platelet aggregation and Often preceded by platelet aggregation and activation of the coagulation system.activation of the coagulation system.

A thrombus may develop at sites of only mild to A thrombus may develop at sites of only mild to moderate coronary stenosis. The majority of moderate coronary stenosis. The majority of coronary events occur where there is less than coronary events occur where there is less than 70% stenosis.70% stenosis.

Occlusive coronary thrombosis plays a role in over Occlusive coronary thrombosis plays a role in over 80% of myocardial infarctions and about 95% of 80% of myocardial infarctions and about 95% of sudden death victims.sudden death victims.

Fibrinogen and AtherosclerosisFibrinogen and Atherosclerosis

Promotes atherosclerosisPromotes atherosclerosis Essential component of platelet aggregationEssential component of platelet aggregation Relates to fibrin deposited and the size of the Relates to fibrin deposited and the size of the

clotclot Increases plasma viscosityIncreases plasma viscosity May also have a proinflammatory roleMay also have a proinflammatory role Measurement of fibrinogen, incl. Test Measurement of fibrinogen, incl. Test

variability, remains difficult. variability, remains difficult. No known therapies to selectively lower No known therapies to selectively lower

fibrinogen levels in order to test efficacy in fibrinogen levels in order to test efficacy in CHD risk reduction via clinical trials.CHD risk reduction via clinical trials.

Fibrinogen and CHD Risk: Fibrinogen and CHD Risk: Epidemiologic StudiesEpidemiologic Studies

Recent meta-analysis of 18 studies involving 4018 Recent meta-analysis of 18 studies involving 4018 CHD cases showed a relative risk of CHD of 1.8 CHD cases showed a relative risk of CHD of 1.8 (95% CI 1.6-2.0) comparing the highest vs lowest (95% CI 1.6-2.0) comparing the highest vs lowest tertile of fibrinogen levels (mean .35 vs. .25 g/dL)tertile of fibrinogen levels (mean .35 vs. .25 g/dL)

ARIC study in 14,477 adults aged 45-64 showed ARIC study in 14,477 adults aged 45-64 showed relative risks of 1.8 in men and 1.5 in women, relative risks of 1.8 in men and 1.5 in women, attenuated to 1.5 and 1.2 after risk factor attenuated to 1.5 and 1.2 after risk factor adjustment.adjustment.

Scottish Heart Health Study of 5095 men and 4860 Scottish Heart Health Study of 5095 men and 4860 women showed fibrinogen to be an independent women showed fibrinogen to be an independent risk factor for new events--RRs 2.2-3.4 for coronary risk factor for new events--RRs 2.2-3.4 for coronary death and all-cause mortality.death and all-cause mortality.

Fibrinogen and CHD Risk FactorsFibrinogen and CHD Risk Factors

Fibrinogen levels increase with age and body Fibrinogen levels increase with age and body mass index, and higher cholesterol levelsmass index, and higher cholesterol levels

Smoking can reversibly elevated fibrinogen Smoking can reversibly elevated fibrinogen levels, and cessation of smoking can lower levels, and cessation of smoking can lower fibrinogen.fibrinogen.

Those who exercise, eat vegetarian diets, and Those who exercise, eat vegetarian diets, and consume alcohol have lower levels. Exercise consume alcohol have lower levels. Exercise may also lower fibrinogen and plasma viscosity.may also lower fibrinogen and plasma viscosity.

Studies also show statin-fibrate combinations Studies also show statin-fibrate combinations (simvastatin-ciprofibrate) and estrogen therapy (simvastatin-ciprofibrate) and estrogen therapy to lower fibrinogen.to lower fibrinogen.

Other Thrombotic Factors and CHDOther Thrombotic Factors and CHD

Mixed reports of coagulation factor VIIc in Mixed reports of coagulation factor VIIc in cardiovascular disease. PROCAM study cardiovascular disease. PROCAM study showed no association with CHD events, CHS showed no association with CHD events, CHS also showed no relation to subclinical CVD.also showed no relation to subclinical CVD.

Endogenous tissue-type plasminogen activator Endogenous tissue-type plasminogen activator (tPA) shown in some studies to relate to (tPA) shown in some studies to relate to increased cardiovascular risk--Physician’s increased cardiovascular risk--Physician’s Health Study showed RR for MI 2.8, stroke 3.5 Health Study showed RR for MI 2.8, stroke 3.5 in those in 5th vs. 1st quintile of tPA.in those in 5th vs. 1st quintile of tPA.

Plasminogen activitor inhibitor type 1 (PAI-1) Plasminogen activitor inhibitor type 1 (PAI-1) shown associated with increased shown associated with increased cardiovascular risk, esp in diabetic patients.cardiovascular risk, esp in diabetic patients.

Aspirin and Cardiovascular Risk: Aspirin and Cardiovascular Risk: Clinical Trial Evidence for Primary Clinical Trial Evidence for Primary

PreventionPrevention US Physician’s Health Study- 22,071 male physicians - US Physician’s Health Study- 22,071 male physicians -

44% reduction in MI risk, 13% nonsignificant increase in 44% reduction in MI risk, 13% nonsignificant increase in risk of strokerisk of stroke

British Doctor’s Study of 5139 male physicians showed British Doctor’s Study of 5139 male physicians showed nonsignificant 3% reduction in MI risk,13% nonsignificant 3% reduction in MI risk,13% nonsignificant increase in strokenonsignificant increase in stroke

Hypertension Optimal Treatment (HOT) study among Hypertension Optimal Treatment (HOT) study among 18,790 pts w/htn showed 15% reduction in CVD events, 18,790 pts w/htn showed 15% reduction in CVD events, 36% reduction in MI36% reduction in MI

Women’s Health Study (n=39,876 women aged 45+) Women’s Health Study (n=39,876 women aged 45+) randomized to 100 mg asprin/day vs placebo, 10 years randomized to 100 mg asprin/day vs placebo, 10 years follow-up – results recently released and asprin follow-up – results recently released and asprin preventive only for stroke (17% reduction overall, preventive only for stroke (17% reduction overall, p=0.04; 24% ischemic stroke, p<.001); nonfatal MI p=0.04; 24% ischemic stroke, p<.001); nonfatal MI RR=1.02, CVD death 0.95, ns) (NEJM 2005; 352: 1366-RR=1.02, CVD death 0.95, ns) (NEJM 2005; 352: 1366-8).8).

Aspirin and Cardiovascular Risk: Aspirin and Cardiovascular Risk: Clinical Trial Evidence for Secondary Clinical Trial Evidence for Secondary

PreventionPrevention

Antiplatelet Trialists Collaboration of 54,000 Antiplatelet Trialists Collaboration of 54,000 patients with cardiovascular disease (10 trials patients with cardiovascular disease (10 trials post-MI) showed 31% reduction in MI, 42% post-MI) showed 31% reduction in MI, 42% reduction in stroke, 13% reduction in total reduction in stroke, 13% reduction in total vascular mortalityvascular mortality

International Study of Infarct Survival of International Study of Infarct Survival of 17,187 pts w/evolving MI showed 49% 17,187 pts w/evolving MI showed 49% reduction in reinfarction, 26% reduction in reduction in reinfarction, 26% reduction in nonfatal stroke, and 23% reduction in total nonfatal stroke, and 23% reduction in total vascular mortalityvascular mortality

Antiplatelet Therapy: TargetsAntiplatelet Therapy: Targets

CollagenCollagenThrombinThrombin

TXATXA22

ADPADP

(Fibrinogen(FibrinogenReceptor)Receptor)

ADP = adenosine diphosphate, TXAADP = adenosine diphosphate, TXA22 = thromboxane A = thromboxane A22, COX = cyclooxygenase, COX = cyclooxygenase

clopidogrel bisulfateclopidogrel bisulfate

TXATXA22

phosphodiesterasephosphodiesterase

ADPADP

Gp IIb/IIIaGp IIb/IIIa ActivationActivation

COXCOX

ticlopidine hydrochlorideticlopidine hydrochloride

aspirinaspirin

Gp 2b/3a InhibitorsGp 2b/3a Inhibitors

dipyridamoledipyridamole

Schafer AI. Am J Med 1996;101:199–209

Antiplatelet Therapy: Common Oral AgentsAntiplatelet Therapy: Common Oral Agents

Acetylsalicylic acid Acetylsalicylic acid (ASA)(ASA)

Clopidogrel bisulfate*Clopidogrel bisulfate* Ticlopidine Ticlopidine hydrochloride*hydrochloride*

Trade NameTrade Name AspirinAspirin Plavix®Plavix® Ticlid®Ticlid®

ClassClass SalicylateSalicylate ThienopyridineThienopyridine ThienopyridineThienopyridine

FormulationFormulation Active DrugActive Drug Pro-DrugPro-Drug Active DrugActive Drug

Maintenance DoseMaintenance Dose 75-325 mg daily75-325 mg daily 75 mg daily75 mg daily 250 mg twice daily250 mg twice daily

Major Bleeding Risk Major Bleeding Risk (%)(%)

2.4-3.3%2.4-3.3%11 1.0-3.7% alone1.0-3.7% alone2,32,3

3.0-4.9% w/ ASA3.0-4.9% w/ ASA44

1.0% alone1.0% alone55

1.7-5.5% w/ ASA1.7-5.5% w/ ASA6,76,7

1Topol EJ et al. Circulation. 2003;108:399-4062Diener H-C et al. Lancet 2004;364;331-73Plavix® package insert. www.sanofi-synthelabo.us4Peters RJ et al. Circulation 2003;108:1682-7 5Hass WK. NEJM 1989;321:501-7 6Urban P. Circulation. 1998;98:2126-327Ticlid® package insert. www.rocheusa.com

*Clopidogrel is generally given preference over Ticlopidine because of a superior safety profile

Aspirin: Mechanism of ActionAspirin: Mechanism of Action

Membrane Phospholipids

ARACHIDONIC ACID

Prostaglandin H2

COX-1

Thromboxane A2

Platelet AggregationVasoconstriction

Prostacyclin Platelet Aggregation

Vasodilitation

Aspirin

Aspirin RecommendationsAspirin Recommendations

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Aspirin (75-162 mg daily) for intermediate risk men Aspirin (75-162 mg daily) for intermediate risk men with a 10 year risk of CHD with a 10 year risk of CHD >>10%.10%.

Aspirin (75-162 mg daily) for intermediate risk Aspirin (75-162 mg daily) for intermediate risk women with a 10 year risk of CHD women with a 10 year risk of CHD >>10%.10%.

Aspirin for low risk women with a 10 year risk of Aspirin for low risk women with a 10 year risk of CHD<10%.CHD<10%.

Aspirin (75-325 mg daily) for those with known CHD.Aspirin (75-325 mg daily) for those with known CHD.

Primary Prevention

Secondary Prevention




Rader, NEJM 2000; 343: 1181.

P. Ridker

CRP vs hs-CRPCRP vs hs-CRP

CRP is an acute-phase protein produced by the liver CRP is an acute-phase protein produced by the liver in response to cytokine production (IL-6, IL-1, tumor in response to cytokine production (IL-6, IL-1, tumor necrosis factor) during tissue injury, inflammation, necrosis factor) during tissue injury, inflammation, or infection.or infection.

Standard CRPStandard CRP tests determine levels which are tests determine levels which are increased up to 1,000-fold in response to infection increased up to 1,000-fold in response to infection or tissue destruction, but cannot adequately assess or tissue destruction, but cannot adequately assess the normal rangethe normal range

High-sensitivity CRPHigh-sensitivity CRP (hs-CRP) assays (i.e. Dade (hs-CRP) assays (i.e. Dade Behring) detect levels of CRP within the normal Behring) detect levels of CRP within the normal range, levels proven to predict future cardiovascular range, levels proven to predict future cardiovascular events.events.

Potential Mechanisms Linking CRP Potential Mechanisms Linking CRP to Atherothrombosisto Atherothrombosis

Confounding by cigarette Confounding by cigarette consumptionconsumption

Innocent bystanderInnocent bystander- Acute phase response- Acute phase response

Cytokine surrogateCytokine surrogate- IL-6, TNF-- IL-6, TNF-, IL-1, IL-1

Direct effects of CRPDirect effects of CRP- Innate immunity- Innate immunity- Complement activation- Complement activation- CAM induction- CAM induction

Prior infectionPrior infection- Chlamydia, H pylori, CMV- Chlamydia, H pylori, CMV

Marker for subclinical atherosclerosis- EBCT / IMT / ABI

Marker for insulin resistance/ obesity

Marker for endothelial dysfunction

Marker for dysmetabolic syndrome

Marker for plaque vulnerability

hs-CRP and Risk of Future MI in hs-CRP and Risk of Future MI in Apparently Healthy MenApparently Healthy Men

PP<0.001<0.001

PP<0.001<0.001

PP=0.03=0.03

Quartile of hs-CRPQuartile of hs-CRP

P P Trend <0.001Trend <0.001

Re

lati

ve

Ris

k o

f M

IR

ela

tiv

e R

isk

of

MI

Ridker et al, N Engl J Med. 1997;336:973–979.

0

1

2

3

1 2 3 4

hs-CRP and Risk of Future Stroke in hs-CRP and Risk of Future Stroke in Apparently Healthy MenApparently Healthy Men

PP<0.02<0.02PP=0.02=0.02

Re

lati

ve

Ris

k o

f R

ela

tiv

e R

isk

of

Isc

he

mic

Str

ok

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ch

em

ic S

tro

ke

P P Trend <0.03Trend <0.03

Ridker et al, N Engl J Med. 1997;336:973–979.

Quartile of hs-CRPQuartile of hs-CRP

0

1

2

1 2 3 4

hs-CRP as a Risk Factor For Future CVD : hs-CRP as a Risk Factor For Future CVD : Primary Prevention CohortsPrimary Prevention Cohorts

0 1.0 2.0 3.0 4.0 5.0 6.0

Kuller MRFIT 1996 CHD DeathRidker PHS 1997 MI

Ridker PHS 1997 Stroke

Tracy CHS/RHPP 1997 CHD

Ridker PHS 1998,2001 PAD

Ridker WHS 1998,2000,2002 CVD

Koenig MONICA 1999 CHD

Roivainen HELSINKI 2000 CHD

Mendall CAERPHILLY 2000 CHD

Danesh BRHS 2000 CHD

Gussekloo LEIDEN 2001 Fatal Stroke

Lowe SPEEDWELL 2001 CHD

Packard WOSCOPS 2001 CV Events*

Ridker AFCAPS 2001 CV Events*

Rost FHS2001 Stroke

Pradhan WHI 2002MI,CVD death

Albert PHS 2002 Sudden Death

Sakkinen HHS 2002 MIRelative Risk (upper vs lower quartile)Ridker PM. Circulation 2003;107:363-9

hs-CRP Adds to Predictive Value of TC:HDL hs-CRP Adds to Predictive Value of TC:HDL Ratio in Determining Risk of First MIRatio in Determining Risk of First MI

0.0

1.0

2.0

3.0

4.0

5.0

High Medium Low Low

Medium

High

Total Cholesterol:HDL RatioTotal Cholesterol:HDL Ratio

Ridker et al, Circulation. 1998;97:2007–2011.

hs-CRP

hs-CRP

Rel

ativ

e R

isk

Rel

ativ

e R

isk

Risk Factors for Future Cardiovascular Risk Factors for Future Cardiovascular Events: WHSEvents: WHS

0 1.0 2.0 4.0 6.0

Lipoprotein(a)

Homocysteine

IL-6

TC

LDLC

sICAM-1

SAA

Apo B

TC: HDLC

hs-CRP

hs-CRP + TC: HDLC

Relative Risk of Future Cardiovascular Events

Ridker et al, N Engl J Med. 2000;342:836-43

1.00

0.99

0.98

0.97

0.96

0.000 2 4 6 8

Years of Follow-up

Low CRP-low LDL

Low CRP-high LDL

High CRP-low LDL

High CRP-high LDL

CV Event-Free Survival Using Combined CV Event-Free Survival Using Combined hs-CRP and LDL-C Measurementshs-CRP and LDL-C Measurements

Ridker et al, N Engl J Med. 2002;347:1157-1165.

Pro

bab

ility

of

Eve

nt-

free

Su

rviv

al

Median LDL 124 mg/dlMedian CRP 1.5mg/l

hs-CRP Adds Prognostic Information at all Levels of hs-CRP Adds Prognostic Information at all Levels of LDL-C and at all Levels of the Framingham Risk ScoreLDL-C and at all Levels of the Framingham Risk Score

0-1

25

20

15

10

5

0

Rel

ativ

e ri

sk

Mu

ltiv

aria

ble

rel

ativ

e ri

sk2-4 5-9 10-20 130-160<130 >160

Framingham estimate of 10-year risk (%) LDL cholesterol (mg/dL)

C-Reactive Protein (mg/L)C-Reactive Protein (mg/L)

1

0

2

3

<1.0 1.0-3.0 >3.0

Ridker et al, N Engl J Med. 2002;347:1557.

<1.0 1.0-3.0 >3.0

0 1 2 3 4 50

2

4

6

8

C-r

ea

cti

ve

pro

tein

(m

g/L

)

Number of Components of the Metabolic Syndrome

Ridker et al, Circulation 2003;107:391-7

Plasma hs-CRP Levels According to Plasma hs-CRP Levels According to Severity of the Metabolic SyndromeSeverity of the Metabolic Syndrome

0 2 4 6 8

Years of Follow-Up

0.95

0.96

0.97

0.98

0.99

1.00C

VD

Ev

ent-

Fre

eS

urv

iva

l Pro

ba

bili

ty

CRP <1 mg/L

CRP 1-3 mg/L

CRP >3 mg/L

Event Free Survival According to hs-CRP Levels: Analysis Event Free Survival According to hs-CRP Levels: Analysis Limited to Participants Limited to Participants withwith Metabolic Syndrome at BaselineMetabolic Syndrome at Baseline

Ridker et al, Circulation 2003;107:391-7

AHA / CDC Scientific StatementAHA / CDC Scientific StatementMarkers of Inflammation and Cardiovascular Disease:Markers of Inflammation and Cardiovascular Disease:

Applications to Clinical and Public Health PracticeApplications to Clinical and Public Health Practice

Circulation January 28, 2003Circulation January 28, 2003

“Measurement of hs-CRP is an independent marker of risk“Measurement of hs-CRP is an independent marker of riskand may be used at the discretion of the physician as partand may be used at the discretion of the physician as part

of global coronary risk assessment in adults without knownof global coronary risk assessment in adults without knowncardiovascular disease. Weight of evidence favors use cardiovascular disease. Weight of evidence favors use particularly among those judged at intermediate risk byparticularly among those judged at intermediate risk by

global risk assessment”.global risk assessment”.

1 mg/L 3 mg/L 10 mg/L

LowRisk

ModerateRisk

HighRisk

Acute Phase ResponseIgnore Value, Repeat Test in 3

weeks

>100 mg/L

Ridker PM. Circulation 2003;107:363-9

Clinical Application of hs-CRP forClinical Application of hs-CRP forCardiovascular Risk Prediction Cardiovascular Risk Prediction

Is there clinical evidence that Is there clinical evidence that

inflammation can be modified by inflammation can be modified by

preventive therapies?preventive therapies?

0

5

10

15

20

25

Elevated CRP Levels in Obesity: Elevated CRP Levels in Obesity: NHANES 1988-1994NHANES 1988-1994

Visser M et al. JAMA 1999;282:2131-2135.

Normal

Perc

en

t w

ith C

RP

0.2

2

mg/d

L

Overweight Obese

Effects of Weight Loss on CRPEffects of Weight Loss on CRPConcentrations in Obese Healthy Concentrations in Obese Healthy

WomenWomen 83 women (mean BMI 33.8, range 28.2-43.8 kg/m2) placed

on very low fat, energy-restricted diet (6.0 MJ, 15% fat) for 12 weeks

Baseline CRP positively associated with BMI (r=0.281, p=0.01)

CRP reduced by 26% (p<0.001)

Average weight loss 7.9 kg, associated with change in CRP

Change in CRP correlated with change in TC (r=0.240, p=0.03) but not changes in LDL-C, HDL-C, or glucose

At 12 weeks, CRP concentration highly correlated with TG (r=0.287, p=0.009), but not with other lipids or glucose

Heilbronn LK et al. Arterioscler Thromb Vasc Biol 2001;21:968-970.

Effect of HRT on hs-CRP: Effect of HRT on hs-CRP: the PEPI the PEPI StudyStudy

3.0

2.0

1.0hs-

CR

P (

mg/d

L)

Months

0 12 36

Cushman M et al. Circulation 1999;100:717-722.1999 Lippincott Williams & Wilkins.

CEE + MPA cyclicCEE + MPA continuousCEE + MP

CEE

Placebo

Long-Term Effect of Statin Therapy on Long-Term Effect of Statin Therapy on hs-CRP: Placebo and Pravastatin Groupshs-CRP: Placebo and Pravastatin Groups

PravastatinPravastatin

PlaceboPlacebo

Me

dia

n h

s-C

RP

Me

dia

n h

s-C

RP

Co

nc

en

tra

tio

nC

on

ce

ntr

ati

on

(mg

/dL

)(m

g/d

L) -21.6%-21.6%

((PP=0.004)=0.004)

0.18

0.19

0.20

0.21

0.22

0.23

0.24

0.25

Baseline 5 Years

Ridker et al, Circulation. 1999;100:230-235.

hs-

CR

P (

mg/L

)Effect of Statin Therapy on hs-CRP Levels Effect of Statin Therapy on hs-CRP Levels

at 6 Weeksat 6 Weeks

Jialal I et al. Circulation 2001;103:1933-1935.2001 Lippincott Williams & Wilkins.

6

5

4

3

2

1

0 Baseline

* * *

Prava(40 mg/d)

Simva(20 mg/d)

Atorva(10 mg/d)

*p<0.025 vs. Baseline

A Randomized Trial of Rosuvastatin in the Preventionof Cardiovascular Events Among 17,802 Apparently Healthy

Men and Women With Elevated Levels of C-Reactive Protein (hsCRP):

The JUPITER Trial

Paul Ridker*, Eleanor Danielson, Francisco Fonseca*, Jacques Genest*,Antonio Gotto*, John Kastelein*, Wolfgang Koenig*, Peter Libby*,

Alberto Lorenzatti*, Jean MacFadyen, Borge Nordestgaard*, James Shepherd*, James Willerson, and Robert Glynn*

on behalf of the JUPITER Trial Study Group

An Investigator Initiated Trial Funded by AstraZeneca, USA

* These authors have received research grant support and/or consultation fees from one or morestatin manufacturers, including Astra-Zeneca. Dr Ridker is a co-inventor on patents held by the

Brigham and Women’s Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease that have been licensed to Dade-Behring and AstraZeneca.

In 2001, in an hypothesis generating analysis of apparently healthy individuals in the AFCAPS / TexCAPS trial*, we observed that those with low levels of both LDL and hsCRP had extremely low vascular event rates and that statin therapy did not reduce events in this subgroup (N=1,448, HR 1.1, 95% CI 0.56-2.08). Thus, a trial of statin therapy in patients with low cholesterol and low hsCRP would not only be infeasible in terms of power and sample size, but would be highly unlikely to show clinical benefit.

In contrast, we also observed within AFCAPS/TexCAPS that among those with low LDL but high hsCRP, vascular event rates were just as high as rates among those with overt hyperlipidemia, and that statin therapy significantly reduced events in this subgroup (N=1,428, HR 0.6, 95% CI 0.34-0.98).

*Ridker et al N Engl J Med 2001;344:1959-65

However, while intriguing and of potential public health importance, the observation in AFCAPS/TexCAPS that statin therapy might be effective among those with elevated hsCRP but low cholesterol was made on a post hoc basis. Thus, a large-scale randomized trial of statin therapy was needed to directly test this hypotheses.

Ridker et al, New Engl J Med 2001;344:1959-65

Low LDL, Low hsCRP

Low LDL, High hsCRP

Statin Effective Statin Not Effective

1.0 2.00.5

[A]

[B]

Low LDL, Low hsCRP

Low LDL, High hsCRP

Statin Effective Statin Not Effective

1.0 2.00.5

AFCAPS/TexCAPS Low LDL Subgroups

RR

To investigate whether rosuvastatin 20 mg compared to placebo would decrease the rate of first major cardiovascularevents among apparently healthy men and women with LDL < 130 mg/dL (3.36 mmol/L) who are nonethelessat increased vascular risk on the basis of an enhanced inflammatory response, as determined by hsCRP > 2 mg/L.

To enroll large numbers of women and individuals of Black or Hispanic ethnicity, groups for whom little data on primaryprevention with statin therapy exists.

Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin

Ridker et al NEJM 2008

Rosuvastatin 20 mg (N=8901)Rosuvastatin 20 mg (N=8901) MIMIStrokeStroke

UnstableUnstable AnginaAngina

CVD DeathCVD DeathCABG/PTCACABG/PTCA

JUPITERJUPITERMulti-National Randomized Double Blind Placebo Controlled Trial of Multi-National Randomized Double Blind Placebo Controlled Trial of

Rosuvastatin in the Prevention of Cardiovascular EventsRosuvastatin in the Prevention of Cardiovascular EventsAmong Individuals With Low LDL and Elevated hsCRPAmong Individuals With Low LDL and Elevated hsCRP

4-week 4-week run-inrun-in

Ridker et al, Circulation 2003;108:2292-2297.

No Prior CVD or DMNo Prior CVD or DMMen Men >>50, Women 50, Women >>6060

LDL <130 mg/dL hsCRP >2 mg/L

JUPITERTrial Design

Placebo (N=8901)Placebo (N=8901)

Argentina, Belgium, Brazil, Bulgaria, Canada, Chile, Colombia, Costa Rica, Denmark, El Salvador, Estonia, Germany, Israel, Mexico, Netherlands, Norway, Panama, Poland, Romania, Russia, South Africa, Switzerland,

United Kingdom, Uruguay, United States, Venezuela

JUPITERBaseline Clinical Characteristics

Rosuvastatin Placebo(N = 8901) (n = 8901)

Age, years (IQR) 66.0 (60.0-71.0) 66.0 (60.0-71.0) Female, N (%) 3,426 (38.5) 3,375 (37.9)Ethnicity, N (%) Caucasian 6,358 (71.4) 6,325 (71.1) Black 1,100 (12.4) 1,124 (12.6) Hispanic 1,121 (12.6) 1,140 (12.8)Blood pressure, mm (IQR) Systolic 134 (124-145) 134 (124-145) Diastolic 80 (75-87) 80 (75-87)Smoker, N (%) 1,400 (15.7) 1,420 (16.0)Family History, N (%) 997 (11.2) 1,048 (11.8)Metabolic Syndrome, N (%) 3,652 (41.0) 3,723 (41.8)Aspirin Use, N (%) 1,481 (16.6) 1,477 (16.6)

All values are median (interquartile range) or N (%)


JUPITERBaseline Blood Levels (median, interquartile range)

Rosuvastatin Placebo(N = 8901) (n = 8901)

hsCRP, mg/L 4.2 (2.8 - 7.1) 4.3 (2.8 - 7.2) LDL, mg/dL 108 (94 - 119) 108 (94 - 119)

HDL, mg/dL 49 (40 – 60) 49 (40 – 60)

Triglycerides, mg/L 118 (85 - 169) 118 (86 - 169)

Total Cholesterol, mg/dL 186 (168 - 200) 185 (169 - 199)

Glucose, mg/dL 94 (87 – 102) 94 (88 – 102)

HbA1c, % 5.7 (5.4 – 5.9) 5.7 (5.5 – 5.9)

All values are median (interquartile range). [ Mean LDL = 104 mg/dL ]


0

1

2

3

4

5

hsC

RP

(m

g/L

)

0

20

40

60

80

100

120

140

LD

L (

mg

/dL

)

Months0 12 24 36 48

0

10

20

30

40

50

60

0

20

40

60

80

100

120

140

0 12 24 36 48

TG

(m

g/d

L)

HD

L (

mg

/dL

)

Months

JUPITEREffects of rosuvastatin 20 mg on LDL, HDL, TG, and hsCRP

LDL decrease 50 percent at 12 months

hsCRP decrease 37 percent at 12 months

HDL increase 4 percent at 12 months

TG decrease 17 percent at 12 months


JUPITERPrimary Trial Endpoint : MI, Stroke, UA/Revascularization, CV Death

Placebo 251 / 8901

Rosuvastatin 142 / 8901

HR 0.56, 95% CI 0.46-0.69P < 0.00001

- 44 %

0 1 2 3 4

0.0

00

.02

0.0

40

.06

0.0

8

Cu

mu

lati

ve In

cid

ence

Number at Risk Follow-up (years)

Rosuvastatin

Placebo

8,901 8,631 8,412 6,540 3,893 1,958 1,353 983 544 157

8,901 8,621 8,353 6,508 3,872 1,963 1,333 955 534 174


JUPITERPrimary Trial Endpoint : MI, Stroke, UA/Revascularization, CV Death

Placebo 251 / 8901


HR 0.56, 95% CI 0.46-0.69P < 0.00001

Number Needed to Treat (NNT5) = 25

- 44 %

0 1 2 3 4

0.0

00

.02

0.0

40

.06

0.0

8

Cu

mu

lati

ve In

cid

ence


Rosuvastatin

Placebo

8,901 8,631 8,412 6,540 3,893 1,958 1,353 983 544 157

8,901 8,621 8,353 6,508 3,872 1,963 1,333 955 534 174


JUPITERGrouped Components of the Primary Endpoint

HR 0.53, CI 0.40-0.70P < 0.00001

Rosuvastatin

Placebo

Myocardial Infarction, Stroke, orCardiovascular Death

Arterial Revascularization orHospitalization for Unstable

Angina

HR 0.53, CI 0.40-0.69P < 0.00001

0 1 2 3 4

0.00

0.01

0.02

0.03

0.04

0.05

0.06

Cu

mu

lati

ve In

cid

ence

Follow-up (years)

0 1 2 3 4

0.00

0.01

0.02

0.03

0.04

0.05

Cu

mu

lati

ve In

cid

ence

Follow-up (years)

Placebo

Rosuvastatin

- 47 %- 47 %


JUPITERIndividual Components of the Primary Endpoint

*Nonfatal MI, nonfatal stroke, revascularization, unstable angina, CV death

Endpoint Rosuvastatin Placebo HR 95%CI P

Primary Endpoint* 142 251 0.56 0.46-0.69 <0.00001

Non-fatal MI 22 62 0.35 0.22-0.58 <0.00001Any MI 31 68 0.46 0.30-0.70 <0.0002

Non-fatal Stroke 30 58 0.52 0.33-0.80 0.003Any Stroke 33 64 0.52 0.34-0.79 0.002

Revascularization or Unstable Angina 76 143 0.53 0.40-0.70 <0.00001

MI, Stroke, CV Death 83 157 0.53 0.40-0.69 <0.00001


JUPITERPrimary Endpoint – Subgroup Analysis I

0.25 0.5 1.0 2.0 4.0

Rosuvastatin Superior Rosuvastatin Inferior

MenWomen

Age < 65Age > 65

SmokerNon-Smoker

CaucasianNon-Caucasian

USA/CanadaRest of World

HypertensionNo Hypertension

All Participants

N P for Interaction

11,001 0.80 6,801

8,541 0.32 9,261

2,820 0.6314,975

12,683 0.57 5,117

6,041 0.5111,761

10,208 0.53 7,586

17,802


JUPITERPrimary Endpoint – Subgroup Analysis II

0.25 0.5 1.0 2.0 4.0

Rosuvastatin Superior Rosuvastatin Inferior

Family HX of CHDNo Family HX of CHD

BMI < 25 kg/m2

BMI 25-29.9 kg/mBMI > 30 kg/m

Metabolic SyndromeNo Metabolic Syndrome

Framingham Risk < 10%Framingham Risk > 10%

hsCRP > 2 mg/L Only

All Participants

N P for Interaction

2,045 0.0715,684

4,073 0.70 7,009 6,675

7,375 0.1410,296

8,882 0.99 8,895

6,375

17,802

2

2

hsCRP > 2 mg/L Only 6,375


JUPITERAdverse Events and Measured Safety Parameters

Event Rosuvastatin Placebo P

Any SAE 1,352 (15.2) 1,337 (15.5) 0.60Muscle weakness 1,421 (16.0) 1,375 (15.4) 0.34Myopathy 10 (0.1) 9 (0.1) 0.82Rhabdomyolysis 1 (0.01)* 0 (0.0) --Incident Cancer 298 (3.4) 314 (3.5) 0.51Cancer Deaths 35 (0.4) 58 (0.7) 0.02Hemorrhagic stroke 6 (0.1) 9 (0.1) 0.44

GFR (ml/min/1.73m2 at 12 mth) 66.8 (59.1-76.5) 66.6 (58.8-76.2) 0.02ALT > 3xULN 23 (0.3) 17 (0.2) 0.34

Fasting glucose (24 mth) 98 (91-107) 98 (90-106) 0.12HbA1c (% at 24 mth) 5.9 (5.7-6.1) 5.8 (5.6-6.1) 0.01Glucosuria (12 mth) 36 (0.5) 32 (0.4) 0.64Incident Diabetes** 270 (3.0) 216 (2.4) 0.01

*Occurred after trial completion, trauma induced. All values are median (interquartile range) or N (%)**Physician reported


JUPITERStatins and the Development of Diabetes

0.25 0.5 1.0 2 4

WOSCOPS Pravastatin

HPS Simvastatin

ASCOT-LLA Atorvastatin

JUPITER Rosuvastatin

PROVE-IT Atorvastatin VS

Pravastatin

0.70 (0.50–0.98)

1.20 (0.98–1.35)

1.20 (0.91–1.44)

1.11 (0.67–1.83)

1.25 (1.05–1.54)

Statin Better Statin Worse

HR (95% CI)

PROSPER Pravastatin 1.34 (1.06–1.68)


JUPITERSecondary Endpoint – All Cause Mortality

Placebo 247 / 8901


HR 0.80, 95%CI 0.67-0.97P= 0.02

- 20 %

0 1 2 3 4

0.00

0.01

0.02

0.03

0.04

0.05

0.06

Cu

mu

lati

ve I

nci

den

ce


RosuvastatinPlacebo

8,901 8,847 8,787 6,999 4,312 2,268 1,602 1,192 683 2278,901 8,852 8,775 6,987 4,319 2,295 1,614 1,196 684 246


JUPITERConclusions – Efficacy I

Among apparently healthy men and women with elevatedhsCRP but low LDL, rosuvastatin reduced by 47 percent incident myocardial infarction, stroke, and cardiovascular death.

Despite evaluating a population with lipid levels widely considered to be “optimal” in almost all current prevention algorithms, the relative benefit observed in JUPITER was greater than in almost all prior statin trials.

In this trial of low LDL/high hsCRP individuals who do notcurrently qualify for statin therapy, rosuvastatin significantlyreduced all-cause mortality by 20 percent.


JUPITERImplications for Primary Prevention

Among men and women age 50 or over :

If diabetic, treatIf LDLC > 160 mg/dL, treat

If hsCRP > 2 mg/L, treat

A simple evidence based approach to statin therapyfor primary prevention.


Inflammatory and Infections Agents in CHDInflammatory and Infections Agents in CHD

Belgian epidemiologic study included 446 of Belgian epidemiologic study included 446 of 16307 male workers aged 35-39 who had 16307 male workers aged 35-39 who had evidence of CHD vs. 892 controls.evidence of CHD vs. 892 controls.

CRP, but none of the infectious agents (H. CRP, but none of the infectious agents (H. pylori, C. pneumoniae, CMV, and EBV) were pylori, C. pneumoniae, CMV, and EBV) were associated with CHD, even after adjustment associated with CHD, even after adjustment for other risk factors.for other risk factors.

De Backer et al. Atherosclerosis 2002; 160: 457-63.

Infection and CHD - is there a Infection and CHD - is there a connection?connection?

Local or systemic infections resulting from Local or systemic infections resulting from gram negative bacteria such as Chlamydia gram negative bacteria such as Chlamydia pneumoniae and Helicobacter pylori, including pneumoniae and Helicobacter pylori, including cytomegalovirus (CMV) have been implicated cytomegalovirus (CMV) have been implicated in atheroscelosisin atheroscelosis

While several case control studies have shown While several case control studies have shown increased titers of C.pneumoniae and H. Pylori increased titers of C.pneumoniae and H. Pylori in those with vs. without CHD, convincing in those with vs. without CHD, convincing evidence from prospective studies is lacking.evidence from prospective studies is lacking.

Prospective Studies of CHD and Prospective Studies of CHD and Infectious PathogensInfectious Pathogens

Physician’s Health Study (nested case-control) Physician’s Health Study (nested case-control) shows RR 1.1 (0.8-1.5) for C. Pneumoniae, shows RR 1.1 (0.8-1.5) for C. Pneumoniae, 0.94 (0.7-1.2) for cytomegalovirus, and 0.72 0.94 (0.7-1.2) for cytomegalovirus, and 0.72 (0.6-0.9) for Herpes simplex virus.(0.6-0.9) for Herpes simplex virus.

H. pylori also shows mixed results. Whincup H. pylori also shows mixed results. Whincup showed a nonsignificant 1.3 OR when adjusted showed a nonsignificant 1.3 OR when adjusted for other risk factors, the large ARIC study for other risk factors, the large ARIC study showed no relation, and the Caerphilly showed no relation, and the Caerphilly Prospective study showed RR=1.05 in 1796 Prospective study showed RR=1.05 in 1796 men followed 14 years.men followed 14 years.

Other Studies of Infectious AgentsOther Studies of Infectious Agents

In South Asian persons with CHD vs. controls, C. pneumoniae In South Asian persons with CHD vs. controls, C. pneumoniae specific IgG antibody was seropositive in similar proportions; risk specific IgG antibody was seropositive in similar proportions; risk factors appeared to mediate any relations (Mendis et al. Int J factors appeared to mediate any relations (Mendis et al. Int J Cardiol 2001; 79: 191-6).Cardiol 2001; 79: 191-6).

Cross-sectional survey of 704 individuals of C. pneumoniae and Cross-sectional survey of 704 individuals of C. pneumoniae and CMV with risk factors did nto show significant associations CMV with risk factors did nto show significant associations (Danesh et al., J Cardiovasc Risk 1999; 6: 387-90).(Danesh et al., J Cardiovasc Risk 1999; 6: 387-90).

Meta-analysis of 24 articles involving H. pylori infection and CHD Meta-analysis of 24 articles involving H. pylori infection and CHD showed a pooled odds ratio of 1.55 (95% CI: 1.38-1.74) (p<0.001), showed a pooled odds ratio of 1.55 (95% CI: 1.38-1.74) (p<0.001), suggested a weak relation, but high hetrogeneity between studies suggested a weak relation, but high hetrogeneity between studies precludes clear demonostration (Pellicano et al., Eur J Epidemiol precludes clear demonostration (Pellicano et al., Eur J Epidemiol 1999; 15: 611-9).1999; 15: 611-9).

ARIC Study failed to show clear relation between IgG antibodies ARIC Study failed to show clear relation between IgG antibodies for C. pneumoniae and incident CHD occurring over average 3.3 for C. pneumoniae and incident CHD occurring over average 3.3 years. (Nieto et al. Am J Epidemiol 1999; 150: 149-56).years. (Nieto et al. Am J Epidemiol 1999; 150: 149-56).

Clinical Trial Evidence for Antibiotic Clinical Trial Evidence for Antibiotic Treatment and Prevention of CVDTreatment and Prevention of CVD

ACADEMIC Study of 302 patients with CHD seropositive to ACADEMIC Study of 302 patients with CHD seropositive to C. Pneumoniae randomized to azithromycin 500 mg/wk or C. Pneumoniae randomized to azithromycin 500 mg/wk or placebo for 3 months showed no significant treatment placebo for 3 months showed no significant treatment difference (HR=0.89, p=0.74) for recurrent events difference (HR=0.89, p=0.74) for recurrent events (Muhlestein et al., Circulation 2000; 102: 1755-60).(Muhlestein et al., Circulation 2000; 102: 1755-60).

AZACS Multicenter study of 1439 pts with unstable angina AZACS Multicenter study of 1439 pts with unstable angina randomized to 250 mg azithromycin/day for up to 6 randomized to 250 mg azithromycin/day for up to 6 months showed no significant benefit for death, recurrent months showed no significant benefit for death, recurrent MI, or recurrent ischemia (Cercek et al., Lancet 2003; 361: MI, or recurrent ischemia (Cercek et al., Lancet 2003; 361: 809-13).809-13).

WIZARD trial of 7,747 pts post-MI randomized to 12 week WIZARD trial of 7,747 pts post-MI randomized to 12 week of therapy with azithromycin or placebo showed no of therapy with azithromycin or placebo showed no significant reduction in reinfarction, revascularization, significant reduction in reinfarction, revascularization, hospitalization for angina, or death (O’Connor et al., JAMA hospitalization for angina, or death (O’Connor et al., JAMA 2003; 290: 1459-66).2003; 290: 1459-66).

Infectious Agents and the FutureInfectious Agents and the Future

Individuals with greater infectious burdens may Individuals with greater infectious burdens may be at greater risk, because they are older, have be at greater risk, because they are older, have poorer health habits, less access to care.poorer health habits, less access to care.

Observed associations often may be due to Observed associations often may be due to selection biases or confounding from age and selection biases or confounding from age and other factorsother factors

Prospective clinical trials under way examining Prospective clinical trials under way examining role of certain antibiotics such as azithromycin role of certain antibiotics such as azithromycin on reduction of recurrent events in CHD on reduction of recurrent events in CHD patients.patients.

Until these data are available, no role for Until these data are available, no role for measurement or treatment of infectious burden.measurement or treatment of infectious burden.

Multiple Biomarkers for the Prediction of Multiple Biomarkers for the Prediction of First CVD Events and Death (Wang TJ et al., First CVD Events and Death (Wang TJ et al.,

NEJM 2006; 355: 2631-9)NEJM 2006; 355: 2631-9) 10 biomarkers examined in 3209 pts of the Framingham 10 biomarkers examined in 3209 pts of the Framingham

Heart StudyHeart Study CRP, BNP, N-T pro-ANP, aldosterone, renin, fibrinogen, d-CRP, BNP, N-T pro-ANP, aldosterone, renin, fibrinogen, d-

dimer, PAI-1, homocysteine, and urine albumin/creatinine dimer, PAI-1, homocysteine, and urine albumin/creatinine ratio.ratio.

7.4 years medial follow-up7.4 years medial follow-up Adjusted HR’s per SD: BNP 1.4, CRP 1.4, Adjusted HR’s per SD: BNP 1.4, CRP 1.4,

albumin/creatinine 1.2, homocysteine 1.2, renin 1.5 for albumin/creatinine 1.2, homocysteine 1.2, renin 1.5 for death, and BNP 1.25, albumin/creatinine 1.2 for CVD death, and BNP 1.25, albumin/creatinine 1.2 for CVD eventsevents

Multimarker scores in highest quintile vs. lowest two Multimarker scores in highest quintile vs. lowest two quintiles had adjusted HR for death of 4.1, p<0.001 and quintiles had adjusted HR for death of 4.1, p<0.001 and CVD events of 1.8, p=0.02CVD events of 1.8, p=0.02

Only moderate increases in C-statistic seen from Only moderate increases in C-statistic seen from biomarkers over standard risk factorsbiomarkers over standard risk factors

Use of Multiple Biomarkers to Improve Use of Multiple Biomarkers to Improve Prediction of CVD Death (Zethelius B et al., Prediction of CVD Death (Zethelius B et al.,

NEJM 2008; 358: 2107-16)NEJM 2008; 358: 2107-16)

1135 elderly men from the Uppsala Longitudinal Study 1135 elderly men from the Uppsala Longitudinal Study of Adult Men, mean age 71 years at baseline, 10 years of Adult Men, mean age 71 years at baseline, 10 years median follow-upmedian follow-up

Examined role of multiple markers reflecting myocardial Examined role of multiple markers reflecting myocardial cell damage—troponin I, LV dysfunction– N-T pro BNP, cell damage—troponin I, LV dysfunction– N-T pro BNP, renal failure—cystatin C, and inflammation – CRPrenal failure—cystatin C, and inflammation – CRP

C-statistic increased significantly when the four C-statistic increased significantly when the four biomarkers were put in a model with established risk biomarkers were put in a model with established risk factors (0.77 vs. 0.66, p<0.0001) in the whole cohort factors (0.77 vs. 0.66, p<0.0001) in the whole cohort and in those without CVD at baseline (0.748 vs. 0.688, and in those without CVD at baseline (0.748 vs. 0.688, p=0.03).p=0.03).

Among elderly men, multiple biomarkers may Among elderly men, multiple biomarkers may significantly improve risk for death from CVD causes significantly improve risk for death from CVD causes beyond standard risk factors.beyond standard risk factors.

Novel Biomarkers and CVD

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