modulation in atherosclerotic patients August 26th, 2017, Barcelona - PowerPoint PPT Presentation

The promise of epigenetic modulation in atherosclerotic patients August 26th, 2017, Barcelona Erik S Stroes Department of Vascular Medicine, AMC, Amsterdam, The Netherlands

Outline  Atherosclerosis ‘ systemic pro-inflammatory state’  Feasibility of epigenetic targeting as ‘anti -atherosclerotic ’ intervention

Inflammation drives CV events

I. Patients with CVD (risk-factors) have increased arterial wall inflammation Valk, Stroes, Rudd, JACC CV Imaging 2016

II. Activation of circulating monocytes in patients with elevated Lp(a) Control Elevated Lp(a) More transmigration in Lp(a) patients And monocytes more motile Valk, Stroes, Circulation 2016

III. Activation of bone marrow in patients up to months after CV-event Persistent increased arterial wall inflammation Increased progenitor potential in CVD patients In CVD patients Van der Valk, Stroes, Eur Heart J 2016

Hyperactivity of the entire inflammatory cascade Atherosclerotic lesion, plasma cells and bone marrow Swirski & Nahrendorf, Science 2013;339:161-6

Cantos study IL1- β antibody August 27: Late Breaking Clinical Trials  Canakinumab reduces CV-events in post ACS patients  Primary endpoints met:  heart attack, stroke and cardiovascular death  Thus, IL1- β inhibition combined with statins significantly reduces CV-risk in post-ACS patients with elevated CRP  Balance anti-inflammatory – immune suppression ?

Outline  Atherosclerosis ‘ systemic pro-inflammatory state’  Feasibility of epigenetic targeting as ‘anti -atherosclerotic ’ intervention

Why epigenetics? Suppose you want to reduce ‘ fuel use ’ Scenario 2: ‘Tweak’ the use Scenario 1: Close down of fuel fuel switch Wing ‘ extensions ’ decrease fuel use by stabilizing the airplane Very carefully

What is epigenetics?  The study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code  To ‘ compare ’ :  Human life = movie  DNA = script  Genetics = screen writing  Epigenetics = director

How does epigenetics work? Change accessibility of chromatin by Among other histone modifications, allowing transcription factors to interact with regulatory regions

Epigenetics • Modifications to chromatin components regulating its activity • Modifications via addition (writers), removal (erasers) or recognition (readers)

Writing and Erasing histone ‘ tails ’ Neele, Eur J Pharmacol 2015

Writers/erasers: Histone (de)methylation K27 methylgroup K27 Methylation of a Lysine (K) opens or closes the chromatin, H3 H2A H3 H2A depending on me1/2/3 and position: H4 H2B H4 H2B Trimethylation of histone 3 at lysine 27 (H3K27Me3): heterochromatin ( closed ) H3 H2A  H2B Gene H4 transcription K4 H3 H2A Trimethylation of histone 3 at lysine 4 (H3K4Me3): euchromatin ( open ) H4 H2B  Gene transcription

Writers/erasers Histone (de)acetylation Acetylation of a Lysine (K) residue opens the chromatin Acetylgroup H3 H2A H4 H2B K27 H3 H2A H4 H2B  Acetylation of histone 3 at lysine 27 Gene (H3K27Ac): euchromatin (open) transcription Hypo acetylation (less acetylgroups) closes the chromatin

Methylation/Acetylation in plaques Acetylation Methylation Macrophages Lymphocytes Macrophages Lymphocytes H3K9Ac + H3K9Ac + H3K9Me2 ++ H3K9Me2 ++ H3K27Ac + H3K27Ac ++ H3K27Me2 ++ H3K27me2 ++ H3K4me2 + H3K4me2 + H3K9Me2  Plaque severity H3K9Ac  H3K9Me2  H3K27Me2  H3K9Ac + H3K27Ac  H3K27Ac  H3K27Me2  H3K27me3 H3K4me2  H3K4me2  Increased activating marks Decreased repressive marks

Monocyte hyperactivity in patients with elevated Lp(a) Van der Valk, Stroes, Circulation 2016

Methylation in plasma monocytes mediating pro-inflammatory activation Lp(a) subjects ** 20 ** Control subjects 10000 Cytokine level in pg/ml % input (H3K4me3) 8000 15 6000 10 K4 4000 * H3 H2 A 2000 H4 H2 5 B ** 40 0 RPMI IL-6 TNFa IL-1b TNF a myo IL-6 Hyperresponsiveness Trimethylation of histone 3 at lysine 4 Of circulating monocytes (H3K4Me3): euchromatin ( open ) Nicorescu, Stroes, data on file

Epigenetics • Modifications via addition (writers), removal (erasers) or recognition (readers)

Readers: Bromodomains and Extra-Terminal Domain (BETs) K27 H3 H2 A H4 H2 B

BET proteins Integral to transcription assembly Nature Reviews Mol Cell Biology 2013;13:543-7

Decreasing BETs decreases adhesion molecule expression & monocyte adhesion Brown, Mol Cell 2014

BET inhibition by Apabetalone selective BD2 inhibitor Inhibitor

Apabetalone decreases monocyte adhesion to endothelium under ‘flow’ Resverlogix, data on file

BET-inhibition attenuates polarisation and activation of ‘pro -inflammatory ’ macrophages Synthetic acetylated histone mimics block BET Thus, BETi protects against activity and inhibit expression of inflammatory inflammatory challenges response genes. Neele A et al. Eur J Pharmacol 2015

Apabetalone (RVX-208) Reduces Atheroma in Aorta of ApoE-/- Mice Chow Chow: TD 2016 +/- High Fat (42% kcal) Diet WK 19 WK 33 WK 9 WK 8 apabetalone Animal HF Diet Chow Diet Necropsy Arrival Aortic sinus Whole aorta Placebo Apabetalone 20 Whole aorta  of -31%  of -40% Plaque/whole area 15 (p<0.016) 11.081-607-040 (p<0.045) (%) +/- SE 15.081-608-519 10 Aortic sinus 5 8.092-895-111 0 16.040-776-379 PlaceboApabetalone PlaceboApabetalone (150 mg/kg) (150 mg/kg) Jahagirdar et al, Atherosclerosis 2015

Effect of Apabetalone on cytokine expression in human PBMCs Resverlogix, data on file

Clinical Analysis of Vascular Inflammation in CVD Patients in ASSURE Study (n=94) Protein Name Gene Symbol Placebo Apabetalone Treatment p-value vs 200mg Difference placebo (n=47) (n=47) C-reactive protein CRP -22.3 -43.6 -21.3 0.02 Tumor necrosis factor receptor TNFRSF11B 7.8 -6.2 -14.0 0.003 superfamily Vascular cell adhesion protein 1 VCAM1 5.7 -6.4 -12.2 0.005 Interleukin-6 receptor subunit alpha IL6R -0.1 -9.3 -9.1 0.01 Fibronectin FN1 -19.8 14.3 34.1 0.04 Gilham et al. Atherosclerosis 2016

The promise of epigenetics in Atheroslerosis  Epigenetic modulation provides a means to reduce ‘ redundant ’ inflammation without risking immune-suppression  BET-inhibition by Apabetalone (selective BD2 inhibitor) has anti- inflammatory and anti-atherogenic effects in experimental setting  BET-inhibition by Apabetalone in patients  Reassuring safety data (>6 months)  Anti-inflammatory effect on biomarkers  Impact on CV-events?  next presentation

Acknowledgements  AMC, dept of vascular medicine  Radboud, Nijmegen  Fleur vd Valk  Mihai Netea  Simone Verwey Siroon Bekkering  Lotte Stiekema  USCD, USA  Renate Hoogeveen  Sam Tsimikas  Joe Witztum  AMC, dept of Radiology  Aart Nederveen  International  Hein Verberne  Alberico Catapano  Funding: EU, Dutch Heart Foundation  Borge Nordestgaard