current concepts in therapeutic angiogenesis c. michael gibson m.s., m.d

Current Concepts In Therapeutic Angiogenesis

C. Michael Gibson M.S., M.D. C. Michael Gibson M.S., M.D.

Scope of Coronary Artery DiseaseScope of Coronary Artery Disease

• ~ 15 - 20 million Americans have a history of MI, angina, or both

• Cardiovascular disease is the number one cause of death in the US

• ~ 500,000 deaths per year

• 1,500,000 new or recurrent MI’s per year

• ~ 15 - 20 million Americans have a history of MI, angina, or both

• Cardiovascular disease is the number one cause of death in the US

• ~ 500,000 deaths per year

• 1,500,000 new or recurrent MI’s per year

AHA DatabankAHA Databank

• ~ 10 million Americans have angina

• ~ 350,000 new cases of angina diagnosed each year

• ~ 1.5 million coronary angiograms per year

• ~ 500,000 PTCA per year

• ~ 500,000 CABGs per year

• ~ 10 million Americans have angina

• ~ 350,000 new cases of angina diagnosed each year

• ~ 1.5 million coronary angiograms per year

• ~ 500,000 PTCA per year

• ~ 500,000 CABGs per year

AHA DatabankAHA Databank

Scope of Coronary Artery DiseaseScope of Coronary Artery Disease

Therapeutic AngiogenesisTherapeutic Angiogenesis

Current Therapeutic OptionsCurrent Therapeutic Options

Medical• Antianginals• Antiplatelet Agents• Lipid Lowering

Agents• Anticoagulants• Vasodilators

Medical• Antianginals• Antiplatelet Agents• Lipid Lowering

Agents• Anticoagulants• Vasodilators

Interventional• PTCA• CABG• TMR/PMR• Cardiac

Transplantation• PVD: Amputation

Interventional• PTCA• CABG• TMR/PMR• Cardiac

Transplantation• PVD: Amputation

New Therapeutic OptionNew Therapeutic Option

Therapeutic Angiogenesis: DefinitionsTherapeutic Angiogenesis: Definitions

Angiogenesis• The formation of new capillary blood vessels from

existing microvessels by sprouting, i.e. cellular outgrowth

Vasculogenesis• The formation of new blood vessels of all types from

blood islands, i.e. committed stem cells, in early embryogenesis

Growth Factor • Polypeptide which acts as a regulator of cellular

function, including proliferation, migration, differentiation, and survival/apoptosis

Angiogenesis• The formation of new capillary blood vessels from

existing microvessels by sprouting, i.e. cellular outgrowth

Vasculogenesis• The formation of new blood vessels of all types from

blood islands, i.e. committed stem cells, in early embryogenesis

Growth Factor • Polypeptide which acts as a regulator of cellular

function, including proliferation, migration, differentiation, and survival/apoptosis

Angiogenic Growth FactorsAngiogenic Growth Factors

• Basic fibroblast growth factor (bFGF)

• Acidic fibroblast growth factor (aFGF)

• Angiogenin

• Angiotropin

• Insulin-like growth factor

• Interleukin-8

• Platelet activating factor (PAF)

• Basic fibroblast growth factor (bFGF)

• Acidic fibroblast growth factor (aFGF)

• Angiogenin

• Angiotropin

• Insulin-like growth factor

• Interleukin-8

• Platelet activating factor (PAF)

J. Battegay: J. Mol Med; 1995J. Battegay: J. Mol Med; 1995

• Platelet-derived growth factor

(PDGF)

• Proliferin

• Transforming growth factor-

• Tumor necrosis factor-

• Vascular endothelial growth

factor (VEGF)

• Platelet-derived growth factor

(PDGF)

• Proliferin

• Transforming growth factor-

• Tumor necrosis factor-

• Vascular endothelial growth

factor (VEGF)

Basic Fibroblast Growth Factor (bFGF)Basic Fibroblast Growth Factor (bFGF)

• 154 amino acids, MW 18 kD• Additional higher MW forms exist• Post-translational modification may yield a

shorter form• Present in almost all cells• Present from embryogenesis to adult cells• Released from extracellular sites by heparin

and various proteolytic enzymes

• 154 amino acids, MW 18 kD• Additional higher MW forms exist• Post-translational modification may yield a

shorter form• Present in almost all cells• Present from embryogenesis to adult cells• Released from extracellular sites by heparin

and various proteolytic enzymes

bFGF ReceptorsbFGF Receptors• The cell receptor is a transmembrane

tyrosine kinase

• Found on numerous cell types

• Receptor expression upregulated by injury (PTCA & ischemia)

• bFGF Binds to heparin which protects it from degradation

• Seperate binding sites for bFGF receptor and heparin

• The cell receptor is a transmembrane tyrosine kinase

• Found on numerous cell types

• Receptor expression upregulated by injury (PTCA & ischemia)

• bFGF Binds to heparin which protects it from degradation

• Seperate binding sites for bFGF receptor and heparin

Functions of Growth FactorsFunctions of Growth Factors

• Embryogenesis: Stimulates proliferation & differentiation of a variety of cells

• Wound Healing: Stimulates migration and proliferation of connective tissue

• Cytoprotection: CNS, vascular smooth muscle and endothelial cells

• Angiogenesis: Ischemic & Non-Ischemic• Active at 0.1 to 1.0 ng/ml

• Embryogenesis: Stimulates proliferation & differentiation of a variety of cells

• Wound Healing: Stimulates migration and proliferation of connective tissue

• Cytoprotection: CNS, vascular smooth muscle and endothelial cells

• Angiogenesis: Ischemic & Non-Ischemic• Active at 0.1 to 1.0 ng/ml

Augustin-Voss et al.Augustin-Voss et al.

5 15 25 35 45

Control +bFGF

5 15 25 35 45

Control +bFGF

Passage NumberPassage Number

lial C

Bovine Endothelial Cell MigrationBovine Endothelial Cell Migration

Control +bFGF

Augustin-Voss et al.Augustin-Voss et al.

Impact of bFGF on Bovine Endothelial Cell ProliferationImpact of bFGF on Bovine Endothelial Cell Proliferation

Functions of bFGFFunctions of bFGF

Non-ischemic Angiogenesis

• Promotes endothelial cell migration and tube formation

• Stimulates the production of collagenases and plasminogen activator necessary for basement membrane remodeling

Non-ischemic Angiogenesis

• Promotes endothelial cell migration and tube formation

• Stimulates the production of collagenases and plasminogen activator necessary for basement membrane remodeling

M. Klagsbrun: Progress Growth Factor Research; 1989M. Klagsbrun: Progress Growth Factor Research; 1989

Ischemic Angiogenesis

• Endogenous bFGF production in the presence of ischemia

• Impact of exogenous bFGF on ischemic tissues

Ischemic Angiogenesis

• Endogenous bFGF production in the presence of ischemia

• Impact of exogenous bFGF on ischemic tissues

Ischemic AngiogenesisIschemic Angiogenesis

M. Cohen: J Mol Cell Cardiol; 1994M. Cohen: J Mol Cell Cardiol; 1994

Longitudinal Changes in Myocardial Basic Fibroblast Growth Factor (FGF-2) Activity

Following Coronary Artery Ligation in the Dog

Michael V. Cohen et al.

Albert Einstein College of Medicine

Longitudinal Changes in Myocardial Basic Fibroblast Growth Factor (FGF-2) Activity

Following Coronary Artery Ligation in the Dog

Michael V. Cohen et al.

Albert Einstein College of Medicine

Demonstration of Endogenous Tissue Production of bFGF: Canine LAD Occlusion Model

Time Following Canine LAD OcclusionTime Following Canine LAD Occlusion

2 Hours 1 Week 2 Weeks 8 Weeks

Cohen et al: J Mol Cell Cardiol; 1994Cohen et al: J Mol Cell Cardiol; 1994

Endogenous bFGF production assayed in ischemic and adjacent normal cardiac tissue bFGF production rose as early as 2 hours

Production of Growth Factors in Ischemia: Other Indirect Evidence

Fujita et al measured the bFGF levels in the pericardial fluid of patients undergoing open heart surgery for unstable angina (CABG) versus those undergoing surgery for non-ischemic causes

Elevated bFGF levels found in the pericardial fluid of patients with unstable angina

Fujita et al measured the bFGF levels in the pericardial fluid of patients undergoing open heart surgery for unstable angina (CABG) versus those undergoing surgery for non-ischemic causes

Elevated bFGF levels found in the pericardial fluid of patients with unstable angina

M. Fujita et al, Circulation; 1996M. Fujita et al, Circulation; 1996

Baffour et al.• Rabbit model of hind limb ischemia (ligated main

arteries in staged procedure over 2 weeks)• Compared two weeks of IM bFGF to saline• Results:

• bFGF groups had angiographically improved collaterals

• bFGF groups had greater capillary density (per mm and per muscle fiber)

• bFGF groups had greater muscle viability

Baffour et al.• Rabbit model of hind limb ischemia (ligated main

arteries in staged procedure over 2 weeks)• Compared two weeks of IM bFGF to saline• Results:

• bFGF groups had angiographically improved collaterals

• bFGF groups had greater capillary density (per mm and per muscle fiber)

• bFGF groups had greater muscle viability

R. Baffour et al, J Vasc Surg; 1992R. Baffour et al, J Vasc Surg; 1992

Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models

Yang et al

• Rat model of hind limb ischemia

• Compared one to four weeks of continuous intra-

arterial bFGF (1 g/day) to heparinized saline control

• Demonstrated improvement in:

• Collateral blood flow by microspheres

• Capillary density

• Muscle performance by stimulated tension

Yang et al

• Rat model of hind limb ischemia

• Compared one to four weeks of continuous intra-

arterial bFGF (1 g/day) to heparinized saline control

• Demonstrated improvement in:

• Collateral blood flow by microspheres

• Muscle performance by stimulated tension

H. Yang et al, Circ. Res 1996H. Yang et al, Circ. Res 1996

Base 1 Week 2 Weeks 4 Weeks

Control

Base 1 Week 2 Weeks 4 Weeks

Control

Time Following Hind Limb Arterial OcclusionTime Following Hind Limb Arterial Occlusion

g) ** **

H. Yang et al, Circ. Res.; 1996H. Yang et al, Circ. Res.; 1996

Uchida et al

• Occluded canine LAD model

• Compared intrapericardial bFGF, heparin, or both to

saline control (drug given 30 minutes after occlusion)

• Measured:

• Ejection fraction

• Infarct size

Uchida et al

• Occluded canine LAD model

• Compared intrapericardial bFGF, heparin, or both to

saline control (drug given 30 minutes after occlusion)

• Measured:

• Ejection fraction

• Infarct size Y. Uchida et al, Am Heart J; 1995Y. Uchida et al, Am Heart J; 1995

Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models

Base 30 min. 1 month

Saline

Heparin

Hep+bFGF

Base 30 min. 1 month

Saline

Heparin

Hep+bFGF

Time Following Arterial OcclusionTime Following Arterial Occlusion

Y. Uchida: Am Heart J; 1995Y. Uchida: Am Heart J; 1995

Saline Heparin bFGF Hep +bFGF

‡‡

Y. Uchida et al, Am Heart J; 1995Y. Uchida et al, Am Heart J; 1995

Saline Heparin bFGF Hep+bFGF

Noninfarct Zone

Infarct Zone

Saline Heparin bFGF Hep+bFGF

Noninfarct Zone

Infarct Zone

m ‡‡

Y. Uchida et al, Am Heart J; 1995Y. Uchida et al, Am Heart J; 1995

Ameroid constriction of porcine circumflex• Compared intrapericardial bFGF and/or heparin to

saline control

• Measured:

• Angiographic collaterals

• Microsphere blood flow

• MRI Cardiac function

• MRI collateral flow

Ameroid constriction of porcine circumflex• Compared intrapericardial bFGF and/or heparin to

saline control

• Measured:

• Angiographic collaterals

• Microsphere blood flow

• MRI Cardiac function

• MRI collateral flow

M. Simmons, personal communication; 1997M. Simmons, personal communication; 1997

0 Weeks 4 Weeks

Saline

Heparin

bFGF 30

bFGF 200

bFGF 2000

0 Weeks 4 Weeks

Saline

Heparin

bFGF 30

bFGF 200

bFGF 2000

Time Post Drug AdministrationTime Post Drug Administration

Saline Heparin bFGF 30

bFGF200

bFGF2000

Saline Heparin bFGF 30

bFGF200

bFGF2000

Lazarous et al.

• Ameroid constriction of porcine circumflex

• Daily systemic bFGF (4 to 9 weeks) vs saline control

• Measured microsphere determinations of collateral blood flow

Lazarous et al.

• Daily systemic bFGF (4 to 9 weeks) vs saline control

D. Lazarous et al, Circulation; 1995D. Lazarous et al, Circulation; 1995

Lazarous et al. Short Infusion Model

• Shorter duration of systemic bFGF (7 days) or VEGF to saline control

Lazarous et al. Short Infusion Model

• Shorter duration of systemic bFGF (7 days) or VEGF to saline control

D. Lazarous: Circulation; 1996D. Lazarous: Circulation; 1996

Lazarous et al: Data Following 7 Day Infusions

Yanagisawa-Miwa et al.

• Acute occlusion of canine LAD

• Compared two bolus circumflex injections of bFGF vs saline

• Measured:• LV Function• Infarct size• Histologic assessment of collateral growth

Yanagisawa-Miwa et al.

• Acute occlusion of canine LAD

• Compared two bolus circumflex injections of bFGF vs saline

• Measured:• LV Function• Infarct size• Histologic assessment of collateral growth

A. Yanagisawa-Miwa et al, Science; 1992A. Yanagisawa-Miwa et al, Science; 1992

Baseline 30 Min. 1 Week

Saline

Baseline 30 Min. 1 Week

Saline

ion **

A. Yanagisawa-Miwa: Science; 1992A. Yanagisawa-Miwa: Science; 1992

Time post InfarctionTime post Infarction

bFGF Saline

Control bFGF

ControlControl bFGFbFGF

Horrigan et al.

• Four hour balloon occlusion of canine LAD

• Compared two bolus LM injections of bFGF or vehicle

• Measured:

• Infarct size

• Histologic assessment of collateral growth

Horrigan et al.

• Four hour balloon occlusion of canine LAD

• Compared two bolus LM injections of bFGF or vehicle

• Measured:

• Infarct size

• Histologic assessment of collateral growth

M. Horrigan et al, Circulation; 1996M. Horrigan et al, Circulation; 1996

Vehicle bFGF

M. Horrigan et al, Circulation; 1996M. Horrigan et al, Circulation; 1996

Chiron StudyChiron Study

Multi-Center, Single-Blind, Dose

Escalation, Safety and Tolerability Study

of Recombinant Fibroblast Growth

Factor-2 (rFGF-2) in Subjects with

Advanced Coronary Artery Disease

Multi-Center, Single-Blind, Dose

Escalation, Safety and Tolerability Study

of Recombinant Fibroblast Growth

Factor-2 (rFGF-2) in Subjects with

Advanced Coronary Artery Disease

Study ObjectivesStudy Objectives

• Evaluate safety, tolerability and

pharmacokinetics of short-term (20 min)

intracoronary (IC) and intravenous (IV) single

infusions of ascending doses of rFGF-2

• Determine maximum tolerated IC and IV doses

• Measure preliminary efficacy data using

nuclear stress imaging and cardiac MRI

• Evaluate safety, tolerability and

pharmacokinetics of short-term (20 min)

intracoronary (IC) and intravenous (IV) single

infusions of ascending doses of rFGF-2

• Determine maximum tolerated IC and IV doses

• Measure preliminary efficacy data using

nuclear stress imaging and cardiac MRI

• Study Agent• Recombinant protein produced in yeast• Differs from native human bFGF by only two amino

acids• Essentially identical angiogenic properties

• Enrollment• Screening physical exam and labs• Exercise or dipyridamole stress test with dual isotope

imaging• Cardiac MRI with cardiac function and collateral flow

determinations• Ophthalmologic exam• Quality of Life questionnaire

• Study Agent• Recombinant protein produced in yeast• Differs from native human bFGF by only two amino

acids• Essentially identical angiogenic properties

• Enrollment• Screening physical exam and labs• Exercise or dipyridamole stress test with dual isotope

imaging• Cardiac MRI with cardiac function and collateral flow

determinations• Ophthalmologic exam• Quality of Life questionnaire

Study DesignStudy Design

Inclusion CriteriaInclusion Criteria

• Severe CAD with inducible ischemia on stress test

• No optimal revascularization option

• Normal routine laboratory screening

• Willingness and ability to complete all components of the study and its follow-up

• Signed informed consent

• Severe CAD with inducible ischemia on stress test

• No optimal revascularization option

• Normal routine laboratory screening

• Willingness and ability to complete all components of the study and its follow-up

• Signed informed consent

• Class IV CHF or EF < 20%

• MI < 3 months

• New or unstable angina < 3 wks

• CABG < 6 months

• PTCA or TMR < 6 months

• Significant arrhythmias

• Pacemaker or AICD

• LBBB

• Class IV CHF or EF < 20%

• MI < 3 months

• New or unstable angina < 3 wks

• CABG < 6 months

• PTCA or TMR < 6 months

• Significant arrhythmias

• Pacemaker or AICD

• LBBB

• Severe valvular heart disease

• Restrictive or hypertrophic cardiomyopathy

• Known AVMs• TIA or CVA < 6 mths• DM with end-organ

damage• Cr Cl < 80 ml/min or

proteinuria• Cancer within 10 years

• Severe valvular heart disease

• Restrictive or hypertrophic cardiomyopathy

• Known AVMs• TIA or CVA < 6 mths• DM with end-organ

damage• Cr Cl < 80 ml/min or

proteinuria• Cancer within 10 years

Exclusion CriteriaExclusion Criteria

Drug AdministrationDrug Administration

• Intracoronary Infusion• Left and Right heart catheterizations• 10 minute infusions of bFGF into the RCA and

LM (or the major supplying bypass graft)• Intravenous Infusion

• Left heart catheterization (if not done within 6 mths)

• 10 minute infusion into a peripheral vein

• Intracoronary Infusion• Left and Right heart catheterizations• 10 minute infusions of bFGF into the RCA and

LM (or the major supplying bypass graft)• Intravenous Infusion

• Left heart catheterization (if not done within 6 mths)

• 10 minute infusion into a peripheral vein

Follow-Up ProtocolFollow-Up Protocol

• Clinic visits with routine blood tests at day 6,

day 14 and at 1, 2, 6 and 12 months

• Repeat stress test and MRI scans at 1 month

• Subsequent exams only if indicated

• Repeat Eye exams at 2 and 12 months

• Repeat Quality of Life questionnaire at 2

months

• Clinic visits with routine blood tests at day 6,

day 14 and at 1, 2, 6 and 12 months

• Repeat stress test and MRI scans at 1 month

• Subsequent exams only if indicated

• Repeat Eye exams at 2 and 12 months

• Repeat Quality of Life questionnaire at 2

months

current concepts in therapeutic angiogenesis c. michael gibson m.s., m.d

growth factorinterleukin

endothelial cellsangiogenesis

new cases of angina

coronary artery ligation

exogenous bfgf

impact of bfgf

proliferation differentiation

coronary angiograms

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