Introduction to cardiac

Marianna Fontana Professor of National Amyloidosis Centre, Royal Free London NHS Foundation Trust and Division of , UCL, London

• Abnormal extracellular fibrillar protein deposit in tissues

• Pathognomonic green birefringence after Congo red staining

• > 30 different amyloid fibril proteins

Merlini G. Am Soc Hematol Educ Program 2017;1:1–12 Sipe et al. Amyloid 2014;21:221–4 Amyloidosis

• Disease caused by amyloid deposits: localised or systemic

• Systemic amyloidosis is usually fatal

• Causes about 1 per 2000 deaths in the UK

• Diagnosis & treatment are difficult

• Major recent advances & better outcomes

• Still a major unmet medical need

Pinney JH et al, Br J Haematol 2013;161:525-532 Cardiac amyloid fibrils

AL Monoclonal Ig Light chains due to plasma cell dyscrasia (MGUS) • Plasma cell dyscrasia usually subtle (i.e., not overt myeloma) • AL often diagnosed late

ATTR • Wild-type (normal) (TTR) • Hereditary (mutated) transthyretin (TTR)

Grogan et al. 2017;103:1065–72; Donnelly & Hanna. Cleve Clin J Med 2017;84:12–26 Systemic AL amyloidosis

Amyloidosis

AL AA Fibrinogen Transthyretin Apo AI-A2 Lysozyme Gelsolin LECT2

Liver Nerves Kidneys Nerves Kidneys Any organ Kidneys Kidneys Kidneys Heart Liver Kidneys Liver Gut

Heterogeneity of systemic AL amyloidosis

AA, amyloid A; Apo, apolipoprotein; LECT2, leukocyte chemotactic factor 2 Images provided by presenter Sipe et al. Amyloid 2016;23:209–13 Wild-type transthyretin (ATTR) amyloidosis

• Amyloid fibril protein is ‘normal’ (non-mutated) transthyretin (TTR)

• Wild-type ATTR amyloidosis (ATTRwt) is a • Increasingly recognised cause of in elderly (94% males, over 50s) • Carpal tunnel syndrome is common (>50%) • Cardiac ATTR amyloid deposits are present in ~25% males over 80 yrs of age • Majority not diagnosed with amyloidosis in life

Lane T, et al. Circulation 2019;140(1):16–26 Hereditary ATTR amyloidosis

Amyloid fibril protein is variant transthyretin (TTR)

Spectrum of hereditary ATTR amyloidosis – Dominantly inherited – More than 130 amyloidogenic mutations of TTR – Variable phenotype, including: peripheral & autonomic neuropathy Mixed Phenotype amyloid cardiomyopathy vitreous amyloid leptomeningeal disease

V30M-associated ATTR amyloidosis most prevalent worldwide – Mixed in UK T60A-associated ATTR amyloidosis most prevalent in British Caucasians (Irish) – Mixed V122I TTR variant present in ~4% of African-Americans & Afro-Caribbeans – ATTR-CM

Reilly MM et al, J Neurol Neurosurg 1995;55:45-49 Carr AS et al, J Neurol Neurosurg Psychiatry 2016;87:620-627 Gillmore JD et al, New Engl J Med 2015; 372:1769 Diagnostic Delay

100 1 attendance 80 2 attendances 3 attendances 60

40

20 Percentageofpatients 0 ERIPOP ERIPOP ERIPOP Year -3 Year -2 Year -1

Lane T, et al. Circulation 2019;140(1):16–26 DIAGNOSIS OF - RED FLAGS.

TTR Cardiac Amyloidosis AL Cardiac Amyloidosis

• HISTORY • HISTORY – Carpal tunnel syndrome – Macroglossia – Previous pacemaker – Easy bruising implantation – “Panda eyes” – Neuromyological disease – Heart Failure symptoms – Sensorimotor peripheral (predominantly right sided HF neuropathy signs – raised JVP, pleural – Unexplained intense myalgia and effusions, ascites, peripheral burning sensations oedema) – Autonomic dysfunction (erectile – Reduced exercise tolerance dysfunction, diarrhoea alternating with constipation), – Syncope dyshidrosis – Intolerance of standard HF – Vitreous humour opacity treatment e.g. ACEI, ARB, ARNI or BB Staging of AL amyloidosis NT-proBNP (332ng/L) & TnT (35ng/L or hsTnT 55ng/L)

• Survival in AL amyloidosis is variable and dependent on: – Organ dysfunction (cardiac involvement most important prognostic determinant) – FLC response to

Stage 3b: NT-proBNP >8500ng/L

Dispenzieri et al. J Clin Oncol 2004;22:3751–7 Manwani et al. Blood 2017;130 (suppl 1):1816; Manwani et al. presented at UK Myeloma Forum, 9 November 2017 Staging of cardiac ATTR amyloidosis NT-proBNP (3000ng/L) & eGFR (45ml/min)

All cardiac ATTR amyloidosis Wild-type cardiac ATTR amyloidosis 1.00 1.00 0.75 0.75 0.50 0.50 Survival probability Survival Survival probability Survival 0.25 0.25

P<0.0001 for Stage I vs II P<0.0001 for Stage I vs II P<0.0001 for Stage II vs III P=0.0003 for Stage II vs III 0.00 0.00 0 20 40 60 0 20 40 60 Follow up (months) Follow up (months) Number at risk Number at risk Stage I 393 254 117 58 Stage I 234 155 66 34 Stage II 334 181 78 30 Stage II 219 120 55 20 Stage III 142 60 15 8 Stage III 100 43 11 5 Stage I Stage II Stage I Stage II Stage III Stage III

Stage I Stage II P value Stage III P value Harrell’s C Stage I Stage II P value Stage III P value Harrell’s C

Number (Total = 869) 393 (45%) 334 (38%) 142 (16%) Number (Total = 553) 234 (42%) 219 (40%) 100 (18%)

Median survival (months) 69.2 46.7 24.1 Median survival (months) Indeterminable 49.2 32.7

Cox Regression: HR (95% CI) 1 2.05 (1.54-2.72) <0.001 3.80 (2.73-5.28) <0.001 0.69 Cox Regression: HR (95% CI) 1 2.26 (1.51-3.36) <0.001 4.37 (2.80-6.83) <0.001 0.70

Gillmore JD et al, Eur Heart J 2018;39:2799–2806 Reducing the supply of the amyloid fibril precursor protein

AA AA

AL

Gillmore JD et al, Lancet 2001;358:24-29 Lachmann HJ et al, NEJM 2007:356;2361-71 Palladini G et al, JCO 2012;30:4541-4549 Martinez-Naharro A et al, JACC CV Imaging, 2018;11:152-154

Current Treatment approach of AL amyloidosis

dFLC – low Low risk Intermediate risk High riskrisk (Mayo stage 1) (Mayo stage 2 & 3A) + Doxycycline (Mayo stage 3B) if stage ΙΙ-ΙΙΙ +/- Amiodarone dFLC – high risk ASCT in eligible patients (?Low dose) Bortezomib CyBorD or CyBorD /VCD (or BMDex) regimens

Frequent assessment of responseHigh risk dFLC relapse: • At least VGPR at 1-3 months 1. dFLC >20 mg/L, 2. dFLC >20% of baseline value, • if not, then consider change of 3. dFLC increase by >50% of value reached at best response.

At Relapse Palladini et al Blood 2017 • Consider agent or combination not previously used unlessDOI 10.1182/blood-2017-04-780544 prolonged prior response •UK – CTD or oral Melphalan dex – IRD – Dara – Pom-D

Neuropathic patient – no good novel 1st line options in UKib - Oral Cyclo-Dex or Mel-Dex - Carfilzomib (second line)

Kastritis E, et al Br J Haematol 2016;72(2):170-8 Disease-modifying treatment strategies in (ATTR) amyloidosis

Tafamidis Acoramidis (AG10) Diflunisal

Patisiran Inotersen Vutrisiran Time matters in hATTR amyloidosis – Earlier intervention can reduce the burden of disease1,2

Earlier intervention

No intervention

Disease stabilising or slowing treatment3 Disease Disease severity

Disease transforming treatment4.

Time

hATTR, hereditary transthyretin amyloidosis 1.Kristen AV et al. Neurodegener Dis Manag 2019;9:5-23 2. Conceicao I, et al. Amyloid 2019;24:1–9; 3. Coelho T et al. 2012;79:785–92; 4. Adams D et al. N Engl J Med 2018;379:11–21. Figure adapted from: Giovannoni G et al. Mult Scler Relat Disord 2016 ;9 Suppl 1:S5-S48 Tafamidis ‘Cardiac’ Study – ATTR-ACT

(n~160)

(n~80)

(n~160)

Primary endpoint measures • All-cause mortality and frequency of CV-related hospitalizations to Month 30

Other endpoints • 6-min WT, KCCQ

ClinicalTrials.gov: NCT01994889 ATTR-ACT Study Results

Maurer M et al, N Engl J Med 2018;79:1007-1016 Patisiran Phase 3 ‘Neurological’ Study (APOLLO) Design

ClinicalTrials.gov: NCT02510261 APOLLO: Polyneuropathy score was improved from baseline by patisiran treatment1

Progression of polyneuropathy in the placebo arm was consistent with the natural progression of the disease described in previous studies1–3

APOLLO: Change in mNIS+7 from baseline to 18 months (primary endpoint)1

35 28.0 (2.6) 30 25 56% 14.0 (2.1) 20 of patisiran-treated patients experienced a Worse 15 Improved poly- Difference at 18 months 10 neuropathy control (Patisiran – Placebo):Patisiran −34.0±3.0 (change <0 point of mNIS+7 from (p<0.001)Placebo 5 baseline at 18 months) from baseline from 0 compared with

-5 -2.0 (1.5) 4.0% of placebo-treated patients at 18

Better -6.0 (1.7) -10 months1 LS mean (SEM) change in mNIS+7 mNIS+7 in change (SEM) mean LS -15 Baseline 9 months 18 months

LS, least squares; mNIS+7, modified Neuropathy Impairment Score +7; SEM, standard error of mean 1. Adams D et al. N Engl J Med 2018;379:11−21; 2. Koike H et al. Neurol Neurosurg Psychiatry 2012;83:152−8. 3. Berk J et al. JAMA 2013;310:2658−67. APOLLO Study - Cardiac Results

*Cardiac subpopulation (N=126): patients with pre-existing cardiac amyloid involvement without confounding medical conditions (i.e. patients with baseline LV wall thickness ≥ 1.3 cm and no aortic valve disease or hypertension in medical history) **p-values are nominal

Solomon et al, Circulation 2019;139:431–43 Adams D et al, Presented at American Academy of Neurology 2018; April 2018, LA, USA APOLLO: Patisiran halved the composite rate of hospitalizations and deaths in hATTR-CM (post-hoc analysis)

Mean cumulative function: Average number of events per patient by a certain time

Composite Rate of All-Cause Composite Rate of Cardiac Hospitalization and Mortality Hospitalization and All-Cause Mortality

Patisiran Patisiran Placebo Approx. Placebo 50% Approx. reduction in 45% event rate* reduction in event rate†

Post-hoc analysis of hospitalization/death, based on data collected from AE CRFs. Hospitalization/death events caused by SAEs within 28 days of last dose of study drug were included; hospitalization events caused by SAEs within SOC of cardiac disorder were classified as cardiac hospitalization

*For any hospitalization/death analysis: Negative binomial regression rate ratio (RR) 0.49 [0.30, 0.79]; Anderson-Gill hazard ratio (HR) 0.48 [0.34, 0.69]. †For cardiac hospitalization/death analysis: negative binomial RR 0.54 [0.25, 1.16]; Anderson-Gill HR 0.54 [0.28, 1.01], respectively. Median follow-up duration was 18.7 months. AE, adverse event; CRF, case report form; hATTR, hereditary transthyretin amyloidosis; SAE, serious adverse event; SOC, system organ class Solomon SD et al. Circulation 2019;139:431–43. NEURO-TTR: Neurologic disease progression slowed (relative to placebo) and QoL changes stabilized (relative to baseline)

Inotersen Phase 3 ‘Neurological’

NEURO-TTR: mNIS+7 IONIS change from baseline at 66 weeks NEURO-TTR: Norfolk QoL-DN change from baseline at 66 weeks (primary endpoint) (primary endpoint)

36.5% vs 19.2% 50.0% vs 26.9% of inotersen- and placebo-treated of inotersen- and placebo-treated patients, respectively, experienced a patients, respectively, showed QoL improvements or stabilization halting or reversal of disease (change <0 points progression (n=60) (n=60) (change <0 point mNIS+7) Norfolk QOL-DN score) Progression Progression

(n=112)

(n=112)

mNIS+7 mean change from baseline Norfolk QoL-DN mean change from baseline NEURO-TTR (66 weeks): 5.8 points [inotersen] vs 25.5 points [placebo] NEURO-TTR (66 weeks): 1.0 points [inotersen] vs 12.7 points [placebo]

Treatment effect = least-squares mean (±SE) change from baseline at Week 66 (15 months); Composite scores on the mNIS+7 scale range from −22.3 to 346.3 (the higher the score, the poorer the function) mNIS+7, modified Neuropathy Impairment Score +7; Norfolk QOL-DN, Norfolk Quality of Life Questionnaire–Diabetic Neuropathy; QOL, quality of life; SE, standard error Benson MD et al. N Engl J Med 2018;379:22–31. Cardiomyopathy Trials in ATTR amyloidosis

• ATTRibute-CM Trial ATTR-CM (NAC Chair of Steering Committee) Phase 3 trial of acoramidis (AG10) vs placebo NAC leading recruiters globally (n=90, completed recruitment, Oct 2020) CMR sub-study at NAC

• HELIOS-B Trial ATTR-CM (NAC involved in Trial Design) Phase 3 trial of vutrisiran vs placebo NAC leading recruiters globally (n=74 dosed, >70 more in screening)

• APOLLO-B Trial ATTR-CM Phase 3 trial of patisiran vs placebo in ATTR-CM Open to recruitment at NAC (via Richmond Pharmacology)

• ION-682884-CS2 Trial ATTR-CM (q1 2021) Phase 3 trial of ION-682884 vs placebo CMR core lab at NAC

Thanks to Research Nurse Team Neuropathy Trials in ATTR amyloidosis

• HELIOS-A Trial hATTR-PN Phase 3 trial of vutrisiran (2nd Gen) vs patisiran n=6 from NAC (Recruitment closed)

• Post-LT Study hATTR-PN after liver transplant Open label study of patisiran in patients with progression after LT n=1 from NAC (Recruitment closed)

• FIH CRISPR/Cas9 gene editing Trial hATTR-PN (first ever human in vivo ‘gene editing’ therapeutic) CMR sub-study/Core lab at NAC First patient (from NAC) treated on 5th November 2020! – ongoing recruitment

• ION-682884-CS3 Trial hATTR-PN (q1 2021) Phase 3 trial of ION-682884 (2nd Gen) vs inotersen N=140 patients (6:1 randomisation)

Thanks to Research Nurse Team Conclusions

• Cardiac amyloidosis is emerging as an unrecognized cause of heart failure • There are two main types of cardiac amyloidosis, AL and ATTR, with drastically different natural history and prognosis • Early diagnosis is of paramount importance to improve patients prognosis • Several treatment are now available Amyloidosis and Aortic stenosis

Figure 5. Kaplan–Meier plot of cumulative survival comparing aortic stenosis patients (n=146) with transthyretin amyloidosis (ATTR) amyloid on myocardial and those without. At median follow-up of 2.3 years (0.02–4.7), 11 patients with calcific aortic stenosis (cAS) had died, whereas all patients with bicuspid AS were alive. Three of 6 cAS with wild-type ATTR amyloid (50%) died compared with 8 of 106 (7.5%) in the remaining calcific AS cohort. AVR indicates surgical aortic valve replacement. Amyloidosis and HFpEF

120 patients 13% wtATTR Inotersen treatment slowed hATTR PN progression with greater stabilization observed in patients who initiated inotersen earlier (data shown from patients who entered OLE)

60 Placebo-inotersen 30 Placebo-inotersen Inotersen-inotersen Inotersen-inotersen 50 Placebo-slope Placebo-slope 20 40 47% ofOLE placebo-inotersen 42% ofOLE placebo-inotersen Baseline Baseline patients had a <0-point score patients had a <0-point score 30 NEURO-TTRchange from OLE baselinea to NEURO-TTRchange from OLE baselinec to −17.1 week 104 10 week 104 −11.9 SE) ±

SE) ± 20 mNIS+7 -11.3 -21.0 24% of inotersen-inotersen QoL-DN Norfolk 46% of inotersen-inotersen 10 patients had a <0-point score 0 patients had a <0-point score change from NEURO-TTR change from NEURO-TTR 0 baselineb to OLE week 104a baselined to OLE week 104 Change From NEURO-TTR Baseline (mean Baseline NEURO-TTR FromChange Change From NEURO-TTR Baseline (mean Baseline NEURO-TTR FromChange -10 -10

035 66 26 52 78 104 035 66 26 52 78 104

Time From NEURO-TTR or OLE Baseline (weeks) Time From NEURO-TTR or OLE Baseline (weeks)

Placebo-inotersen, n 49 50 49 47 34 22 19 Placebo-inotersen, n 50 50 49 46 38 22 19 Inotersen-inotersen, n 80 79 80 78 70 53 39 Inotersen-inotersen, n 79 78 78 78 76 53 41

mNIS+7, modified Neuropathy Impairment Score +7 neurophysiologic tests composite score; Norfolk QoL-DN, Norfolk Quality of Life–Diabetic Neuropathy questionnaire total score; PN, peripheral neuropathy; QoL, quality of life; SE, standard error. OLE Open Label Extension aAt OLE baseline, mean (SD) mNIS+7 scores were 98.7 (51.1) and 85.8 (41.1) for placebo-inotersen (n = 49) and inotersen-inotersen (n = 80), respectively; bAt NEURO-TTR baseline, mean (SD) mNIS+7 scores were 74.4 (40.1) and 81.8 (38.0) for placebo-inotersen (n = 50) and inotersen-inotersen (n = 81), respectively; cAt OLE baseline, mean (SD) Norfolk QoL-DN scores were 60.1 (32.0) and 48.2 (29.2) for placebo-inotersen (n = 49) and inotersen-inotersen (n = 78), respectively; dAt NEURO-TTR baseline, mean (SD) Norfolk QoL-DN scores were 49.0 (26.9) and 49.3 (27.0) for placebo-inotersen (n = 50) and inotersen-inotersen (n = 80), respectively. The population analysed in these figures includes only the patients who continued on from NEURO-TTR to the OLE study. Brannagan T, et al. Presented at PNS Annual Meeting. Genoa, Italy, June 22-26, 2019 Inotersen Phase 3 ‘Neurological’ Study Design

NEURO-TTR Open-Label Extension 2 Inotersen

Screen Stratification Inotersen 1 Placebo 15 month Randomization treatment (2:1)

• Randomised, placebo-controlled Phase 3 study in 172 hATTR patients with Stage I or II PN • Once weekly SC administration of Inotersen, 300 mg • Stratification: – Stage 1 versus Stage 2 – Val30Met TTR mutation versus non-Val30Met TTR mutation – Previous treatment with either tafamidis or diflunisal versus no known previous treatment

• Two primary endpoints: Norfolk QoL-DN and mNIS+7