Original Article
Effects of Torcetrapib in Patients at High Risk for Coronary Events
N Engl J Med 2007; 357:2109-2122November 22, 2007
- Abstract
Background
Inhibition of cholesteryl ester transfer protein (CETP) has been shown to have a substantial effect on plasma lipoprotein levels. We investigated whether torcetrapib, a potent CETP inhibitor, might reduce major cardiovascular events. The trial was terminated prematurely because of an increased risk of death and cardiac events in patients receiving torcetrapib.
Methods
We conducted a randomized, double-blind study involving 15,067 patients at high cardiovascular risk. The patients received either torcetrapib plus atorvastatin or atorvastatin alone. The primary outcome was the time to the first major cardiovascular event, which was defined as death from coronary heart disease, nonfatal myocardial infarction, stroke, or hospitalization for unstable angina.
Results
At 12 months in patients who received torcetrapib, there was an increase of 72.1% in high-density lipoprotein cholesterol and a decrease of 24.9% in low-density lipoprotein cholesterol, as compared with baseline (P<0.001 for both comparisons), in addition to an increase of 5.4 mm Hg in systolic blood pressure, a decrease in serum potassium, and increases in serum sodium, bicarbonate, and aldosterone (P<0.001 for all comparisons). There was also an increased risk of cardiovascular events (hazard ratio, 1.25; 95% confidence interval [CI], 1.09 to 1.44; P=0.001) and death from any cause (hazard ratio, 1.58; 95% CI, 1.14 to 2.19; P=0.006). Post hoc analyses showed an increased risk of death in patients treated with torcetrapib whose reduction in potassium or increase in bicarbonate was greater than the median change.
Conclusions
Torcetrapib therapy resulted in an increased risk of mortality and morbidity of unknown mechanism. Although there was evidence of an off-target effect of torcetrapib, we cannot rule out adverse effects related to CETP inhibition. (ClinicalTrials.gov number, NCT00134264.)
Media in This Article
Figure 1
Enrollment and Outcomes.Figure 2
Kaplan–Meier Curves for Death from Any Cause and for the Primary Composite Outcome.Article Activity
- Article
Evidence supporting the proposition that high-density lipoprotein (HDL) cholesterol should be considered as a therapeutic target includes experimental models of atherosclerosis,1 an inverse relationship to the risk of cardiovascular disease in humans,2 clinical trials of drugs for which raising HDL cholesterol levels is a primary pharmacologic effect,3 and the residual risk of cardiovascular disease associated with a low HDL cholesterol level after effective statin therapy.4
Cholesteryl ester transfer protein (CETP) promotes the transfer of cholesteryl esters from HDL to other lipoproteins; the inhibition of this protein raises HDL cholesterol levels and decreases low-density lipoprotein (LDL) cholesterol levels. There is evidence supporting CETP inhibition as a therapeutic approach to the prevention of major cardiovascular events, although there is also evidence to the contrary.5-7
Torcetrapib is an inhibitor of CETP that has been shown to inhibit the development of atherosclerosis in rabbits.8 In early-phase studies in humans, the drug increased HDL cholesterol by 60 to 100% at the same time that it lowered LDL cholesterol by up to 20%.9,10 Torcetrapib was subsequently investigated in three large trials with the use of ultrasonography and other imaging techniques and was found to have no significant effect on coronary atheroma burden11 or carotid intima–media thickness.12,13 Concurrent with these imaging studies, the Investigation of Lipid Level Management to Understand its Impact in Atherosclerotic Events (ILLUMINATE) trial tested the proposition that torcetrapib would decrease the risk of clinical cardiovascular events. This trial was terminated prematurely on December 2, 2006, in a decision made by the sponsor on the basis of the recommendation of the trial's independent steering committee, which was acting on advice from the independent data and safety monitoring board.14 This report describes the main results of the ILLUMINATE trial.
Methods
Study Design
We conducted a prospective, randomized, multicenter, double-blind clinical trial, using a centralized randomization strategy with a block size of four. The trial was designed by an independent steering committee in collaboration with the sponsor, Pfizer. Data were collected by PharmaNet Development Group and analyzed independently by the Statistical Data Analysis Center at the University of Wisconsin, Madison; representatives of these organizations vouch for the completeness and veracity of the data and the analyses, respectively. An institutional review board at each center approved the protocol, and patients provided written informed consent. The original protocol was amended on November 28, 2006, a change that had not yet received institutional review board approval at the time of the trial's termination. The amendment included the addition of hospitalization for unstable angina to the primary outcome to increase the number of events and thus increase the statistical power to reject the null hypothesis.
Men and women between the ages of 45 and 75 years were eligible to participate in the study if they had a history of cardiovascular disease (including myocardial infarction, stroke, acute coronary syndrome, unstable angina, peripheral vascular disease, and cardiac revascularization) 30 days to 5 years before screening. Patients with type 2 diabetes without previous cardiovascular disease who met American Diabetes Association criteria or were receiving hypoglycemic agents were also eligible. Patients were excluded if they had evidence of an unstable medical condition, a life expectancy of less than 5 years, or an LDL cholesterol level of less than 100 mg per deciliter (2.6 mmol per liter) if the patient was not receiving a lipid-altering drug. Patients were also excluded if they had had a cardiovascular event during the run-in period or uncontrolled hypertension (defined as a systolic blood pressure of >140 mm Hg or a diastolic blood pressure of >90 mm Hg) or if the LDL cholesterol target level had not been reached at the end of the run-in period.
During a run-in period of 4 to 10 weeks, patients underwent lifestyle counseling and also received atorvastatin titrated (if needed) at 2-week intervals to achieve an LDL cholesterol level of less than 100 mg per deciliter. A variability tolerance of +15 mg per deciliter (0.4 mmol per liter) was allowed. Patients whose LDL level met the target were randomly assigned to receive either atorvastatin (at a dose established during the run-in period) plus 60 mg of torcetrapib or atorvastatin plus placebo. After termination of the trial, the sponsor maintained support for independent oversight during the trial's closeout (which involved four of the academic authors) with continuing support from the Statistical Data Analysis Center, which performed the primary statistical analyses.
Study Outcomes
Patients' visits were scheduled at 1, 3, 6, 9, and 12 months after randomization. Thereafter, patients were to be seen twice yearly. An increase or decrease in the dose of atorvastatin was allowed at the 12-month visit on the basis of predefined LDL cholesterol levels. The level of HDL cholesterol was determined through enzyme analysis with the use of polyethylene glycol–modified cholesterol esterase, cholesterol oxidase, and dextran sulfate to generate peroxide that was measured calorimetrically. Total cholesterol and triglyceride levels were determined by standard enzymatic techniques. LDL cholesterol was quantified by the Friedewald formula, except when the triglyceride level was more than 400 mg per deciliter (4.5 mmol per liter), in which case the level was measured by direct beta quantification. Apolipoproteins A-I and B-100 were measured by means of immunoturbidimetric assay. High-sensitivity C-reactive protein (CRP) was measured with the use of a particle-enhanced immunoturbidimetric assay. All measurements were performed at a central laboratory (MDS). Blood pressure was measured in triplicate at each visit with the use of a standard calibrated measuring device with the patient seated after 5 minutes of rest. The first reading was not used, and the latter two readings were averaged for the visit measurement. The estimated glomerular filtration rate was calculated as described previously.15
The QT interval was calculated with the use of Bazett's correction. A decision to measure aldosterone was made after termination of the trial after investigators observed a pattern of change in serum electrolytes and blood pressure. Stored serum samples that had been obtained from patients at baseline and at 3 months were used, with measurements made by means of liquid chromatography–tandem mass spectrometry (Mayo Central Laboratory for Clinic Trials).
Efficacy Measures
The primary outcome was the time to the first occurrence of a major cardiovascular event, a composite that included four components: death from coronary heart disease (defined as fatal myocardial infarction excluding procedure-related events, fatal heart failure, sudden cardiac death, or other cardiac death), nonfatal myocardial infarction (excluding procedure-related events), stroke, and hospitalization for unstable angina.
Secondary outcomes were the time to the first occurrence of each individual component of the primary outcome, the time to death from any cause, and the change from baseline in LDL and HDL cholesterol levels. Tertiary outcomes included further breakdowns in categories and composites of secondary outcomes.
Members of a central committee who were unaware of study-group assignments adjudicated potential outcomes as reported by the investigators. Adjudicated outcomes are not included in totals of adverse events and serious adverse events.
Statistical Analysis
The original design assumed a sample size of 13,000 patients (6500 per treatment group) to yield 551 primary outcomes in the atorvastatin-only group (8.48%) and 433 in the group receiving both atorvastatin and torcetrapib (6.66%) after an average of 4.5 years of follow-up — in other words, an absolute reduction of 1.82 percentage points or a relative reduction of 21% in the cumulative incidence. This number of patients would provide a statistical power of 90% to detect a treatment difference in the primary efficacy analysis at the two-sided level of 0.05 with the use of a log-rank test. A total of 15,067 patients underwent randomization, with overenrollment owing to an increase in screening activity after notification of an upcoming closure in enrollment at each site. On the basis of the modified primary outcome in the amended protocol and on the increased number of patients, the number of primary outcomes at an average follow-up of 4.5 years was expected to be 1820.
The prespecified safety-monitoring boundary (a P value <0.01, unadjusted for multiple comparisons) was based on a log-rank test for death from any cause. An efficacy-monitoring boundary (to be implemented after approximately 50% of the expected number of events had occurred in the primary outcome) was prespecified, but the requisite event count was never reached.
All treatment comparisons were performed with the use of an intention-to-treat analysis. All data were censored for the primary analyses on December 2, 2006, when the trial was terminated. Events occurring after that date, in the period between termination of the study and the end of data collection, are also reported. These events were captured either at a final visit after the discontinuation of a study drug (active surveillance) or as a result of instructions to patients to report serious adverse events (passive surveillance). The last adjudicated outcome reported during this observation period occurred on July 15, 2007.
P values for continuous and ordered categorical data were computed with the use of a nonparametric Wilcoxon test. Pearson's chi-square test (without continuity correction) was used for dichotomous and unordered categorical data. The log-rank test was used for time-to-event analyses. Post hoc exploratory analyses were also performed; only descriptive statistics were used to identify patterns of association, since these analyses were not inferential in nature. No adjustments have been made for multiple comparisons.
Results
Patients
Between August 23, 2004, and December 28, 2005, a total of 15,067 patients underwent randomization at 260 centers in seven countries. Of these patients, 7534 were assigned to receive atorvastatin plus placebo (atorvastatin-only group), and 7533 were assigned to receive torcetrapib plus atorvastatin (torcetrapib group) (Figure 1Figure 1
Enrollment and Outcomes.). At the end of the study on December 2, 2006, the median follow-up in each group was 550 days. Earlier discontinuation of treatment had occurred in 831 patients in the atorvastatin-only group (11.0%) and in 1008 patients in the torcetrapib group (13.4%). Higher rates of discontinuation owing to nonfatal adverse events in the torcetrapib group were associated mainly with a higher frequency of hypertension, nonspecific gastrointestinal symptoms, and headache. Follow-up was 99.7% complete, with 20 patients in the atorvastatin-only group and 19 patients in the torcetrapib group who were not followed until December 2, 2006. Baseline demographic and clinical characteristics of the two groups are presented in Table 1Table 1
Demographic and Clinical Characteristics of the Patients.. Patients with a history of diabetes but no evidence of cardiovascular disease at study entry represented 18.8% of the atorvastatin-only group and 17.9% of the torcetrapib group (data not shown).Baseline and Follow-up Laboratory and Clinical Assessments
Changes in lipids were evident within the first month after randomization (Fig. 1 of the Supplementary Appendix, available with the full text of this article at www.nejm.org). At 1 year, there were significant differences (P<0.001) between the torcetrapib group and the atorvastatin-only group. In the atorvastatin-only group, all lipid changes were minimal during the study; in the torcetrapib group, these changes included an increase of 72.1% in the HDL cholesterol, a decrease of 24.9% in LDL cholesterol, and a decrease of 9% in triglycerides (Table 2Table 2
Changes from Baseline at 3 Months and 12 Months in Selected Measures.). Apolipoprotein measurements at 3 months reflected the changes in lipids. The mean increase in systolic blood pressure from baseline to month 12 was 5.4 mm Hg in the torcetrapib group, as compared with 0.9 mm Hg in the atorvastatin-only group (P<0.001). The change in high-sensitivity C-reactive protein from baseline to month 3 differed significantly between the two groups (P=0.01), but the magnitude of the difference (0.04 mg per liter) was small.Electrolyte levels were similar in the two groups at baseline (Table 1). At 12 months, there was a mean decrease in potassium of 0.08 mmol per liter in the torcetrapib group, as compared with an increase of 0.06 mmol per liter in the atorvastatin-only group (P<0.001). After 12 months, 2.3% of patients in the torcetrapib group and 0.6% of patients in the atorvastatin-only group had potassium levels of less than 3.5 mmol per liter (P<0.001). In the torcetrapib group, as compared with the atorvastatin-only group, there were greater increases in levels of sodium (1.39 mmol per liter and 0.78 mmol per liter, respectively) and bicarbonate (2.28 mmol per liter and 1.93 mmol per liter, respectively; P<0.001).
At 12 months, the estimated glomerular filtration rate increased by 0.8 ml per minute per 1.73 m2 of body-surface area in the torcetrapib group but decreased by 0.3 ml per minute per 1.73 m2 in the atorvastatin-only group (P<0.001). The median change from baseline to month 12 in the QT interval was an increase of 3.3 msec in the torcetrapib group and a decrease of 0.3 msec in the atorvastatin-only group (P<0.001).
Post hoc measurements of aldosterone were performed for all patients for whom stored samples from both baseline and 3 months were available. One percent of samples submitted to the laboratory were of insufficient volume to permit analysis. Analysis was performed on baseline samples obtained from 6745 patients in the atorvastatin-only group (90.0%) and 6662 patients in the torcetrapib group (88.5%) and on samples obtained at 3 months for 6664 patients (88.4%) and 6562 patients (87.1%), respectively. Most analyzed samples (56.5% in the atorvastatin-only group and 52.7% in the torcetrapib group) had aldosterone levels below the lower limit of quantification for the test used (<4 ng per deciliter for samples with sufficient volume for undiluted testing and <8 ng per deciliter for samples with insufficient volume requiring dilution). Because of this, a direct comparison of median or mean values was not possible with these data. However, it was possible to calculate values in the 85th percentile and above, since this calculation depended only on the values of 8 ng per deciliter or more for which data were complete. At baseline, the 85th, 90th, and 95th percentiles were 8.5, 10.0, and 13.0 ng per deciliter, respectively, in the atorvastatin-only group and 8.3, 10.0, and 13.0 ng per deciliter, respectively, in the torcetrapib group (P=0.21). At 3 months, these percentiles were 8.6, 10.0, and 13.0 ng per deciliter in the atorvastatin-only group and 9.5, 11.0, and 14.0 ng per deciliter in the torcetrapib group (P<0.001). (The P values are Wilcoxon comparisons performed after truncating the data below 8 ng per deciliter.)
Study Outcomes
Figures 2A and 2BFigure 2
Kaplan–Meier Curves for Death from Any Cause and for the Primary Composite Outcome. show Kaplan–Meier curves for death from any cause and the primary composite outcome. The hazard ratio for the primary outcome — major cardiovascular events — was 1.25 in the torcetrapib group, as compared with the atorvastatin-only group (95% confidence interval [CI], 1.09 to 1.44; P=0.001) (Table 3Table 3
Estimated Hazard Ratios for Protocol-Specified Cardiovascular Outcomes.). The hazard ratio estimates for the individual components of the composite outcome ranged from 1.35 for hospitalization for unstable angina (P=0.001) to 1.08 for stroke (P=0.74).At study termination, there were 93 deaths in the torcetrapib group and 59 in the atorvastatin-only group, for a hazard ratio of 1.58 in the torcetrapib group (95% CI, 1.14 to 2.19; P=0.006). The adjudicated causes of death are shown in Table 4Table 4
Causes of Death.. There was no significant interaction between study-group assignment and cause of death (P=0.18). In the torcetrapib group, as compared with the atorvastatin-only group, there was an increased risk of death from both cardiovascular causes (49 vs. 35) and noncardiovascular causes (40 vs. 20). No single cause of death explained the increased cardiovascular risks. For death from noncardiovascular causes, more patients in the torcetrapib group than in the atorvastatin-only group died from cancer (24 vs. 14) and infection (9 vs. 0). The primary sites of fatal cancers were similar in the two groups (Table 1 of the Supplementary Appendix). Seven of the nine deaths from infection were in patients with diabetes.Numbers of reported major cardiovascular events and deaths occurring after the termination of the trial were similar in the two groups: 38 major cardiovascular events in each group, with 14 deaths in the torcetrapib group and 20 deaths in the atorvastatin-only group.
Adverse Events
Adverse events were reported in 86.6% of patients in the torcetrapib group and in 83.3% of patients in the atorvastatin-only group (P<0.001). Among events that were significantly more frequent in the torcetrapib group than in the atorvastatin-only group were reported hypertension, which occurred in 1411 patients (18.7%) and 564 patients (7.5%, P<0.001), respectively; peripheral edema, in 467 (6.2%) and 353 (4.7%, P<0.001); angina pectoris, in 451 (6.0%) and 360 (4.8%, P=0.001); dyspnea, in 313 (4.2%) and 243 (3.2%, P=0.003); and headache, in 412 (5.5%) and 296 (3.9%, P<0.001). Serious adverse events were reported more frequently in the torcetrapib group than in the atorvastatin-only group (16.4% vs. 15.0%, P=0.02) (Table 2 of the Supplementary Appendix). Reported neoplasms (128 in the torcetrapib group and 136 in the atorvastatin-only group) and infections or infestations (182 and 177) were reported with similar frequencies in the two groups.
Post Hoc Exploratory Analyses
Post-randomization changes in selected measurements in the torcetrapib group were examined for their relationship to major cardiovascular events and death from any cause and from coronary heart disease (Table 5Table 5
Relationship between Changes from Baseline to 1 Month in Key Measurements and Death from Any Cause or from Coronary Heart Disease and the Primary Outcome among 7533 Patients Who Received Torcetrapib.). The numbers and rates for these outcomes are given for subgroups whose change in the indicated measure from baseline to month 1 (or to month 3 for apolipoprotein A-I) was at or below the study-group median, as compared with above the median. The earliest time points were chosen to capture the maximum amount of information available before death. For death from any cause, higher rates were observed in association with greater decreases in potassium and greater increases in bicarbonate. For major cardiovascular events, lower rates were apparent in those with greater increases in HDL cholesterol and apolipoprotein A-I and for those who had smaller decreases in potassium and increases in bicarbonate. Paradoxically, there was an increased risk of death and major cardiovascular events in patients whose increase in systolic blood pressure was less than the median. It should be emphasized that the results shown in Table 5 were both exploratory and post hoc.Discussion
The increased mortality associated with the use of torcetrapib included increased risks of death from both cardiovascular and noncardiovascular causes. There was also a significant increase in the risk of major cardiovascular events in the torcetrapib-treated group. The question arises: By what mechanism did torcetrapib cause harm?
Clinical trials such as ours are not designed to elucidate mechanisms of either benefit or harm associated with the use of a drug. However, they may provide clues that have the potential to inform future research. To this end, we conducted a series of exploratory post hoc analyses in an attempt to gain some insight into what might have occurred.
There are at least two possible explanations for the observation of increased mortality and morbidity associated with the use of torcetrapib in our study: an off-target effect of torcetrapib, unrelated to CETP inhibition, and an adverse effect of CETP inhibition per se, with the possible generation of dysfunctional or even proatherogenic HDL cholesterol.
A known off-target effect of torcetrapib is an increase in blood pressure. At 12 months in our study, systolic blood pressure increased by a mean of 5.4 mm Hg in the torcetrapib group from baseline, a greater effect than had been observed in earlier studies of shorter duration9,10 but consistent with the longer phase 3 imaging trials.11,13 The relationship between changes in blood pressure and clinical outcome in the torcetrapib group was counterintuitive, with an apparent increased risk of death in patients whose increase in systolic blood pressure was less than the median. However, it appeared that an increase in blood pressure above the median identified a group with lower baseline blood pressure levels, making it difficult to interpret the relationship without further analysis. The observed reduction in potassium and increases in sodium and bicarbonate in the torcetrapib group, as compared with the atorvastatin-only group, raised the possibility that the increase in blood pressure may have been a manifestation of mineralocorticoid excess. This proposition gained further support from post hoc findings of an increase in aldosterone levels in the torcetrapib group. The mechanism by which torcetrapib may have increased aldosterone levels is unknown.
Although cardiovascular events caused by a torcetrapib-induced increase in aldosterone is one possible explanation for the observed adverse outcomes, it does not rule out other unknown off-target effects of the agent. Nor does it rule out the possibility that CETP inhibition per se may have adverse effects. It has been suggested that the inhibition of CETP may generate HDL particles that are nonfunctional or even proatherogenic.16 Our study does not address the issue of how torcetrapib has a functional effect on HDL particles, although it was interesting to note that in the torcetrapib group, rates of cardiovascular events and death from coronary heart disease were lower in those whose increase in HDL cholesterol or apolipoprotein A-I was greater than the median. However, it must be emphasized that these post hoc observations are merely suggestive and do not rule out HDL dysfunctionality, nor do they rule out the possibility that other unknown effects of CETP inhibition may have contributed to a mechanism-related adverse outcome.
In conclusion, our study neither validates nor invalidates the hypothesis that raising levels of HDL cholesterol by the inhibition of CETP may be cardioprotective. Thus, the possibility that the inhibition of CETP may be beneficial will remain hypothetical until it is put to the test in a trial with a CETP inhibitor that does not share the off-target pharmacologic effects of torcetrapib.
Supported by Pfizer.
Dr. Barter reports receiving consulting fees from Abbott, AstraZeneca, CSL, Genfit, LifeCycle Pharma, Merck, Pfizer, and Resverlogix, lecture fees from Abbott, AstraZeneca, Merck, Pfizer, and Sanofi–Aventis, and grant support from Pfizer; Dr. Caulfield, consulting fees from Novartis and Pfizer, lecture fees from Novartis, Servier, and Pfizer, and grant support from Pfizer and Novartis; Dr. Eriksson, consulting fees from AstraZeneca, Abbott, Sanofi–Aventis, and Pfizer, lecture fees from Merck Sharp & Dohme, and grant support from AstraZeneca and Merck–Schering-Plough, and having equity interests in KaroBio and Biophausia; Dr. Grundy, consulting fees from Merck, Merck–Schering-Plough, AstraZeneca, and Pfizer, and grant support from Merck and Abbott; Dr. Kastelein, consulting fees from Pfizer, AstraZeneca, Merck, and Merck–Schering-Plough, lecture fees from Pfizer, AstraZeneca, and Merck–Schering-Plough, and grant support from Pfizer and AstraZeneca; Dr. Komajda, consulting fees from Pfizer and Servier and lecture fees from AstraZeneca, Sanofi Synthelabo, and Bristol-Myers Squibb; Dr. Lopez-Sendon, consulting fees from Pfizer, Servier, CV Therapeutics, and Lilly, lecture fees from Pfizer, Servier, and Lilly, and grant support from Pfizer, Servier, Lilly, Bristol-Myers Squibb, and Bayer; Dr. Mosca, consulting fees and grant support from Pfizer; Dr. Tardif, consulting fees and grant support from Pfizer and lecture fees from Pfizer and AstraZeneca; Dr. Waters, consulting fees from Pfizer and Merck–Schering-Plough and lecture fees from Pfizer; Drs. Shear and Revkin, being employees of Pfizer and holding equity or other ownership interest in the company; Dr. Fisher, consulting fees from Boehringer Ingelheim, Genentech, GlaxoSmithKline, and Novartis and grant support from Pfizer, GlaxoSmithKline, and Novartis; Dr. Buhr, grant support from Pfizer; Dr. Tall, consulting fees from AstraZeneca, Pfizer, Merck and Roche, lecture fees from Merck, and grant support from Merck and Pfizer; and Dr. Brewer, consulting and lecture fees from Pfizer, Merck, and Roche. No other conflict of interest relevant to this article was reported.
This article (10.1056/NEJMoa0706628) was published at www.nejm.org on November 5, 2007.
We thank Pfizer representatives Diane T. Hessinger, William C. Ports, Lynne M. Dugan, Allison G. O'Reilly, William T. Duggan, Robert Burnside, Darlene Ambrose, and Andrea J. Maynard for their efforts in the conduct of this study; and Thomas D. Cook and Michelle A. Detry of the Department of Biostatistics and Medical Informatics at the University of Wisconsin, Madison.
Source Information
From the Heart Research Institute, Sydney (P.J.B.); St. Bartholomew's Hospital, London (M.C.); Karolinska University Hospital, Huddinge, Stockholm (M.E.); University of Texas Southwestern Medical Center, Dallas (S.M.G.); Academic Medical Center, University of Amsterdam, Amsterdam (J.J.P.K.); University Pierre et Marie Curie and Hôpital Pitié–Salpêtrière, Paris (M.K.); Hospital Universitario La Paz, Madrid (J.L.-S.); Columbia University, New York (L.M.); Montreal Heart Institute, Montreal (J.-C.T.); San Francisco General Hospital, San Francisco (D.D.W.); Pfizer, New London, CT (C.L.S., J.H.R.); University of Wisconsin, Madison (K.A.B., M.R.F.); Columbia University Medical Center, New York (A.R.T.); and Medstar Institute, Washington, DC (B.B.).
Address reprint requests to Dr. Barter at the Heart Research Institute, 145 Missenden Rd., Camperdown, Sydney, NSW 2050, Australia, or at barterp@hri.org.au.
Members of the committees of the Investigation of Lipid Level Management to Understand its Impact in Atherosclerotic Events (ILLUMINATE) trial are listed in the Appendix. All investigators are listed in the Supplementary Appendix, available with the full text of this article at www.nejm.org.
Appendix
Committee members of the ILLUMINATE trial are as follows: Steering Committee — P.J. Barter, Heart Research Institute, Sydney (chair); M. Caulfield, the Royal London School of Medicine, London; M. Eriksson, Karolinska University Hospital, Huddinge, Stockholm; S. Grundy, University of Texas Southwestern Medical Center, Dallas; J. Kastelein, Academic Medical Center, Amsterdam; M. Komajda, University Pierre et Marie Curie, Paris; J. Lopez-Sendon, Hospital Universitario La Paz, Madrid; L. Mosca, Columbia University, New York; J.-C. Tardif, Montreal Heart Institute, Montreal; D. Waters, San Francisco General Hospital, San Francisco. Clinical Outcome Adjudication Committee — B. O'Neil, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (chair); C. O'Connor, Duke University Medical Center, Durham, NC; U. Sechtem, Robert Bosch Krankenhaus, Stuttgart, Germany; J.-M. LaBlanche, Hôpital Cardiologique, Lille, France; F. Welty, Beth Israel Deaconess Medical Center, Boston; J.D. Easton, Brown University, Providence, RI; M.M. Brown, University College, London; I.E. Silverman, the Stroke Center at Hartford Hospital, Hartford, CT.
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Citing Articles
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Harumi Kondo, Makoto Ayaori, Katsunori Ikewaki. 2012. Is Coffee the Next Red Wine? Coffee Polyphenol and Cholesterol Efflux. , 227-231.
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Robert Rosenson, John Horowitz, Juan-Carlos Kaski, Henry Krum, Willem Remme. (2012) Clinical Trials Update Esc Congress 2011. Cardiovascular Drugs and Therapy
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Hideaki Kaneda, Mitsuyasu Terashima, Hiroshi Yamaguchi. (2012) The Role of Intravascular Ultrasound in the Determination of Progression and Regression of Coronary Artery Disease. Current Atherosclerosis Reports
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Raul C. Maranhão, Fatima R. Freitas, Célia M. Strunz, Raul D. Santos, Alfredo J. Mansur, Antônio P. Mansur. (2012) Lipid transfers to HDL are predictors of precocious clinical coronary heart disease. Clinica Chimica Acta 413:3-4, 502-505
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Gregory G. Schwartz. (2012) New Horizons for Cholesterol Ester Transfer Protein Inhibitors. Current Atherosclerosis Reports 14:1, 41-48
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Uchechukwu K. Sampson, Sergio Fazio, MacRae F. Linton. (2012) Residual Cardiovascular Risk Despite Optimal LDL Cholesterol Reduction with Statins: The Evidence, Etiology, and Therapeutic Challenges. Current Atherosclerosis Reports 14:1, 1-10
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Rachel Golan, Amir Tirosh, Dan Schwarzfuchs, Ilana Harman-Boehm, Joachim Thiery, Georg Martin Fiedler, Matthias Blüher, Michael Stumvoll, Iris Shai. (2012) Dietary intervention induces flow of changes within biomarkers of lipids, inflammation, liver enzymes, and glycemic control. Nutrition 28:2, 131-137
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Michael-Friedrich Boettcher, Roland Heinig, Carsten Schmeck, Christian Kohlsdorfer, Matthias Ludwig, Anja Schaefer, Sabine Gelfert-Peukert, Georg Wensing, Olaf Weber. (2012) Single dose pharmacokinetics, pharmacodynamics, tolerability and safety of BAY 60-5521, a potent inhibitor of cholesteryl ester transfer protein. British Journal of Clinical Pharmacology 73:2, 210-218
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Olaf Weber, Stefan Willmann, Hilmar Bischoff, Volkhart Li, Alexandros Vakalopoulos, Klemens Lustig, Frank-Thorsten Hafner, Roland Heinig, Carsten Schmeck, Klaus Buehner. (2012) Prediction of a potentially effective dose in humans for BAY 60-5521, a potent inhibitor of cholesteryl ester transfer protein (CETP) by allometric species scaling and combined pharmacodynamic and physiologically-based pharmacokinetic modelling. British Journal of Clinical Pharmacology 73:2, 219-231
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Valerie Cheung, Robert A. Hegele. (2012) CETP Inhibitors: Will They Live up to Their Promise?. Current Cardiovascular Risk Reports 6:1, 4-11
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Denise E. Bonds. (2012) Targeting High-Density Lipoprotein and Triglycerides in Statin-Treated Patients with Diabetes. Current Cardiovascular Risk Reports 6:1, 102-107
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B. Maisch. (2012) Kardiologische Rehabilitation – mehr als nur für den Schrebergarten?. Herz
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J.R. Schaefer. (2012) HDL-Spiegel oder HDL-Funktion als primäres Target der präventiven Kardiologie. Herz
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Kevin A. Buhr. (2012) Surrogate End Points in Secondary Analyses of Cardiovascular Trials. Progress in Cardiovascular Diseases 54:4, 343-350
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Anthula E. Kavo, Loukianos S. Rallidis, George C. Sakellaropoulos, Stefan Lehr, Sonja Hartwig, Juergen Eckel, Polyxeni I. Bozatzi, Maria Anastasiou-Nana, Panagiota Tsikrika, Kyriakos E. Kypreos. (2012) Qualitative characteristics of HDL in young patients of an acute myocardial infarction. Atherosclerosis 220:1, 257-264
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Rishi Puri, MyNgan Duong, Kiyoko Uno, Yu Kataoka, Stephen J Nicholls. (2012) The emerging role of plasma lipidomics in cardiovascular drug discovery. Expert Opinion on Drug Discovery 7:1, 63-72
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A. F. H. Stalenhoef, M. H. Davidson, J. G. Robinson, T. Burgess, R. Duttlinger-Maddux, D. Kallend, A. C. Goldberg, H. Bays. (2012) Efficacy and safety of dalcetrapib in type 2 diabetes mellitus and/or metabolic syndrome patients, at high cardiovascular disease risk. Diabetes, Obesity and Metabolism 14:1, 30-39
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Giovanni A. Infusino, Jeffrey R. Jacobson. (2012) Endothelial FAK as a therapeutic target in disease. Microvascular Research 83:1, 89-96
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Zhi Gang Guo, Chen Li, Jian Kai Zhong, Yan Tu, Di Xie. (2012) Laboratory investigation of dysfunctional HDL. Chemistry and Physics of Lipids 165:1, 32-37
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D E Gutstein, R Krishna, D Johns, H K Surks, H M Dansky, S Shah, Y B Mitchel, J Arena, J A Wagner. (2012) Anacetrapib, a Novel CETP Inhibitor: Pursuing a New Approach to Cardiovascular Risk Reduction. Clinical Pharmacology & Therapeutics 91:1, 109-122
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Amanda J Hooper, John R Burnett. (2012) Anacetrapib , a cholesteryl ester transfer protein inhibitor. Expert Opinion on Investigational Drugs 21:1, 103-109
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Nicola Martinelli, Roberta Micaglio, Letizia Consoli, Patrizia Guarini, Elisa Grison, Francesca Pizzolo, Simonetta Friso, Elisabetta Trabetti, Pier Franco Pignatti, Roberto Corrocher, Oliviero Olivieri, Domenico Girelli. (2012) Low Levels of Serum Paraoxonase Activities are Characteristic of Metabolic Syndrome and May Influence the Metabolic-Syndrome-Related Risk of Coronary Artery Disease. Experimental Diabetes Research 2012, 1-9
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Zhijian Lu, Yi-heng Chen, Joann B. Napolitano, Gayle Taylor, Amjad Ali, Milton L. Hammond, Qiaolin Deng, Eugene Tan, Xinchun Tong, Suoyu S. Xu, Melanie J. Latham, Laurence B. Peterson, Matt S. Anderson, Suzanne S. Eveland, Qiu Guo, Sheryl A. Hyland, Denise P. Milot, Ying Chen, Carl P. Sparrow, Samuel D. Wright, Peter J. Sinclair. (2012) SAR studies on the central phenyl ring of substituted biphenyl oxazolidinone-potent CETP inhibitors. Bioorganic & Medicinal Chemistry Letters 22:1, 199-203
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Katya B. Rubinow, Chongren Tang, Andrew N. Hoofnagle, Christin N. Snyder, John K. Amory, Jay W. Heinecke, Stephanie T. Page. (2012) Acute Sex Steroid Withdrawal Increases Cholesterol Efflux Capacity and HDL-Associated Clusterin in Men. Steroids
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J.C. Hoflack, L. Mueller, S. Fowler, A. Braendli-Baiocco, N. Flint, O. Kuhlmann, T. Singer, A. Roth. (2012) Monitoring Cyp2b10 mRNA expression at cessation of 2-year carcinogenesis bioassay in mouse liver provides evidence for a carcinogenic mechanism devoid of human relevance: The dalcetrapib experience. Toxicology and Applied Pharmacology
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2011. Enhancement of HDL Formation and Normalization of Intravascular HDL Remodeling. , 423-523.
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2011. Frontmatter. , i-xxxvi.
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Jan I. Pedersen, Kaare R. Norum, Philip T. James, Ingeborg A Brouwer, Martijn B. Katan, Robert Clarke, Ibrahim Elmadfa, Penny M. Kris-Etherton, Daan Kromhout, Barrie M. Margetts, Ronald P. Mensink, Mike Rayner, Matti Uusitupa. (2011) Response to Hoenselaar from Pedersen et al.. British Journal of Nutrition1-3
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Philip Barter, Kerry-Anne Rye. (2011) Cholesteryl ester transfer protein inhibition to reduce cardiovascular risk: where are we now?. Trends in Pharmacological Sciences 32:12, 694-699
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Guohua Song, Hua Tian, Shucun Qin, Xuejun Sun, Shutong Yao, Chuanlong Zong, Yingying Luo, Jia Liu, Yang Yu, Hui Sang, Xinnong Wang. (2011) Hydrogen decreases athero-susceptibility in apolipoprotein B-containing lipoproteins and aorta of apolipoprotein E knockout mice. Atherosclerosis
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Martin Wehling. (2011) Drug development in the light of translational science: shine or shade?. Drug Discovery Today 16:23-24, 1076-1083
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Paul J. W. H. Kappelle, Arie van Tol, Bruce H. R. Wolffenbuttel, Robin P. F. Dullaart. (2011) Cholesteryl Ester Transfer Protein Inhibition in Cardiovascular Risk Management: Ongoing Trials will End the Confusion. Cardiovascular Therapeutics 29:6, e89-e99
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Agnieszka Belter, Miroslawa Skupinska, Malgorzata Giel-Pietraszuk, Tomasz Grabarkiewicz, Leszek Rychlewski, Jan Barciszewski. (2011) Squalene monooxygenase – a target for hypercholesterolemic therapy. Biological Chemistry 392:12, 1053-1075
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B. Sjouke, D. M. Kusters, J. J. P. Kastelein, G. K. Hovingh. (2011) Familial Hypercholesterolemia: Present and Future Management. Current Cardiology Reports 13:6, 527-536
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Paul St. Laurent. (2011) Acute Coronary Syndrome: New and Evolving Therapies. Critical Care Nursing Clinics of North America 23:4, 559-571
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Peter P. Toth. (2011) CETP Inhibition: Does the Future Look Promising?. Current Cardiology Reports 13:6, 559-565
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Asit Baran Shil. (2011) Termination of Atherothrombosis Intervention in Metabolic Syndrome with Low High-Density Lipoprotein Cholesterol and High Triglycerides: Impact on Global Health Study and Decision to Use Extended-Release Niacin in Elderly. Journal of the American Geriatrics Society 59:12, 2397-2398
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Salim S. Virani, Christie M. Ballantyne. (2011) Update on therapies targeting HDL. Current Opinion in Lipidology 22:6, 514-516
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François Briand, Quentin Thieblemont, Agnès André, Khadija Ouguerram, Thierry Sulpice. (2011) CETP Inhibitor Torcetrapib Promotes Reverse Cholesterol Transport in Obese Insulin-Resistant CETP-ApoB100 Transgenic Mice. Clinical and Translational Science 4:6, 414-420
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Sergio Fazio, MacRae F. Linton. (2011) Low Levels of High-Density Lipoprotein Cholesterol Due to Lecithin:Cholesterol Acyltransferase Mutations Increase Carotid Atherosclerosis. Journal of the American College of Cardiology 58:24, 2488-2490
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Wael ElMallah, Richard A. Krasuski. (2011) Therapy and clinical trials. Current Opinion in Lipidology 22:6, 512-513
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Željko Reiner, Alberico L. Catapano, Guy De Backer, Ian Graham, Marja-Riitta Taskinen, Olov Wiklund, Stefan Agewall, Eduardo Alegría, M. John Chapman, Paul Durrington, Serap Erdine, Julian Halcox, Richard Hobbs, John Kjekshus, Pasquale Perrone Filardi, Gabriele Riccardi, Robert F. Storey, David Wood. (2011) Guía de la ESC/EAS sobre el manejo de las dislipemias. Revista Española de Cardiología 64:12, 1168.e1-1168.e60
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Stephen J. Nicholls. (2011) Apo A-I Modulating Therapies. Current Cardiology Reports 13:6, 537-543
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Gian P. Rossi, Teresa M. Seccia, Carmela Maniero, Achille C. Pessina. (2011) Drug-related hypertension and resistance to antihypertensive treatment. Journal of Hypertension 29:12, 2295-2309
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Marica Grskovic, Ashkan Javaherian, Berta Strulovici, George Q. Daley. (2011) Induced pluripotent stem cells — opportunities for disease modelling and drug discovery. Nature Reviews Drug Discovery
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Stephen J Nicholls. (2011) Will apoA-I-based therapies step up to cure coronary artery disease?. Expert Review of Cardiovascular Therapy 9:11, 1367-1370
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Parin J. Patel, Amit V. Khera, Kashif Jafri, Robert L. Wilensky, Daniel J. Rader. (2011) The Anti-Oxidative Capacity of High-Density Lipoprotein Is Reduced in Acute Coronary Syndrome But Not in Stable Coronary Artery Disease. Journal of the American College of Cardiology 58:20, 2068-2075
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Anthony S. Wierzbicki. (2011) HDL: who needs it?. International Journal of Clinical Practice 65:11, 1111-1113
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Cesare R Sirtori. (2011) Investigational CETP antagonists for hyperlipidemia and atherosclerosis prevention. Expert Opinion on Investigational Drugs 20:11, 1543-1554
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Kristina Duwensee, Stefan Schwaiger, Ivan Tancevski, Kathrin Eller, Miranda van Eck, Patrick Markt, Tobias Linder, Ursula Stanzl, Andreas Ritsch, Josef R. Patsch, Daniela Schuster, Hermann Stuppner, David Bernhard, Philipp Eller. (2011) Leoligin, the major lignan from Edelweiss, activates cholesteryl ester transfer protein. Atherosclerosis 219:1, 109-115
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B. J. Arsenault, S. M. Boekholdt, J.-C. Tardif, J. J. P. Kastelein. (2011) De-risking the clinical development of cholesteryl ester transfer protein inhibitors: how much is good enough?. European Heart Journal
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Agnieszka Belter,, Miroslawa Skupinska,, Malgorzata Giel-Pietraszuk,, Tomasz Grabarkiewicz,, Leszek Rychlewski,, Jan Barciszewski,. (2011) Squalene monooxygenase - a target for hypercholesterolemic therapy. Biological Chemistry---
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Hayes M. Dansky, Daniel Bloomfield, Patrice Gibbons, Sherry Liu, Christine McCrary Sisk, Diane Tribble, James M. McKenney, Thomas W. Littlejohn, Yale Mitchel. (2011) Efficacy and safety after cessation of treatment with the cholesteryl ester transfer protein inhibitor anacetrapib (MK-0859) in patients with primary hypercholesterolemia or mixed hyperlipidemia. American Heart Journal 162:4, 708-716
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Erik S G Stroes, Diederik F van Wijk. (2011) Dalcetrapib: turning the tide for CETP inhibition?. The Lancet 378:9802, 1529-1530
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Zahi A Fayad, Venkatesh Mani, Mark Woodward, David Kallend, Markus Abt, Tracy Burgess, Valentin Fuster, Christie M Ballantyne, Evan A Stein, Jean-Claude Tardif, James H F Rudd, Michael E Farkouh, Ahmed Tawakol. (2011) Safety and efficacy of dalcetrapib on atherosclerotic disease using novel non-invasive multimodality imaging (dal-PLAQUE): a randomised clinical trial. The Lancet 378:9802, 1547-1559
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J C Kovacic, V Fuster. (2011) From Treating Complex Coronary Artery Disease to Promoting Cardiovascular Health: Therapeutic Transitions and Challenges, 2010–2020. Clinical Pharmacology & Therapeutics 90:4, 509-518
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Laurent Camont, M. John Chapman, Anatol Kontush. (2011) Biological activities of HDL subpopulations and their relevance to cardiovascular disease. Trends in Molecular Medicine 17:10, 594-603
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Kuang-Yuh Chyu, Anish Peter, Prediman K. Shah. (2011) Progress in HDL-Based Therapies for Atherosclerosis. Current Atherosclerosis Reports 13:5, 405-412
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Ronen Gurfinkel, Tisha R. Joy. (2011) Anacetrapib: Hope for CETP Inhibitors?. Cardiovascular Therapeutics 29:5, 327-339
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Thomas H. Marwick, Jagat Narula. (2011) Imaging of Pharmacologic Intervention. JACC: Cardiovascular Imaging 4:10, 1146-1147
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Claudio Cimminiello. (2011) What intervention trials don’t tell us: the residual risk in primary prevention. Internal and Emergency Medicine 6:S1, 53-60
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Ananth Kadambi, Daniel L. Young, Kapil Gadkar. 2011. Systems Modeling Applied to Candidate Biomarker Identification. , 239-263.
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B. Simic, M. Hermann, S. G. Shaw, L. Bigler, U. Stalder, C. Dorries, C. Besler, T. F. Luscher, F. Ruschitzka. (2011) Torcetrapib impairs endothelial function in hypertension. European Heart Journal
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Tina Costacou, Rhobert W. Evans, Trevor J. Orchard. (2011) High-density lipoprotein cholesterol in diabetes: Is higher always better?. Journal of Clinical Lipidology 5:5, 387-394
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Yuhua Liu, Chongren Tang. (2011) Regulation of ABCA1 functions by signaling pathways. Biochimica et Biophysica Acta (BBA) - Molecular and Cell Biology of Lipids
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John D. Brunzell, Alberto Zambon, Samir S. Deeb. (2011) The effect of hepatic lipase on coronary artery disease in humans is influenced by the underlying lipoprotein phenotype. Biochimica et Biophysica Acta (BBA) - Molecular and Cell Biology of Lipids
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Michael Domanski, Stuart Pocock, Corine Bernaud, Jeffrey Borer, Nancy Geller, James Revkin, Faiez Zannad. (2011) Surrogate endpoints in randomized cardiovascular clinical trials. Fundamental & Clinical Pharmacology 25:4, 411-413
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Serena Tonstad, Jean-Pierre Després. (2011) Treatment of lipid disorders in obesity. Expert Review of Cardiovascular Therapy 9:8, 1069-1080
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Zahi A. Fayad, Venkatesh Mani, Mark Woodward, David Kallend, Sameer Bansilal, Joseph Pozza, Tracy Burgess, Valentin Fuster, James H.F. Rudd, Ahmed Tawakol, Michael E. Farkouh. (2011) Rationale and design of dal-PLAQUE: A study assessing efficacy and safety of dalcetrapib on progression or regression of atherosclerosis using magnetic resonance imaging and 18F-fluorodeoxyglucose positron emission tomography/computed tomography. American Heart Journal 162:2, 214-221.e2
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Sanjay Rajagopalan, Georgeta Mihai. (2011) Perspectives on Optimizing Trial Design and Endpoints in Peripheral Arterial Disease: A Case for Imaging-Based Surrogates as Endpoints of Functional Efficacy. Cardiology Clinics 29:3, 419-431
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Philip Joseph, Koon Teo. (2011) Optimal Medical Therapy, Lifestyle Intervention, and Secondary Prevention Strategies for Cardiovascular Event Reduction in Ischemic Heart Disease. Current Cardiology Reports 13:4, 287-295
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Klaus G Parhofer. (2011) Pathophysiology of diabetic dyslipidemia: implications for atherogenesis and treatment. Clinical Lipidology 6:4, 401-411
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Justin Hall, Xiayang Qiu. (2011) Structural and biophysical insight into cholesteryl ester-transfer protein. Biochemical Society Transactions 39:4, 1000-1005
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Sanne A.E. Peters, Hester M. den Ruijter, Michiel L. Bots. (2011) Attenuation of Rate of Change in Carotid Intima-Media Thickness by Lipid-Modifying Drugs. American Journal Cardiovascular Drugs 11:4, 253-263
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K. Hanai, T. Babazono, N. Yoshida, I. Nyumura, K. Toya, T. Hayashi, R. Bouchi, N. Tanaka, A. Ishii, Y. Iwamoto. (2011) Gender differences in the association between HDL cholesterol and the progression of diabetic kidney disease in type 2 diabetic patients. Nephrology Dialysis Transplantation
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Cameron J. Smith, Amjad Ali, Milton L. Hammond, Hong Li, Zhijian Lu, Joann Napolitano, Gayle E. Taylor, Christopher F. Thompson, Matt S. Anderson, Ying Chen, Suzanne S. Eveland, Qiu Guo, Sheryl A. Hyland, Denise P. Milot, Carl P. Sparrow, Samuel D. Wright, Anne-Marie Cumiskey, Melanie Latham, Laurence B. Peterson, Ray Rosa, James V. Pivnichny, Xinchun Tong, Suoyu S. Xu, Peter J. Sinclair. (2011) Biphenyl-Substituted Oxazolidinones as Cholesteryl Ester Transfer Protein Inhibitors: Modifications of the Oxazolidinone Ring Leading to the Discovery of Anacetrapib. Journal of Medicinal Chemistry 54:13, 4880-4895
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Chieko Mineo, Philip W. Shaul. (2011) PON-dering differences in HDL function in coronary artery disease. Journal of Clinical Investigation 121:7, 2545-2548
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Alberico L. Catapano, Željko Reiner, Guy De Backer, Ian Graham, Marja-Riitta Taskinen, Olov Wiklund, Stefan Agewall, Eduardo Alegria, M. John Chapman, Paul Durrington, Serap Erdine, Julian Halcox, Richard Hobbs, John Kjekshus, Pasquale Perrone Filardi, Gabriele Riccardi, Robert F. Storey, David Wood. (2011) ESC/EAS Guidelines for the management of dyslipidaemias. Atherosclerosis 217:1, 3-46
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Christopher F. Thompson, Amjad Ali, Nazia Quraishi, Zhijian Lu, Milton L. Hammond, Peter J. Sinclair, Matt S. Anderson, Suzanne S. Eveland, Qiu Guo, Sheryl A. Hyland, Denise P. Milot, Carl P. Sparrow, Samuel D. Wright. (2011) Discovery of Substituted Biphenyl Oxazolidinone Inhibitors of Cholesteryl Ester Transfer Protein. ACS Medicinal Chemistry Letters 2:6, 424-427
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