1. Potential Utility of rNAPC2 in ACS: Phase 2 Heparin Replacement Trial Evaluating RNAPc2 In Acute Coronary Syndromes Robert P. Giugliano, MD, SM, Associate Physician, Cardiovascular Division Brigham and Women's Hospital Assistant Professor in Medicine Harvard Medical School Boston, MA

2. Novel Tissue Factor / Factor VIIa Inhibitor Reduces Ischemia in Patients with NSTE-ACS: Results of the Dose-Ranging and Heparin De-Escalation Phases of the ANTHEM-TIMI 32 Trial
RP Giugliano1, SD Wiviott1, DI Simon2, MJ Schweiger3,
MA Leesar4, PH Stone1, R Bach5, A Skene6, SR Deitcher7, E Braunwald1
on behalf of the ANTHEM-TIMI 32 Investigators
(1) Brigham & Women’s Hospital, Boston, MA. (2) University Hospitals – Case Medical Center, Cleveland, OH. (3) Baystate Medical Center, Springfield, MA. (4)U of Louisville, Louisville, KY. (5) Washington U School of Medicine, St. Louis, MO. (6) Nottingham Clinical Research Limited, Nottingham, UK. (7) Nuvelo, Inc., San Carlos, USA

3. Disclosures
The TIMI Study Group received research/grant support in the last 2 yrs through Brigham & Women’s Hospital from (alphabetical order):
Accumetrics, Inc.
Amgen, Inc.
AstraZeneca Pharmaceuticals
Baxter
Bayer Healthcare LLC
Beckman Coulter, Inc.
Biosite Incorporated
Bristol-Myers Squibb
CardioKinetix
CV Therapeutics, Inc.
Eli Lilly and Company
FoldRx
GlaxoSmithKline
INO Therapeutics LLC
Inotek Pharmaceuticals Corp
Integrated Therapeutics Corp
KAI Pharmaceuticals
Merck & Co., Inc.
Millennium Pharmaceuticals, Inc.
Novartis Pharmaceuticals
Nuvelo, Inc.
Ortho-Clinical Diagnostics, Inc.
Pfizer, Inc.
Roche Diagnostics Corporation
Roche Diagnostics GmbH
Sanofi-Aventis
Sanofi-Synthelabo Recherche
Schering-Plough
St Jude Medical
The National Institutes of Health
MJ Schweiger, MA Leesar, R Bach, and A Skene received research grant support from Nuvelo; SR Deitcher is an employee of Nuvelo

4. Background
Exposure of tissue factor (TF) initiates coagulation at sites of vascular injury (plaque rupture, PCI)
rNAPc2 is a recombinant, modified version of NAPc2 (derived from the hookworm) that provides potent factor X(a)-dependent inhibition of the TF/fVIIa complex
rNAPc2 prevented new thrombin generation in a dose-dependent manner in phase 2 studies of elective knee surgery and elective PTCA
Ischemia during continuous ECG monitoring identifies patients with ACS at high risk of adverse cardiac events
Enoxaparin was associated with less ischemia based on continuous ECG and better clinical outcomes than UFH, suggesting more proximal inhibition may be more effective than distal inhibition of the coagulation cascade

5. Trial Design: Dose Ranging
nSTE ACS -> Early Catheterization
ASA, Enox or UFH, GP IIb/IIIa*, clopidogrel*
Blinded Randomized 4:1
rNAPc2 (n=163)
IV bolus q 48h
8 escalating doses
(1.5, 2, 3, 4, 5, 7.5, 10† mcg/kg)
Placebo
IV q 48h
n = 40
Major Endpoints
Safety
Major/Minor Bleed
Efficacy
F1+2, PT, PK
Holter Ischemia
PK, PD: pre-dose, 2-6h, 48h, d7, d42
Continuous ECG x 7 days
Clinical f/u to 6 months
* Encouraged per current practice guidelines
† 10 mcg/kg dose panel repeated

6. Heparin De-Escalation (HDE) Design (n=52)
Unblinded
nSTE ACS
Early Cath
ASA
GP IIb/IIIa*
clopidogrel*
rNAPc2
10 mcg/kg
2 Sequential Panels 1
½ Std† UFH (n=26) 2
No UFH (n=26)
Endpoints
Major/Minor Bleed
Thrombotic Bailout‡
F1+2, PT, PK
Holter Ischemia
PK, PD, Cont ECG, 6 mth clinical
Angiograms reviewed by Core Lab
Thrombosis monitored by Investigators
* Encouraged per current practice guidelines
† 30 U/kg bolus (max 2500 U); 6 U/kg/h (max 600 U/h)
‡ Defined as use of open-label anticoagulant to manage a thrombotic complication

7. Entry Criteria and Study Schema
Inclusion: Age 18-75, rest sx > 5min w/i 48h c/w ACS
+ markers or ST deviation or TIMI Risk Score > 3
Planned early invasive strategy
Exclusions: STEMI, creatinine > 4, bleed risk, planned CABG <7d R
in hospital
Angio +/- PCI
IV GP IIb/IIIa (encouraged)
Clopidogrel 300/75 (encouraged)
Enox q 12h or UFH
Aspirin mg daily x 6 mths
48h
96h
144h
192h
(8d)
rNAPc2/
placebo
(rNAPc2/
placebo)
(rNAPc2/
placebo)
Up to 3 doses administered as determined by clinical circumstances and length of hospitalization

8. Baseline Characteristics
rNAPc2 Placebo
No. of patients
Age (median) 58 yrs 56 yrs
Age > 65 yrs 28 18
Women 34 20
nSTE-MI 53 50
ST dev > 0.5mm 47 45
Diabetes 34 33
Mean TIMI Risk Score (0-7)
Data shown are % of patients All p = NS

9. Concomitant Treatments
rNAPc2 Placebo
(n=215) (n=40)
# Study drug doses:
*Enoxaparin / UFH / / 33
Clopidogrel
GP IIb/IIIa inhibitor
Treatment Strategy: PCI
CABG
Medical
Data shown are % of patients
* Excludes 52 patients in the heparin de-escalation phase All p = NS

10. 1° Study Endpoint: Adjudicated TIMI Major or Minor Bleeding
Dose- Ranging Phase
HDE
All
rNAPc2
p-value for trend = 0.23
p = NS for each pairwise comparisons with placebo
*p = 0.50 for comparison with placebo (1° endpoint)
7.5
4.8
4.8
5.0
5.0
3.8
3.7*
2.5 4
# bleeds -> 1 1 1 1 1 3† 1 4†
Dose of rNAPc2 (mcg/kg)
# patients:
† 3/4 major bleeds were CABG-related 2-3 days post dose

11. Other Safety Endpoints
rNAPc2 Placebo
(n = 215) (n = 40) P-value
Minimal Bleeding NS
Provoked by procedure NS
Spontaneous NS
RBC Transfusion NS
Fresh Frozen Plasma NS
Platelet Transfusion NS
Recombinant FVIIa (antidote)
Serious Adverse Events NS
rNAPc2 42d 13*
Data shown are % of patients
* No allergic symptoms, anaphylaxis, or clinical manifestations were reported

12. Plasma Concentration of rNAPc2 (Dose Ranging Phase)
rNAPc2 (ng/mL)
rNAPc2 dose
Trend p < at 2-6h and 48h

13. Median International Normalized Ratio (INR) – Dose Ranging
rNAPc2 dose
Trend p <0.0001
Trend p = 0.02

14. Correlation of Log Conc and INR
2-6 hours post dose 5
Adjusted r2 = 0.26
correlation coefficient = 0.51
p < 4
INR 3 2 1 3 4 5 6
log(rNAPc2 concentration µg/kg)

15. F1+2 Concentration: A Measure of New Thrombin Generation (All Pts)
%D in Median F1+2
from Randomization
rNAPc2 dose
Randomization
2-6h
48h
F1/F2 with pci *
7d post **
*p = 0.04 vs. placebo
** p = vs. placebo
***p = vs. placebo
† p = 0.08 vs. placebo
p = NS for all others †
***

16. Incidence of Ischemia by Dose
% pts
Trend p = 0.013
Median duration of recording was 6.7 days
Continuous ECGs were interpreted by a blinded central core laboratory
7/34
6/18
4/19
5/19
7/19
3/18
2/18
7/79
Dose of rNAPc2 in mcg/kg

17. Incidence of Ischemia 3-way p = 0.007 % pts 7/34 25/93 9/97 p = 0.12

18. Heparin De-Escalation Results
Unblinded HDE Double-blind
rNAPc2 dose (mcg/kg) placebo
Heparin Dose None ½Std Std Std
(n=26) (n=26) (n=40) (n=40)
Major/Minor Bleed, %
D Median F1.2 from rand.
At 2-6 hours -8% -17* -23* -1
At 48 hours -5% -28%* -9* +31
% Holter ischemia 4†
% Thrombotic Bailout 19‡
*p < 0.05 vs placebo † p = 0.12 vs placebo ‡ p = vs ½ Std heparin.
Note: TBO was prospectively assessed only during heparin de-escalation, 1 case was retrospectively identified in patients receiving 10 mcg/kg rNAPc2 + standard heparin

19. Clinical Endpoints at 42 Days
rNAPc2 placebo
(n=215) (n = 40)
All-cause Mortality
New Myocardial Infarct*
Clinical Rec Ischemia*
D / MI* / RI*
Holter ischemia* 0-7 days
Revasc post discharge
Stroke
Any of the above
Data shown are % of patients
* Central blinded adjudicated All p = NS

20. Summary and Conclusions
rNAPc2 did not increase bleeding despite dose-related increase in INR
Higher dose rNAPc2 (> 7.5 mcg/kg) suppressed new thrombin generation and these doses  ischemia by 50%
Some heparin may be necessary to avoid procedure-related thrombosis
These proof of concept data warrant larger-scale evaluation to determine if rNAPc2 improves clinical outcomes

21. Question
&
Answer