Heart Disease

In 1995:
481,000 deaths related to Coronary Artery Disease (CAD)
1,100,000 new or recurrent cases of CAD
Estimated that 7.2 million people experienced angina to
some degree
Treatment
434,000 angioplasties performed
573,000 Bypasses performed

60,000-100,000 patients not good candidates for

bypass/angioplasty
(Possibly up to 250,000 patients a year)

Use of Vascular
Endothelial Growth
Factor (VEGF) as a
Treatment for End Stage
Coronary Artery Disease
(CAD)
By: Jeremy Gillis
SeniorBiochemistry and Molecular Biology

Current Treatments for CAD

Percutaneous Transluminal Coronary
Angioplasty or PTCA (434,000)
Coronary Artery Bypass Graft (CABG)
cabbage (573,000)
Vascular Stents (wire props for an artery)
Rotational Atherectomy (much like a drill)

Problems with Current Treatments

Restenosis
Graft disease
Arterial puncture
Coronary thrombosis

How can we help people who dont respond

well or are not good candidates for
conventional treatments?

It is thought that VEGF is involved in

Angiogenesis
Angiogenesis: the formation of new blood vessels
(collaterals) from existing microvessels
Contributes to the preservation of ischemic tissue and
myocardial pump function after myocardial infarction
Important in:
Embryogenesis (called vasculogenesis)
Wound healing
Tumor growth and metastasization
Rheumatoid arthritis
Ischemic heart disease
Ischemic peripheral vascular disease

Inducing Angiogenesis
1. Need a stimulus
Hypoxic tissue, Ischemic tissue, Mechanically damaged
tissue
2. Need expression of angiogenic molecules to
initiate angiogenesis
VEGF, FGF, TGF, PDGF
3. Need angiogenesis to occur
1. Proliferation and migration of endothelial cells from
the microvasculature
2. Controlled expression of proteolytic enzymes
3. Breakdown and reassembly of extracellular matrix
4. Morphogenic process of endothelial tube formation
Mechanism of Angiogenesis not completely known

Why use VEGF to Promote Angiogenesis?

VEGF (vascular endothelial growth factor)
Specific for only endothelial cells
May inhibit smooth muscle growthreduce restenosis
FGF (fibroblast growth factor)
Associated with tumor angiogenesis
Can stimulate growth in other cells besides endothelial cells
Not as specific as VEGF
TGF- (transforming growth factor )
Indirect angiogenesis effect
Possibly induces VEGF expression (Protein Kinase C pathway)
PDGF (platelet derived growth factor)
Not well characterized in angiogenesis

Other VEGF Characteristics

VEGF expressed by Macrophages, fibroblasts,
smooth muscle cells, endothelial cells (all are
present in the heart)
Action is direct because of the exclusive
specificity for receptors (flt-1 and flk-1)
Receptors only found on endothelial cells
Causes activation of many other genes involved
in angiogenic response

How to Deliver VEGF

Protein Therapy
Direct injection of protein
Time delay delivery
Local intercoronary bolus
Gene Therapy
Adenovirus vector
Excellent specificity for endothelial cells
Extended expression of VEGF
Direct gene transfer
Involves direct injection of eukaryotic plasmid DNA
containing VEGF cDNA
Should VEGF administration prove effective, it is likely that
VEGF/VEGF DNA will be delivered on a catheter platform

Case Studies
Injection of naked VEGF cDNA contained in
an Eukaryotic Expression Vector
Jeffery Isner et al. St. Elizabeths Medical Center
Phase I clinical trialdesigned to assess safety
and bioactivity of treatment methods
Limited sampleonly 5 patients involved
Prior Bypass and/or angioplasty
Class 3-4 Angina
No longer respond to additional treatment

Results
Age Lifestyle Before Treatment Lifestyle After Treatment
Angina virtually gone
67
Angina from Mild activity
Able to resume swimming
Nitroglycerin (NTG) no longer needed
69
Angina after walking 10 yards 30 days post needed very little NTG
60 days post could exercise for 30
minutes on a stationary bike
53
Angina after walking 50 yards 60 days post could walk ? mile
Claims to have felt beneficial effects
after only two weeks
71
Angina from walking 100 yards 30 days NTG use decreased dramatically
Returned to work part time
30 days later could walk up to ? mile
59
Daily Angina
without pain
Less need for supplemental oxygen
2 episodes of angina/month

Also notable:
Nitroglycerin usage dropped from 7.7 pills per
day to 1.4 per day for the group (60 days post)
Effective biological outcomes despite low
transfection rates
Because of the condition of the patients in the
study, the improvements to health were not
likely random events

All 5 patients had remarkable gains in

quality of life post procedure

Animal Data:
Charles Mack et al. New York HospitalCornell Medical Center
Administration VEGF gene through
Adenovirus mediated gene therapy
Preclinical work to determine efficacy
in an animal model of ischemia

Model:
Pig with a constrictor band around circumflex artery to
induce myocardial infarction and ischemia
Eventually results in complete occlusion of circumflex
artery

Vector:
Adenovirus vector in E1a-, partial E1b-, and partial E3mutations (makes them replication deficient)
Adenovirus used because of the natural selectivity for
endothelial cells
Minimal inflammation detected in animals 4 weeks post
therapy
In vivo conformation of expression confirmed by ELISA 3
days after injection

Results
Treatment Resulted in significantly reduced
ischemic area (area of oxygen starved tissue)
and
Ischemic maximum (severity of ischemia) in
treated animals
Strength of heartbeat returned in treated
animals more than untreated animals
More vessels visible angiographically in treated
animals vs. untreated animals
Treated animals seemed to route around the
occlusion as demonstrated by the filling of
branching arteries

Why it works?
Placebo effect?
VEGF stimulates growth of
collateral vessels?
Microvessel growth due to physical
damage of heart?
Real or perceived Angiogenesis?

Problems:
Doesnt work as well on older patients with more
advanced disease
VEGF may stimulate undetected cancer growth
(tumors cannot be larger than a few mm3 without
revascularization?
Limited number of trials and patients
Treatment kills some patients?
What are the effects on women?
No placebo substance given for ethical reasons

References
Battegay, E.J. Angiogenesis: mechanistic insights, neovascular diseases, and
therapeutic prospects. Journal of Molecular Medicine (1995) 73:333-346.
Losordo, Douglas W., et al. Gene therapy for Myocardial Angiogenesis: Initial Clinical
Results With Direct Myocardial Injection of phVEGF165 as Sole Therapy for
Myocardial Ischemia. Circulation (1998) 98:2800-2804.
Mack, Charles A., et al. Biologic Bypass With the Use of Adenovirus-Mediated Gene
Transfer of the Complementary Deoxyribonucleic Acid for Vascular Endothelial
Growth Factor 121 Improves Myocardial Perfusion and Function in the Ischemic
Porcine Heart. Journal of Thoracic and Cardiovascular Surgery (1998) 115:168-77.
Li, Jian, et al. Stretch-induced VEGF Expression in the Heart. Journal of Clinical
Investigation (1997) 100:18-24.
Seko, Yoshinori, et al. Serum levels of vascular endothelial growth factor in patients
with acute myocardial infarction undergoing reperfusion therapy. Clinical Science
(1997) 92:453-454.
Lopez, John J., et al. VEGF administration in chronic myocardial ischemia in pigs.
Cardiovascular Research (1998) 40:272-281.
Metais, Caroline, et al. Effects of coronary artery disease on expression and
microvascular response to VEGF. American Journal of Physiology (1998)
275:H1411-H1418.