Effect of Infusion of High-Density Lipoprotein Mimetic Containing Recombinant Apolipoprotein A-I Milano on Coronary Disease in Patients With an Acute Coronary Syndrome in the MILANO-PILOT Trial
Authors: Stephen J. Nicholls, Rishi Puri, Christie M. Ballantyne, J. Wouter Jukema, John J. P. Kastelein, Wolfgang Koenig, R. Scott Wright, David Kallend, Peter Wijngaard, Marilyn Borgman, Kathy Wolski, Steven E. Nissen
Journal: JAMA Cardiology (2018)

<h3>Importance</h3> Infusing a high-density lipoprotein mimetic containing apolipoprotein A-I Milano demonstrated potential atheroma regression in patients following an acute coronary syndrome. To our knowledge, the effect of infusing a new mimetic preparation (MDCO-216) with contemporary statin therapy is unknown. <h3>Objective</h3> To determine the effect of infusing MDCO-216 on coronary atherosclerosis progression. <h3>Design, Setting, and Participants</h3> This double-blind, randomized clinical trial conducted in 22 hospitals in Canada and Europe compared the effects of 5 weekly intravenous infusions of MDCO-216 at a dose of 20 mg/kg weekly (n = 59) with placebo (n = 67) in statin-treated patients with an acute coronary syndrome. <h3>Main Outcomes and Measures</h3> The primary efficacy measure was the nominal change in percent atheroma volume (PAV) from baseline to day 36 as measured by serial intravascular ultrasonography. The secondary efficacy measures were the nominal changes in normalized total atheroma volume (TAV), atheroma volume in the most diseased 10-mm segment, and the percentage of patients who demonstrated plaque regression. Safety and tolerability were also evaluated. <h3>Results</h3> Among 122 randomized patients (mean [SD] age, 61.8 [10.4] years; 93 men [76.2%]; 61 [50.0%] with prior statin use; and a mean [SD] low-density lipoprotein cholesterol [LDL-C] level of 87.6 [40.5] mg/dL [to convert to millimoles per liter, multiply by 0.0259]), 113 (92.6%) had evaluable imaging results at follow-up. The receiving-treatment LDL-C levels were comparable with the placebo and MDCO-216 (68.6 vs 70.5 mg/dL; difference, −2.5 mg/dL; 95% CI, −10.1 to 5.0;<i>P</i> = .51). A reduction in high-density lipoprotein cholesterol levels was observed in MDCO, but not placebo patients (−3.3 vs 3.0 mg/dL [to convert to millimoles per liter, multiply by 0.0259]; difference, −6.3 mg/dL; 95% CI, −8.5 to −4.1;<i>P</i> &lt; .001). Percent atheroma volume, which was adjusted for baseline values, decreased 0.94% with the placebo and 0.21% with MDCO-216 (difference, 0.73%; 95% CI, −0.07 to 1.52;<i>P</i> = .07). Normalized TAV decreased 7.9 mm<sup>3</sup>with the placebo and 6.4 mm<sup>3</sup>with MDCO-216 (difference, 1.6 mm<sup>3</sup>; 95% CI, −5.6 to 8.7;<i>P</i> = .67), and atheroma volume in the most diseased segment decreased 1.8 mm<sup>3</sup>with the placebo and 2.2 mm<sup>3</sup>with MDCO-216 (difference 0.4 mm<sup>3</sup>; 95% CI, −4.4 to 3.5;<i>P</i> = .83). A similar percentage of patients demonstrated a regression of PAV (67.2% vs 55.8%;<i>P</i> = .21) and TAV (68.9% vs 71.2%;<i>P</i> = .79) in the placebo and MDCO-216 groups, respectively. <h3>Conclusions and Relevance</h3> Among patients with an acute coronary syndrome, infusing MDCO-216 did not produce an incremental plaque regression in the setting of contemporary statin therapy. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02678923