U.S. patent application number 15/409283 was filed with the patent office on 2017-05-04 for methods of treating cardiovascular diseases and predicting the efficacy of exercise therapy.
This patent application is currently assigned to Critical Care Diagnostics, Inc.. The applicant listed for this patent is Critical Care Diagnostics, Inc.. Invention is credited to Robert W. Gerwien, James V. Snider.
Application Number | 20170122942 15/409283 |
Document ID | / |
Family ID | 47558450 |
Filed Date | 2017-05-04 |
United States Patent
Application |
20170122942 |
Kind Code |
A1 |
Snider; James V. ; et
al. |
May 4, 2017 |
Methods of Treating Cardiovascular Diseases and Predicting the
Efficacy of Exercise Therapy
Abstract
Methods of treating a subject having a cardiovascular disease,
selecting a therapy for a subject having a cardiovascular disease,
identifying a subject having a cardiovascular disease that will
benefit or not benefit from exercise therapy, determining whether a
subject having a cardiovascular disease should begin, continue, not
begin, discontinue, or avoid exercise therapy, determining whether
a subject having a cardiovascular disease should continue,
discontinue, or avoid exercise therapy, reducing the risk of an
adverse outcome (e.g., death) in a subject having a cardiovascular
disease, and predicting the efficacy of exercise therapy in a
subject having a cardiovascular disease. These methods include
determining a level of soluble ST2 in a subject.
Inventors: |
Snider; James V.; (San
Diego, CA) ; Gerwien; Robert W.; (Newington,
CT) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Critical Care Diagnostics, Inc. |
San Diego |
CA |
US |
|
|
Assignee: |
Critical Care Diagnostics,
Inc.
San Diego
CA
|
Family ID: |
47558450 |
Appl. No.: |
15/409283 |
Filed: |
January 18, 2017 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14299851 |
Jun 9, 2014 |
9551708 |
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15409283 |
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13552533 |
Jul 18, 2012 |
8748110 |
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14299851 |
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61508923 |
Jul 18, 2011 |
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61509359 |
Jul 19, 2011 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61P 9/00 20180101; A61P
9/10 20180101; A61P 9/04 20180101; C07K 14/54 20130101; C07K
14/7155 20130101; G01N 33/53 20130101; G01N 2800/52 20130101; G01N
33/6893 20130101; G01N 33/6869 20130101; G01N 2333/7155 20130101;
C07K 16/2866 20130101; G01N 33/566 20130101; G01N 2800/32
20130101 |
International
Class: |
G01N 33/566 20060101
G01N033/566 |
Claims
1. A method of treating a subject having a cardiovascular disease,
the method comprising: a) determining a level of soluble ST2 in a
biological sample from the subject; b) identifying a subject that
has a decreased level of soluble ST2 in the biological sample
compared to a risk or efficacy reference level of soluble ST2; and
c) selecting the identified subject for exercise therapy.
2. A method of treating a subject having a cardiovascular disease,
the method comprising: a) determining a level of soluble ST2 in a
biological sample from the subject; b) identifying a subject that
has an elevated level of soluble ST2 in the biological sample
compared to a risk or efficacy reference level of soluble ST2; and
c) instructing the identified subject not to begin, to discontinue,
or to avoid exercise therapy.
3. A method of selecting a therapy for a subject having a
cardiovascular disease, the method comprising: a) determining a
level of soluble ST2 in a biological sample from the subject, and
b) comparing the level of soluble ST2 in the biological sample to a
risk or efficacy reference level of soluble ST2, wherein a
decreased level of soluble ST2 in the biological sample compared to
the risk or efficacy reference level indicates that the subject
should begin or continue exercise therapy, and an elevated level of
soluble ST2 in the biological sample compared to the risk or
efficacy reference level indicates that the subject should not
begin or should discontinue exercise therapy.
4. A method of identifying a subject having a cardiovascular
disease that will benefit from exercise therapy, the method
comprising: a) determining a level of soluble ST2 in a biological
sample from the subject, and b) selecting a subject that has a
decreased level of soluble ST2 in the biological sample compared to
an efficacy reference level of soluble ST2, wherein the selected
subject is identified as a subject that will benefit from exercise
therapy.
5. A method of identifying a subject having a cardiovascular
disease that will not benefit from exercise therapy, the method
comprising: a) determining a level of soluble ST2 in a biological
sample from the subject, and b) selecting a subject that has an
elevated level of soluble ST2 in the biological sample compared to
an efficacy reference level of soluble ST2, wherein the selected
subject is identified as a subject that will not benefit from
exercise therapy.
6. A method of determining whether a subject having a
cardiovascular disease should begin, continue, not begin, or
discontinue exercise therapy, the method comprising determining a
level of soluble ST2 in a biological sample from the subject,
wherein a decreased level of soluble ST2 in the biological sample
compared to a risk or efficacy reference level of soluble ST2
indicates that the subject should begin or continue exercise
therapy, and an elevated level of soluble ST2 in the biological
sample compared to a risk or efficacy reference level of soluble
ST2 indicates that the subject should not begin or discontinue
exercise therapy.
7. A method of determining whether a subject having a
cardiovascular disease should discontinue or continue exercise
therapy, the method comprising: a) determining a level of soluble
ST2 in a biological sample from the subject at a first time point
before or after the start of exercise therapy; and b) determining a
level of soluble ST2 in a biological sample from the subject
undergoing exercise therapy at a second time point after the start
of exercise therapy and after the first time point, wherein an
elevation in the level of soluble ST2 in the biological sample at
the second time point compared to the level of soluble ST2 in the
biological sample at the first time point indicates that the
subject should discontinue exercise therapy, and a decrease in the
level of soluble ST2 in the biological sample at the second time
point compared to the level of soluble ST2 in the biological sample
at the first time point indicates that the subject should continue
exercise therapy.
8. A method of reducing the risk of an adverse outcome in a subject
having a cardiovascular disease, the method comprising: a)
determining a level of soluble ST2 in a biological sample from the
subject; b) identifying a subject that has a decreased level of
soluble ST2 in the biological sample compared to a risk reference
level of soluble ST2; and c) selecting the identified subject for
exercise therapy.
9. A method of reducing the risk of an adverse outcome in a subject
having a cardiovascular disease, the method comprising: a)
determining a level of soluble ST2 in a biological sample from the
subject; b) identifying a subject that has an elevated level of
soluble ST2 in the biological sample compared to a risk reference
level of soluble ST2; and c) instructing the identified subject not
to begin or to discontinue exercise therapy.
10. The method of claim 8 or 9, where the risk of an adverse
outcome is risk of death.
11. A method of predicting the efficacy of exercise therapy in a
subject having a cardiovascular disease, the method comprising: a)
determining a level of soluble ST2 in a biological sample from the
subject; and b) comparing the level of soluble ST2 in the
biological sample to an efficacy reference level of soluble ST2,
wherein a decreased level of soluble ST2 in the biological sample
compared to the efficacy reference level of soluble ST2 indicates
that exercise therapy will be effective in the subject, and an
elevated level of soluble ST2 in the biological sample compared to
the efficacy reference level of soluble ST2 indicates that the
exercise therapy will not be effective in the subject.
12. The method of any one of claims 1-9 and 11, wherein the
biological sample comprises blood or serum.
13. The method of any one of claims 1-9 and 11, wherein the
determining is performed using an antibody or an antibody fragment
therof that binds to soluble ST2.
14. The method of any one of claims 1-9 and 11, wherein the risk or
efficacy reference level of soluble ST2 is a predetermined
threshold value.
15. The method of any one of claims 1-9 and 11, wherein the
reference level is a risk reference level
16. The method of claim 15, wherein the reference level is a risk
reference level of soluble ST2 in a subject who experienced or was
more likely to experience an adverse outcome and engaged in
exercise, a level in a population of subjects who experienced or
were more likely to experience an adverse outcome and engaged in
exercise, or a threshold level of soluble ST2 above which the risk
of an adverse outcome is increased in those who engage in exercise
therapy.
17. The method of any one of claims 1-9 and 11, wherein the
reference level is an efficacy reference level.
18. The method of claim 17, wherein the efficacy reference level of
soluble ST2 is a level in a subject who experienced a therapeutic
benefit from exercise therapy, a level in a population of subjects
who experienced a therapeutic benefit from exercise therapy, or a
threshold level of soluble ST2 below which the subject is likely to
experience a therapeutic benefit from exercise therapy.
19. The method of any one of claims 1-9 and 11, wherein the subject
is hypercholesterolemic, hypertriglyceridemic, hyperlidemic, a
smoker, hypertensive, or has a body mass index of greater than
30.
20. The method of any one of claims 1-6, 8, 9, and 11, further
comprising determining a level of cardiac troponin I, B-type
natriuretic peptide, atrial natriuretic peptide, or C-reactive
protein in the biological sample.
21. The method of claim 7, further comprising determining a level
of cardiac troponin I, B type natriuretic peptide, atrial
natriuretic peptide, or C-reactive protein in the biological sample
at the first time point or the biological sample at the second time
point.
22. The method of any one of claims 1-9 and 11, wherein the
cardiovascular disease is selected from the group consisting of:
cardiac hypertrophy, myocardial infarction, stroke,
arteriosclerosis, and heart failure.
23. The method of any one of claims 1-9 and 11, wherein the subject
is administered at least one therapeutic agent selected from the
group consisting of: anti-inflammatory agents, anti-thrombotic
agents, anti-coagulants, anti-platelet agents, lipid-reducing
agents, direct thrombin inhibitors, glycoprotein IIb/IIIb receptor
inhibitors, calcium channel blockers, beta-adrenergic receptor
blockers, cyclooxygenase-2 inhibitors, and
renin-angiotensin-aldosterone system (RAAS) inhibitors.
24. The method of claim 23, wherein the RAAS inhibitor is selected
from the group consisting of: an angiotensin-converting enzyme
inhibitor, an angiotensin II receptor blocker, and an aldosterone
antagonist.
25. The method of claim 23, wherein the lipid-reducing agent is a
statin.
Description
CLAIM OF PRIORITY
[0001] This application is a continuation of U.S. patent
application Ser. No. 14/299,851, filed on Jun. 9, 2014, which
claims the benefit of Ser. No. 13/552,533, filed on Jul. 18, 2012,
which claims the benefit of U.S. Provisional Patent Application
Ser. No. 61/508,923, filed on Jul. 18, 2011, and U.S. Provisional
Patent Application Ser. No. 61/509,359, filed on Jul. 19, 2011, the
entire contents of which are hereby incorporated by reference.
TECHNICAL FIELD
[0002] This invention relates to methods of treating cardiovascular
diseases using exercise therapy, and predicting the efficacy of
exercise therapy.
BACKGROUND
[0003] Circulating biomarkers play a critical role in the diagnosis
and management of patients with chronic heart failure (Braunwald,
N. Engl. J. Med. 358:2148-2159, 2008).
[0004] Natriuretic peptides, such as brain natriuretic peptide
(BNP) and N-terminal pro-BNP (NT-proBNP), have been demonstrated to
be powerful tools for the diagnosis, risk stratification, and
management of patients with heart failure (Felker et al., Canadian
Med. Assoc. J. 175:611-617, 2006). In addition to being useful for
clinical management, biomarkers can provide insights into the
mechanisms underlying important physiologic relationships. Exercise
intolerance, typically manifested as exertional dyspnea, is a major
morbidity of chronic heart failure. Both maximal (e.g., as measured
by peak oxygen uptake [peak VO.sub.2]) (Aaronson et al.,
Circulation 95:2660-2667, 1997; Mancini et al., Circulation
83:778-786, 1991) and submaximal exercise capacity (e.g., as
measured by distance in the 6-minute walk test) (Bittner et al.,
JAMA 270:1702-1707, 1993) have been demonstrated to be of
substantial prognostic importance in chronic heart failure.
[0005] A variety of therapies can be used to treat patients
diagnosed with a cardiovascular disease. For example, exercise
therapy is commonly used to treat patients diagnosed with a
cardiovascular disease (see, for example, Korhonen et al., J.
Womens Health 20:1051-1064, 2011).
SUMMARY
[0006] Applicants have discovered a correlation between the level
of soluble ST2 and the efficacy of exercise therapy in subjects
having a cardiovascular disease, and a correlation between soluble
ST2 level, exercise therapy, and the risk of an adverse outcome
(e.g., death) in a subject having a cardiovascular disease.
[0007] Provided herein are methods of treating a subject having a
cardiovascular disease that, in some embodiments, include
determining a level of soluble ST2 in a biological sample from the
subject, identifying a subject that has a decreased level of
soluble ST2 in the biological sample compared to a risk reference
level of soluble ST2, and selecting the identified subject for
exercise therapy. Also provided are methods of treating a subject
having a cardiovascular disease that include determining a level of
soluble ST2 in a biological sample from the subject, identifying a
subject that has an elevated level of soluble ST2 in the biological
sample compared to a risk reference level of soluble ST2; and
instructing the identified subject not to begin, to discontinue, or
to avoid exercise therapy.
[0008] Also provided are methods of selecting a therapy for a
subject having a cardiovascular disease that include determining a
level of soluble ST2 in a biological sample from the subject, and
comparing the level of soluble ST2 in the biological sample to a
risk reference level of soluble ST2, where a decreased level of
soluble ST2 in the biological sample compared to the risk reference
level indicates that the subject should begin or continue exercise
therapy, and an elevated level of soluble ST2 in the biological
sample compared to the risk reference level indicates that the
subject should not begin or should discontinue exercise
therapy.
[0009] Also provided are methods of identifying a subject having a
cardiovascular disease that will benefit from exercise therapy that
include determining a level of soluble ST2 in a biological sample
from the subject, and selecting a subject that has a decreased
level of soluble ST2 in the biological sample as compared to a risk
reference level of soluble ST2, where the selected subject is
identified as a subject that will benefit from exercise therapy.
Also provided are methods of identifying a subject having a
cardiovascular disease that will not benefit from exercise therapy
that include determining a level of soluble ST2 in a biological
sample from the subject, and selecting a subject that has an
elevated level of soluble ST2 in the biological sample compared to
a risk reference level of soluble ST2, where the selected subject
is identified as a subject that will not benefit from exercise
therapy.
[0010] Also provided are methods of determining whether a subject
having a cardiovascular disease should begin, continue, not begin,
or discontinue exercise therapy that include determining a level of
soluble ST2 in a biological sample from the subject, where a
decreased level of soluble ST2 in the biological sample compared to
a risk reference level of soluble ST2 indicates that the subject
should begin or continue exercise therapy, and an elevated level of
soluble ST2 indicates that the subject should not begin or
discontinue exercise therapy.
[0011] Also provided are methods of determining whether a subject
having a cardiovascular disease should discontinue or continue
exercise therapy that include determining a level of soluble ST2 in
a biological sample from the subject at a first time point before
or after the start of exercise therapy, and determining a level of
soluble ST2 in a biological sample from the subject undergoing
exercise therapy at a second time point after the start of exercise
therapy and after the first time point, where an elevation in the
level of soluble ST2 in the biological sample at the second time
point compared to the level of soluble ST2 in the biological sample
at the first time point indicates that the subject should
discontinue exercise therapy, and a decrease in the level of
soluble ST2 in the biological sample at the second time point
compared to the level of soluble ST2 in the biological sample at
the first time point indicates that the subject should continue
exercise therapy.
[0012] In some embodiments of the methods described herein, the
methods include determining that the subject has a level of soluble
ST2 that is above a first reference level (e.g., a first level
indicating that the subject has a cardiovascular disease, or is at
risk of an adverse cardiovascular event; e.g., as described in U.S.
Pat. No. 7,998,683; US2011/0262941; US2012/0040381; U.S. Pat. No.
8,090,562; US2012/0065897; U.S. Pat. Nos. 7,670,769; 7,655,415;
7,989,210; US2011/0250703; U.S.. Pat. Nos. 7,432,060; 7,985,558;
US2011/028088, all of which are incorporated herein by reference)
and below a second, risk reference level (e.g., below a level
indicating that the subject is at risk of an adverse event if they
engage in exercise, as described herein), and the subject is
selected for exercise therapy. Thus in some embodiments, the
methods include determining that the subject has a level of ST2
that falls within a range that is associated with the presence of a
cardiovascular disease that would benefit from exercise therapy and
the absence of high risk of an adverse event associated with
exercise therapy.
[0013] Also provided are methods of reducing the risk of an adverse
outcome in a subject having a cardiovascular disease that include
determining a level of soluble ST2 in a biological sample from the
subject, identifying a subject that has a decreased level of
soluble ST2 in the biological sample compared to a risk reference
level of soluble ST2, and selecting the identified subject for
exercise therapy. Also provided are methods of reducing the risk of
an adverse outcome in a subject having a cardiovascular disease
that include determining a level of soluble ST2 in a biological
sample from the subject, identifying a subject that has an elevated
level of soluble ST2 in the biological sample compared to a risk
reference level of soluble ST2, and instructing the subject to not
begin or to discontinue exercise therapy. In some embodiments of
these methods, the risk of adverse outcome is risk of death.
[0014] Also provided are methods of predicting the efficacy of
exercise therapy in a subject having a cardiovascular disease that
include determining a level of soluble ST2 in a biological sample
from the subject, and comparing the level of soluble ST2 in the
biological sample to an efficacy reference level of soluble ST2,
where a decreased level of soluble ST2 in the biological sample
compared to the efficacy reference level of soluble ST2 indicates
that the exercise therapy will be effective in the subject, and an
elevated level of soluble ST2 in the biological sample compared to
the efficacy reference level of soluble ST2 indicates that the
exercise therapy will not be effective in the subject.
[0015] In any of the methods described herein, the biological
sample contains blood or serum. In any of the methods described
herein, the determining is performed using an antibody or an
antibody fragment that binds to soluble ST2. In any of the methods
described herein, the reference level of soluble ST2 is a
predetermined threshold value. In any of the methods described
herein, the reference level of soluble ST2 is a level of soluble
ST2 in a healthy subject. In any of the methods described herein,
the subject is hyperchlosterolemic, hypertriglyceridemic,
hyperlipidemic, a smoker, hypertensive, or has a body mass index of
greater than 30. Some embodiments of the methods described herein
further include determining a level of cardiac troponin I, B-type
natriuretic peptide, atrial natriuretic peptide, or C-reactive
protein in the biological sample. Some embodiments of the methods
described herein further include determining a level of level of
cardiac troponin I, B-type natriuretic peptide, atrial natriuretic
peptide, or C-reactive protein in the biological sample at the
first time point or the biological sample at the second time
point.
[0016] In some embodiments of any of the methods described herein,
the cardiovascular disease is selected from the group of: cardiac
hypertrophy, myocardial infarction, stroke, arteriosclerosis, and
heart failure. In some embodiments of any of the methods described
herein, the subject is administered at least one therapeutic agent
selected from the group of: anti-inflammatory agents,
anti-thrombotic agents, anti-coagulants, anti-platelet agents,
lipid-reducing agents (e.g., a statin), direct thrombin inhibitors,
glycoprotein IIb/IIIb receptor inhibitors, calcium channel
blockers, beta-adrenergic receptor blockers, cyclooxygenase-2
inhibitors, and renin-angiotensin-aldosterone system (RAAS)
inhibitors. In some embodiments, the RAAS inhibitor is selected
from the group of: an angiotensin-converting enzyme inhibitor, an
angiotensin II receptor blocker, and an aldosterone antagonist.
[0017] As used herein, the term "cardiovascular disease" refers to
a disorder of the heart and blood vessels, and includes disorders
of the arteries, veins, arterioles, venules, and capillaries.
Non-limiting examples of cardiovascular diseases include cardiac
hypertrophy, myocardial infarction, stroke, arteriosclerosis, and
heart failure. Additional examples of cardiovascular diseases are
known in the art.
[0018] By the term "soluble ST2" is meant a soluble protein
containing a sequence at least 90% identical (e.g., at least 95%,
96%, 97%, 98%, 99%, or 100% identical) to NCBI Accession No.
NP_003847.2 (SEQ ID NO: 1) or containing a sequence at least 90%
identical (e.g., at least 95%, 96%, 97%, 98%, 99%, or 100%
identical) to amino acids 19-328 of SEQ ID NO: 1, or a nucleic acid
containing a sequence at least 90% identical (e.g., at least 95%,
96%, 97%, 98%, 99%, or 100% identical) to NCBI Accession No.
NM_003856.2 (SEQ ID NO: 2) or containing a sequence at least 90%
identical (e.g., at least 95%, 96%, 97%, 98%, 99%, or 100%
identical) to nucleotides 285 to 1214 of SEQ ID NO: 2.
[0019] By the term "elevated" or "elevation" is meant a difference,
e.g., the presence of a statistically significant or detectable
increase in a determined or measured level (e.g., a human soluble
ST2 protein level) compared to a reference level (e.g., a level of
human soluble ST2 in a subject not having a disease, a subject not
presenting with two or more symptoms of a disease, or a subject not
identified as being at risk of developing a disease, or a threshold
level of human soluble ST2). In some embodiments, the reference is
a threshold level, and any level above that is considered
"elevated." Additional reference levels of human soluble ST2 are
described herein and are known in the art.
[0020] By the term "reference level" is meant a threshold level or
a level in a control subject or control patient population. A
reference level will depend on the assay performed and can be
determined by one of ordinary skill in the art. Non-limiting
examples of reference levels are described herein and are known in
the art. Reference levels of human soluble ST2 can be determined
using methods known in the art.
[0021] In some embodiments, the reference level is a risk reference
level, e.g., a risk reference level of soluble ST2 in a subject who
experienced or was more likely to experience an adverse outcome and
engaged in exercise, a level in a population of subjects who
experienced or were more likely to experience an adverse outcome
and engaged in exercise, or a threshold level of soluble ST2 above
which the risk of an adverse outcome is increased in those who
engage in exercise therapy.
[0022] In some embodiments, the reference level is an efficacy
reference level, e.g., an efficacy reference level of soluble ST2
is a level in a subject who experienced a therapeutic benefit from
exercise therapy, a level in a population of subjects who
experienced a therapeutic benefit from exercise therapy, or a
threshold level of soluble ST2 below which the subject is likely to
experience a therapeutic benefit from exercise therapy.
[0023] By the term "additional marker" is meant a protein, nucleic
acid, lipid, or carbohydrate, or a combination (e.g., two or more)
thereof, that is diagnostic of the presence of a particular
disease. The methods described herein can include detecting the
level of soluble human ST2 and at least one additional marker in a
biological sample from a subject. Non-limiting examples of
additional markers that can be detected include: proANP, NT-proANP,
ANP, proBNP, NT-proBNP, BNP, troponin, CRP, creatinine, Blood Urea
Nitrogen (BUN), liver function enzymes, albumin, and bacterial
endotoxin; and those markers described in U.S. Patent Application
Publication Nos.: 2007/0248981; 2011/0053170; 2010/0009356;
2010/0055683; and 2009/0264779 (each of which is hereby
incorporated by reference).
[0024] By the term "hypertriglyceridemia" is meant a triglyceride
level that is greater than or equal to 180 ng/mL (e.g., greater
than or equal to 200 ng/mL).
[0025] By the term "hypercholesterolemia" is meant an increased
level of at least one form of cholesterol or total cholesterol in a
subject. For example, a subject with hypercholesterolemia can have
a high density lipoprotein (HDL) level of .gtoreq.40 mg/dL (e.g.,
.gtoreq.50 mg/dL or .gtoreq.60 mg/mL), a low density lipoprotein
(LDL) level of .gtoreq.130 mg/dL (e.g., .gtoreq.160 mg/dL or
.gtoreq.200 mg/dL), and/or a total cholesterol level of .gtoreq.200
mg/dL (e.g., 240 mg/dL).
[0026] By the term "hypertension" is meant an increased level of
systolic and/or diastolic blood pressure. For example, a subject
with hypertension can have a systolic blood pressure that is
.gtoreq.120 mmHg (e.g., .gtoreq.140 mmHg or .gtoreq.160 mmHg)
and/or a diastolic blood pressure that is .gtoreq.80 mmHg (e.g.,
.gtoreq.90 mmHg or .gtoreq.100 mmHg).
[0027] By the term "healthy subject" is meant a subject that does
not have a disease (e.g., cardiovascular disease). For example, a
healthy subject has not been diagnosed as having a disease and is
not presenting with two or more (e.g., two, three, four, or five)
symptoms of a disease state.
[0028] By "risk of death" is meant the risk of death in a subject
from a disease or complications associated with a disease (e.g., a
cardiovascular disease) compared to a reference population. The
term risk of death as used herein excludes intentional or
accidental death, e.g., death by blunt or crushing trauma, such as
a car accident.
[0029] As used herein, a "biological sample" includes one or more
of blood, serum, plasma, urine, and body tissue. Generally, a
biological sample is a sample containing serum, blood, or
plasma.
[0030] By the term "statin" is meant a therapeutic molecule that
inhibits the enzyme HMG-CoA reductase. Non-limiting examples of
statins include: atorvastatin, fluvastatin, lovastatin,
pitavastatin, pravastatin, rosuvastatin, and simvastatin.
Additional examples of statins are known in the art.
[0031] By "adverse outcome" is meant any detrimental event that
occurs in a subject as a result of a disease (e.g., a
cardiovascular disease). Non-limiting examples of adverse outcomes
in a subject having a cardiovascular disease include: organ
failure, organ transplantation, hospitalization or
rehospitalization, recurrence of one or more symptoms of a
cardiovascular disease, development of one or more additional
symptoms of a cardiovascular disease, an increase in the frequency,
intensity, or duration of one or more symptoms of a cardiovascular
disease experienced by the subject, a first or subsequent
myocardial infarction, or death (mortality). In preferred
embodiments, the adverse outcome is mortality.
[0032] Unless otherwise defined, all technical and scientific terms
used herein have the same meaning as commonly understood by one of
ordinary skill in the art to which this invention belongs. Methods
and materials are described herein for use in the present
invention; other, suitable methods and materials known in the art
can also be used. The materials, methods, and examples are
illustrative only and not intended to be limiting. All
publications, patent applications, patents, sequences, database
entries, and other references mentioned herein are incorporated by
reference in their entirety. In case of conflict, the present
specification, including definitions, will control.
[0033] The details of one or more embodiments of the invention are
set forth in the accompanying drawings and the description below.
Other features, objects, and advantages of the invention will be
apparent from the description and drawings, and from the
claims.
DESCRIPTION OF DRAWINGS
[0034] FIG. 1 is a Kaplan-Meier graph showing the surviving
proportion of heart failure subjects over time within the
identified groups. The survival data for subjects having a soluble
ST2 level less than or equal to 20.4 ng/mL (top line); greater than
20.4 ng/mL, but less than or equal to 28.6 ng/mL (middle line); and
greater than 28.6 ng/mL (bottom line) are shown (log-rank test,
p<0.001).
[0035] FIG. 2 is a graph and table showing the percentage of
mortality in heart failure subjects over time. The percentage
mortality data for heart failure subjects having a soluble ST2
level equal to or less than 35 ng/mL (left bar for each time
point), or greater than 35 ng/mL (right bar for each time point)
are shown. The table also shows the relative risk of mortality at
each time point for subjects having a soluble ST2 level greater
than 35 ng/mL compared to subjects having a soluble ST2 level less
than or equal to 35 ng/mL.
[0036] FIG. 3 is a Kaplan-Meier graph showing the surviving
proportion of heart failure subjects over time within the
identified groups. The survival data for subjects having a soluble
ST2 level equal to or less than 35 ng/mL and performing an exercise
treatment regimen (top line), subjects having a level of soluble
ST2 greater than 35 ng/mL and not performing an exercise treatment
regimen (second line from top), subject having a level of soluble
ST2 greater than 35 ng/mL and not performing an exercise treatment
regime (second line from bottom), and subjects having a level of
soluble ST2 equal to or less than 35 ng/mL and performing an
exercise treatment regime (bottom line) are shown.
[0037] FIG. 4 is a graph of the hazard ratio for mortality within 1
year in heart failure subjects performing an exercise treatment
regime compared to heart failure subjects not performing an
exercise treatment regime having the different soluble ST2 levels
shown.
[0038] FIG. 5 shows the protein sequence of Soluble Human ST2.
Signal Peptide Amino acids 1-18 (underlined); Mature Peptide after
removal of signal sequence amino acids (19-328).
[0039] FIG. 6 shows the mRNA sequence of soluble human ST2.
Nucleotides 285 to 1214 encode the amino acid sequence (without the
signal sequence) of soluble human ST2.
[0040] FIGS. 7A-B shows the protein sequence of the long form of
human St2 (membrane-bound). Signal Peptide Amino acids 1-18
(underlined); Mature Peptide after removal of signal sequence amino
acids (19-556).
[0041] FIG. 8 shows the mRNA sequence of human ST2. Nucleotides 326
to 1939 encode the amino acid sequence (without the signal
sequence) of the long form of human ST2.
DETAILED DESCRIPTION
[0042] Provided herein are methods of treating a subject having a
cardiovascular disease;
[0043] selecting a therapy for a subject having a cardiovascular
disease; identifying a subject that will benefit or will not
benefit from exercise therapy; determining whether a subject having
a cardiovascular disease should begin, continue, or discontinue
exercise therapy; and predicting the efficacy of exercise therapy
in a subject having a cardiovascular disease. Also provided are
methods of reducing the risk an adverse outcome (e.g., death) in a
subject having a cardiovascular disease. These methods require
determining a level of soluble ST2 in a biological sample from the
subject.
Cardiovascular Diseases
[0044] A cardiovascular disease is a disorder of the heart and
blood vessels (e.g., disorders of the arteries, veins, arterioles,
venules, and capillaries). Cardiovascular diseases can be diagnosed
using methods known in the art. Non-limiting examples of
cardiovascular disease include congestive heart failure, stroke,
acute coronary artery disease, arrhythmia, asymmetric septal
hypertrophy (e.g., left ventricular hypertrophy with resultant
diastolic dysfunction), cardiomyopathy, valvular dysfunction,
pericarditis, atherosclerosis, and myocardial infarction. A subject
can be diagnosed as having a cardiovascular disease by a medical
professional (e.g., a physician, a physician's assistant, a nurse,
a nurse's assistant, or a laboratory technician) using exemplary
methods described herein. Additional methods for diagnosing a
cardiovascular disease are known in the art.
[0045] Heart failure is a clinical syndrome of diverse etiologies
linked by the common feature of impaired heart pumping and
characterized by the failure of the heart to pump blood
commensurate with the requirements of the metabolizing tissues.
Heart failure can be diagnosed in a subject by the observation of
one or more of the following non-limiting symptoms in a subject:
dyspnea, fatigue and weakness, edema in the legs, ankles, and feet,
rapid or irregular heartbeat, reduced ability to exercise,
persistent cough or wheezing, white or pink blood-tinged phlegm,
abdominal swelling (ascites), sudden weight gain from fluid
retention, lack of appetite, nausea, difficulty concentrating or
decreased alertness, and chest pain. Additional non-limiting
methods for diagnosing heart failure in a subject include the use
of commercially available diagnostic tests (e.g., enzyme-linked
immunosorbent assays) known in the art.
[0046] A myocardial infarction is a focus of necrosis resulting
from inadequate perfusion of the cardiac tissue. Myocardial
infarction generally occurs from an abrupt decrease in coronary
blood flow that follows a thrombotic occlusion of a coronary artery
previously narrowed by atherosclerosis. Generally, a myocardial
infarction occurs when an atherosclerotic plaque fissures,
ruptures, or ulcerates, and a mural thrombus forms leading to
coronary artery occlusion. Non-limiting methods of diagnosing a
myocardial infarction include the use of a number of commercially
available diagnostic tests known in the art. Generally, these
diagnostic tests may be divided into four main categories: (1)
nonspecific indexes of tissue necrosis and inflammation; (2)
electrocardiograms; (3) serum enzyme changes (e.g., creatine
phosphokinase levels); and (4) cardiac imaging. A myocardial
infarction can also be diagnosed by the observation of one or more
of the following symptoms in a subject: chest pain (typically on
the left side of the body), neck or jaw pain, shoulder or arm pain,
clammy skin, dyspnea, nausea, and vomiting. Additional methods of
diagnosing a myocardial infarction are known in the art.
[0047] A stroke can be diagnosed in a subject by the observation of
one or more symptoms and/or by a physical examination (e.g.,
interventional and non-interventional diagnostic tools, such as
computed tomography and magnetic resonance imaging). Non-limiting
symptoms of a stroke include: paralysis, weakness, decreased
sensation and/or vision, numbness, tingling, aphasia (e.g.,
inability to speak or slurred speech, or difficulty reading or
writing), agnosia (i.e., inability to recognize or identify sensory
stimuli), loss of memory, coordination difficulties, lethargy,
sleepiness or unconsciousness, lack of bladder or bowel control,
and cognitive decline (e.g., dementia, limited attention span, and
inability to concentrate). In some examples, medical imaging
techniques can be used identify a subject having an infarct or a
hemorrhage in the brain.
[0048] Cardiac hypertrophy is typically characterized by left
ventricular hypertrophy, usually of a non-dilated chamber, that
occurs without an obvious antecedent cause. Cardiac hypertrophy can
be diagnosed through the use of electrocardiography or
echocardiography.
[0049] Arteriosclerosis is a cardiovascular disease characterized
by a hardening or loss of elasticity. Arteriosclerosis can be
diagnosed by the detection of one or more of the following physical
symptoms: a weak or absent pulse below the narrowed area of an
artery, decreased blood pressure in an affected limb, bruits caused
by turbulent flow in an artery, an aneurysm in the abdomen or
behind the knee, poor wound healing, and increased levels of
cholesterol. Atherosclerosis can also be detected using imaging
techniques including, but not limited to: Doppler ultrasound,
electrocardiography, angiography, computed tomography, or magnetic
reasonance (e.g., magnetic reasonance angiography).
[0050] A subject can be diagnosed as having a cardiovascular
disease following admission to a hospital or following presentation
to a health care clinic. Effective therapeutic treatment of a
cardiovascular disease can be determined by observing a decrease in
the number of symptoms of a cardiovascular disease in a subject or
a decrease in the frequency, intensity, and/or duration of one or
more symptoms of a cardiovascular disease (e.g., any of the
symptoms described herein) in a subject. Effective therapeutic
treatment of a cardiovascular disease can also be determined by
detecting a decrease in the levels of one or more markers of a
cardiovascular disease (e.g., any of the markers of cardiovascular
disease known in the art or described herein) in a biological
sample from a subject over time (e.g., a significant decrease in
the level of at least one marker at a second time point compared to
the level of the biomarker at a first time point prior to the start
of treatment or at an earlier time point during the treatment
period). Successful treatment of a cardiovascular disease can also
be determined by a decreased risk of an adverse event (e.g., a
decreased risk of death, hospitalization or rehospitalization,
organ failure, organ transplantation, or a first or subsequent
myocardial infarction) (e.g., compared to the risk of an adverse
event in patient population diagnosed with the same cardiovascular
disease but receiving no treatment or a different treatment).
Exercise Therapy
[0051] Subjects diagnosed as having a cardiovascular disease are
often directed/instructed by a healthcare provider to perform an
exercise therapy regime. Exercise therapy is a treatment regime
that involves the periodic performance of physical activity by a
subject (e.g., a subject diagnosed as having a cardiovascular
disease). The physical activity performed during this type of
therapy can be aerobic (e.g., walking, jogging/running, swimming,
biking, or rowing) or anaerobic (e.g., weight lifting or resistance
training) exercise. The physical activity can be performed in the
presence of a health care professional (e.g., a physical therapist,
a nurse, a nurse's assistant, a physician's assistant, or a
physician). The physical activity can be performed at least once a
week (e.g., at least once a day, twice a day, two times a week,
three times a week, four times a week, five times a week, or six
times a week). In some embodiments, a single episode of physical
activity within the exercise therapy regime can last between 5
minutes and 3 hours, between 5 minutes and 2 hours, between 5
minutes and 1 hour, or between 10 minutes and 1 hour. The intensity
and/or type of the physical activity performed by the subject can
vary with the physical condition of the subject (e.g., age,
severity of cardiovascular disease, additional disease states,
weight, and blood pressure). A subject can continue to perform an
exercise therapy regime over an extended period of time (e.g., over
a period of 1 month to 1 year, 1 month to 2 years, 1 year to 3
years, 2 years to 5 years, or 4 years to 10 years). In some
embodiments, a subject can be monitored by a health care
professional to adjust one or more parameters of the exercise
therapy regime, including the frequency, intensity, length of
individual episodes of physical activity, and the type of physical
activity performed. The efficacy of exercise therapy in a subject
having a cardiovascular disease can be determined using any of the
methods for determining successful treatment of a cardiovascular
disease (e.g., those methods described herein or known in the art).
A subject can continue to perform an exercise therapy regime until
instructed by a health care professional to discontinue the
exercise therapy or until a specific therapeutic outcome has been
achieved (e.g., a decrease in the number of symptoms of a
cardiovascular disease has been achieved, a decrease in severity,
intensity, or frequency of one or more symptoms of a cardiovascular
disease has been achieved, or a decrease in the levels of one or
more markers of a cardiovascular disease has been achieved in the
subject).
ST2
[0052] The ST2 gene is a member of the interleukin-1 receptor
family whose protein product exists both as a trans-membrane form
as well as a soluble receptor that is detectable in serum (Kieser
et al., FEBS Lett. 372(2-3):189-193, 1995; Kumar et al., J. Biol.
Chem. 270(46):27905-27913, 1995; Yanagisawa et al., FEBS Lett.
302(1):51-53, 1992; Kuroiwa et al., Hybridoma 19(2):151-159, 2000).
Soluble ST2 was described to be markedly up-regulated in an
experimental model of heart failure (Weinberg et al., Circulation
106(23):2961-2966, 2002), and data suggest that human soluble ST2
concentrations are also elevated in those with chronic severe heart
failure (Weinberg et al., Circulation 107(5):721-726, 2003), as
well as in those with acute myocardial infarction (Shimpo et al.,
Circulation 109(18):2186-2190, 2004).
[0053] Without wishing to be bound by theory, the transmembrane
form of ST2 is thought to play a role in modulating responses of T
helper type 2 cells (Lohning et al., Proc. Natl. Acad. Sci. U.S.A.
95(12):6930-6935, 1998; Schmitz et al., Immunity 23(5):479-490,
2005), and may play a role in development of tolerance in states of
severe or chronic inflammation (Brint et al., Nat. Immunol.
5(4):373-379, 2004), while the soluble form of ST2 is up-regulated
in growth stimulated fibroblasts (Yanagisawa et al., 1992, supra).
Experimental data suggest that the ST2 gene is markedly
up-regulated in states of cardiomyocyte stretch (Weinberg et al.,
2002, supra) in a manner analogous to the induction of the BNP gene
(Bruneau et al., Cardiovasc. Res. 28(10):1519-1525, 1994).
[0054] Tominaga et al. (FEBS Lett. 258:301-304, 1989) isolated
murine genes that were specifically expressed by growth stimulation
in BALB/c-3T3 cells. Haga et al. (Eur. J. Biochem. 270:163-170,
2003) describes that the ST2 gene was named on the basis of its
induction by growth stimulation. The ST2 gene encodes two protein
products: ST2 or sST2, which is a soluble secreted form, and ST2L,
a transmembrane receptor form that is very similar to the
interleukin-1 receptors. The HUGO Nomenclature Committee designated
the human homolog of ST2, the cloning of which was described in
Tominaga et al., Biochim. Biophys. Acta. 1171:215-218, 1992, as
Interleukin 1 Receptor-Like 1 (IL1RL1). The two terms are used
interchangeably in the art.
[0055] The mRNA sequence of the shorter, soluble isoform of human
ST2 can be found at GenBank Acc. No. NM_003856.2 (SEQ ID NO: 2),
and the polypeptide sequence is at GenBank Acc. No. NP_003847.2
(SEQ ID NO: 1). The mRNA sequence for the longer form of human ST2
is at GenBank Acc. No. NM_016232.4 (SEQ ID NO: 4), and the
polypeptide sequence is at GenBank Acc. No. NP_057316.3 (SEQ ID NO:
3). Additional information is available in the public databases at
GeneID: 9173, MIM ID #601203, and UniGene No. Hs.66.
[0056] Methods for detecting and measuring soluble ST2 are known in
the art, e.g., as described in U.S. Patent Application Publication
Nos. 2003/0124624, 2004/0048286, and 2005/0130136, and U.S. patent
application Ser. No. 13/083,333 and PCT Application No.
PCT/US2011/031801, the entire contents of which are incorporated
herein by reference. These U.S. patent application publications
describe methods of determining the level of soluble ST2 using an
antibody or antibody fragment that binds to soluble ST2. Kits for
measuring soluble ST2 are also commercially available, e.g., the
ST2 ELISA Kit manufactured by Medical & Biological Laboratories
Co., Ltd. (MBL International Corp., Woburn, Mass.), No. 7638. In
addition, devices for measuring ST2 and other biomarkers are
described in U.S. Patent Application Publication No. 2005/0250156
(incorporated herein by reference in its entirety).
[0057] As described in detail herein, soluble ST2 levels can be
determined in any biological sample from a subject, including
blood, serum, plasma, urine, and body tissue. Generally, the level
of soluble ST2 is determined in a sample containing serum, blood,
or plasma. The level of soluble ST2 can be determined in a
biological sample that has been stored for a period of time (e.g.,
for at least 1 hour, 1 day, 1 week, or 1 month) at a temperature at
or below 10.degree. C. (e.g., below 0.degree. C., below -20.degree.
C., or around -196.degree. C.).
[0058] Elevated concentrations of soluble ST2 are markedly
prognostic for death in patients with heart failure, with a
dramatic divergence in survival curves for those with elevated
soluble ST2 soon after presentation (Weinberg et al., Circulation
107:721-726, 2003; Mueller et al., Clin Chem. 54(4):752-756, 2008;
Daniels et al., Am. Heart J. 160:721-728, 2010; Ky et al., Circ.
Heart Fail. 4(2):180-187, 2011; and Manzano-Fernandez et al., Am.
J. Cardiol. 107:259-267, 2011). The relationship between soluble
ST2 and death in heart failure patients was shown to be independent
of etiology, and superseded all other biomarker predictors of
mortality in this setting, including other markers of inflammation,
myonecrosis, renal dysfunction, and most notably NT-proBNP, a
marker well known as having value for predicting death in heart
failure patients.
Reference Levels of ST2
[0059] As described herein, the level of soluble ST2 in a subject
indicates whether a subject having a cardiovascular disease should
be selected for exercise therapy, whether a subject will benefit or
will not benefit from exercise therapy, or whether a subject should
begin, continue, or discontinue exercise therapy. In addition, the
level of soluble ST2 in a subject can be used to select a therapy
including exercise for a subject having a cardiovascular disease.
Additional clinical and therapeutic uses of detecting a level of
soluble ST2 are described herein and are known in the art.
Reference levels of human soluble ST2 can be determined using
methods known in the art (e.g., using the antibodies described in
U.S. patent application Ser. No. 13/083,333 and PCT Application No.
PCT/US2011/031801). In general, it will be desirable to use a
reference level of soluble ST2 determined using the same method as
is used to determine the level of soluble ST2 in the subject.
Risk Reference Levels
[0060] The methods described herein can include comparing the level
of soluble ST2 in a biological sample to a reference level of
soluble ST2. A reference level of soluble ST2 can be or represent a
level of soluble ST2 found in a biological sample from a subject
(e.g., a control subject who experienced or was more likely to
experience an adverse outcome and engaged in exercise) or a
population (e.g., a population of subjects who experienced or were
more likely to experience an adverse outcome and engaged in
exercise), or can be or represent a threshold level of soluble ST2
above which the risk of an adverse outcome is increased in those
who engage in exercise therapy. These reference levels are referred
to herein as the "risk reference level." In general, the presence
of a level of ST2 below the risk reference level indicates that the
subject does not have an elevated risk of an adverse outcome if
they engage in exercise therapy, while the presence of a level of
ST2 above the risk reference level indicates that the subject has
an elevated risk of an adverse outcome if they do engage in
exercise therapy.
[0061] In some embodiments, the risk reference level of soluble ST2
is a threshold level of soluble ST2 or a percentile (e.g., 75th,
80th, 85th, 90th, or 95th percentile) of soluble ST2 levels in a
population of subjects who experienced an adverse outcome and
engaged in exercise.
[0062] In some embodiments, efficacy reference level is about 55
ng/mL, determined using the Presage ST2 kit, or the equivalent
thereof.
Efficacy Reference Levels
[0063] Alternatively or in addition, the methods described herein
can include comparing the level of soluble ST2 in a biological
sample to a reference level of soluble ST2 that is or represents a
level of soluble ST2 found in a biological sample from a subject
(e.g., a control subject who experienced a therapeutic benefit from
exercise therapy, i.e., did not or was less likely to experience an
adverse outcome and engaged in exercise) or a population (e.g., a
population of subjects who experienced a therapeutic benefit from
exercise therapy, i.e., did not experience or were less likely to
experience an adverse outcome and engaged in exercise), or can be
or represent a threshold level of soluble ST2 below which the
subject is likely to experience a therapeutic benefit from exercise
therapy, i.e., a threshold level of soluble ST2 below which the
likelihood of an adverse outcome is decreased in those who engage
in exercise therapy. These reference levels are referred to herein
as the "efficacy reference level." In general, the presence of a
level of ST2 below the efficacy reference level indicates that the
subject has an increased likelihood of not experiencing an adverse
outcome if they engage in exercise therapy, while the presence of a
level of ST2 above the efficacy reference level indicates that the
subject has an elevated risk of an adverse outcome if they do
engage in exercise therapy.
[0064] In some embodiments, the efficacy reference level of soluble
ST2 is a threshold level of soluble ST2 or a percentile (e.g.,
75th, 80th, 85th, 90th, or 95th percentile) of soluble ST2 levels
in a population of subjects who experienced an adverse outcome and
engaged in exercise.
[0065] In some embodiments, efficacy reference level is about 35
ng/mL, determined using the Presage ST2 kit, or the equivalent
thereof.
Healthy Controls and Other Reference Levels
[0066] In some embodiments, the methods described herein can also
include comparing the level of soluble ST2 in a biological sample
to a reference level of soluble ST2 that represent the average
level of soluble ST2 present in a population of subjects: a
population of subjects diagnosed as having a specific
cardiovascular disease, a population of healthy subjects not
diagnosed with a disease (e.g., a healthy male patient population
or a healthy female patient population), a population of subjects
not at risk of developing a cardiovascular disease, or a population
of subjects not presenting with two or more symptoms of a
cardiovascular disease. A reference level can also be a baseline
level or a level in the same patient measured at an earlier or
later point in time. Additional non-limiting examples of reference
levels of human soluble ST2 include the level of human soluble ST2
in a subject or a patient population that: does not have high risk
cardiovascular disease; does not have renal failure; does not have
hypertriglyceridemia, hypercholesterolemia, hypertension, and/or a
body mass index of <30 (e.g., a BMI under 25); and/or does not
suffer from a pulmonary disease, sepsis, or Kawasaki disease.
[0067] In some embodiments, the reference level of soluble ST2 is a
threshold level of soluble ST2. In some embodiments, the threshold
level of soluble ST2 is a median level of soluble ST2 or a
percentile (e.g., 75th, 80th, 85th, 90th, or 95th percentile) of
soluble ST2 levels in a healthy patient population, e.g., a healthy
male patient population or a healthy female patient population
(e.g., any of the values or ranges listed in Table 1).
TABLE-US-00001 TABLE 1 sST2 Concentrations at Specific Thresholds-
US Self-Reported Healthy Cohort.sup.1 Entire Cohort Male Female
Per- ST2 ST2 ST2 cen- (ng/ (ng/ (ng/ tiles mL) 95% CI mL) 95% CI
mL) 95% CI 2.5 8.0 7.1 to 8.6 8.6 7.7 to 11.8 7.3 5.5 to 8.4 5 9.3
8.4 to 10.2 11.8 8.6 to 12.7 8.5 7.3 to 9.4 10 11.5 10.3 to 11.9
13.7 12.2 to 14.8 10.2 9.0 to 11.2 25 14.5 13.7 to 15.2 17.6 16.8
to 18.7 12.4 11.9 to 13.5 me- 18.8 18.2 to 19.9 23.6 21.3 to 25.1
16.2 15.4 to 17.4 dian 75 25.3 23.8 to 26.9 30.6 28.7 to 33.3 19.9
18.8 to 20.8 90 34.3 32.4 to 35.6 37.2 35.5 to 40.9 23.7 22.2 to
25.8 95 37.9 35.9 to 41.3 45.4 39.4 to 48.6 29.0 24.6 to 33.2 97.5
45.6 40.1 to 48.7 48.5 45.8 to 58.5 33.1 29.6 to 39.9 .sup.1These
levels were determined using the antibodies described in U.S.
patent application Ser. No. 13/083,333 and PCT Application No.
PCT/US2011/031801.
[0068] In some embodiments, the threshold level is 28.6 ng/mL,
about 28 ng/mL to about 35 ng/mL, 35 ng/mL, about 35 ng/mL to about
45 ng/mL, about 45 ng/mL to about 55 ng/mL, or the range of 55 to
60 ng/mL (e.g., the entire range or any level between 55 to 60
ng/mL) (e.g., using the antibodies described in U.S. patent
application Ser. No. 13/083,333 and PCT Application No.
PCT/US2011/031801). Reference levels of human soluble ST2 can be
determined using methods known in the art (e.g., using the
antibodies described in U.S. patent application Ser. No. 13/083,333
and PCT Application No. PCT/US2011/031801). Additional reference
levels of soluble ST2 are known in the art. As is known in the art,
the reference level of soluble ST2 can vary based on the assay used
to determine soluble ST2 levels.
Subjects
[0069] The methods described herein can be performed on a variety
of subjects having a cardiovascular disease (e.g., any of the
subjects described herein). In some embodiments of any of the
methods, the subject has been previously diagnosed as having a
cardiovascular disease. In some embodiments of any of the methods,
the subject is hyperchlosterolemic, hypertriglyceridemic,
hyperlidemic, a smoker, hypertensive, or has a body mass index of
greater than 25 (e.g., between 25 and 30, or greater than 30). In
some embodiments of any of the methods, the subject can already be
receiving a therapeutic agent (e.g., one or more of the additional
therapeutic agents described herein or known in the art for
treating a cardiovascular disease). In some embodiments, the
subject has heart failure.
[0070] In some embodiments of any of the methods, the subject can
have previously been admitted to a hospital or can be receiving
treatment on an outpatient basis. In some embodiments of any of the
methods, the patient can be 20 to 40 years old, 40 to 50 years old,
50 to 60 years old, 60 to 70 years old, 70 to 80 years old, 80 to
90 years old, or 90 to 100 years old.
Methods of Treating a Subject having a Cardiovascular Disease
[0071] Provided herein are methods of treating a subject having a
cardiovascular disease (e.g., any of the cardiovascular diseases
described herein or known in the art, e.g., heart fauilure). These
methods include determining a level of soluble ST2 in a biological
sample from the subject, identifying a subject that has a decreased
(e.g., a significant or detectable decrease) level of soluble ST2
in the biological sample compared to a risk or efficacy reference
level of soluble ST2 (e.g., as described herein), and selecting the
identified subject for exercise therapy (e.g., any form of exercise
therapy described herein or known in the art). Also provided are
methods of treating a subject that include determining a level of
soluble ST2 in a biological sample from the subject, identifying a
subject that has an increased (e.g., a significant or detectable
increase) level of soluble ST2 in the biological sample compared to
a risk or efficacy reference level of soluble ST2 (e.g., as
described herein), and instructing the identified subject not to
begin, to discontinue, or to avoid exercise therapy. The level of
soluble ST2 in the biological sample can be determined using any of
the methods described herein (e.g., methods using an antibody or
antibody fragment that binds specifically to soluble ST2). The
biological sample can be any of the biological samples described
herein. In some embodiments, the biological sample is collected
from a subject within 2 or 4 years of diagnosis with a
cardiovascular disease, a myocardial infarction, or heart
failure.
[0072] The selected subject can begin performance of any of the
exercise therapy regimes described herein. Some embodiments of
these methods further include monitoring the subject to determine
whether the exercise therapy regime should be continued or altered
in one or more aspects (e.g., any of the aspects of exercise
therapy regimes described herein). Methods for monitoring the
subject to determine whether the exercise therapy should be
continued or discontinued are described herein. These methods can
be performed by any health care professional (e.g., a physician, a
physical therapist, a nurse, a physician's assistant, a laboratory
technician, or a nursing assistant).
[0073] In some embodiments, the treating results in a reduced
(e.g., a significant decrease) in the risk of an adverse outcome
(e.g., any of the adverse outcomes described herein) in the
subject. In some embodiments, the treating results in a decrease in
the number of symptoms of a cardiovascular disease, a decrease
(e.g., a significant or detectable decrease) in the intensity,
frequency, or duration of one or more symptoms of a cardiovascular
disease, or a decrease in the level of at least one marker of a
cardiovascular disease in a biological sample from the subject.
Methods of Selecting a Therapy for a Subject having a
Cardiovascular Disease
[0074] Also provided are methods of selecting a therapy for a
subject having a cardiovascular disease. These methods include
determining a level of soluble ST2 in a biological sample from the
subject and comparing the level of soluble ST2 in the biological
sample to a risk or efficacy reference level of soluble ST2 (e.g.,
any of the reference levels of soluble ST2 described herein or
known in the art), where a decreased (e.g., a significant or
detectable decrease) level of soluble ST2 in the biological sample
compared to the risk or efficacy reference level of soluble ST2
indicates that the subject should begin or continue exercise
therapy (e.g., any of the exercise therapy regimes described
herein), and an elevated (e.g., a significant or detectable
increase) level of soluble ST2 in the biological sample compared to
the risk or efficacy reference level of soluble ST2 indicates that
the subject should not begin or should discontinue exercise
therapy. The level of soluble ST2 in the biological sample can be
determined using any of the methods described herein, and the
biological sample can be any of the biological samples described
herein. In some embodiments, the biological sample is collected
from a subject within 2 or 4 years of diagnosis with a
cardiovascular disease, a myocardial infarction, or heart failure.
These methods can be performed by any health care professional
(e.g., a physician, a physical therapist, a nurse, a physician's
assistant, a laboratory technician, or a nursing assistant). In
some embodiments, the subject can already be performing an exercise
therapy regime.
Methods of Identifying a Subject that will Benefit/Not Benefit from
Exercise Therapy
[0075] Also provided herein are methods for identifying a subject
that will benefit from exercise therapy (benefit from the
performance of any of the exercise therapy regimes described
herein). The methods include determining a level of soluble ST2 in
a biological sample from the subject, and selecting a subject that
has a decreased (e.g., a significant or detectable decrease) level
of soluble ST2 in the biological sample compared to an efficacy
reference level of soluble ST2 (e.g., any of the reference levels
of soluble ST2 described herein or known in the art), where the
selected subject is identified as a subject that will benefit from
exercise therapy (e.g., any of the exercise therapy regimes
described herein). Also provided are methods of identifying a
subject that will not benefit from exercise therapy (will not
benefit from the performance of any of the exercise therapy regimes
described herein) that include determining a level of soluble ST2
in a biological sample from the subject, and selecting a subject
that has an elevated (e.g., a significant or detectable increase)
level of soluble ST2 in the biological sample compared to an
efficacy reference level of soluble ST2 (e.g., any of the reference
levels of soluble ST2 described here in or known in the art), where
the selected subject is identified as a subject that will not
benefit from exercise therapy (e.g., any of the exercise therapy
regimes described herein).
[0076] In some embodiments, the biological sample is collected from
a subject within 2 or 4 years of diagnosis with a cardiovascular
disease, a myocardial infarction, or heart failure. In some
embodiments, the efficacy reference level of soluble ST2 is a
threshold soluble ST2 level of less than or equal to 35 ng/mL or a
range of 55 to 60 ng/mL (e.g., the entire range or any level
between 55 to 60 ng/mL). The level of soluble ST2 in the biological
sample can be determined using any of the methods described herein
(e.g., methods using an antibody or antibody fragment that binds
specifically to soluble ST2), and the biological sample can be any
of the biological samples described herein.
[0077] In some embodiments of these methods, the subject has been
previously diagnosed as having a cardiovascular disease (e.g.,
previously diagnosed as having heart failure). In some embodiments,
the subject is hyperchlosterolemic, hypertriglyceridemic,
hyperlidemic, a smoker, hypertensive, or has a body mass index of
greater than 25 (e.g., between 25 and 30, or greater than 30). In
some embodiments, the subject can already be receiving a
therapeutic agent (e.g., one or more of the additional therapeutic
agents described herein or known in the art for treating a
cardiovascular disease). In some embodiments, the subject can have
previously been admitted to a hospital or can be receiving
treatment on an outpatient basis. In some embodiments, the patient
can be 20 to 40 years old, 40 to 50 years old, 50 to 60 years old,
60 to 70 years old, 70 to 80 years old, 80 to 90 years old, or 90
to 100 years old.
[0078] In some embodiments, the benefit from exercise therapy can
be one or more of the following: a reduction (e.g., a significant
decrease) in the risk of an adverse outcome (e.g., any of the
adverse outcomes described herein) in the subject, a reduction in
the number of symptoms of a cardiovascular disease, a reduction
(e.g., a detectable or observable decrease) in the intensity,
frequency, or duration of one or more symptoms of a cardiovascular
disease, or a reduction (e.g., detectable decrease) in the levels
of at least one marker of a cardiovascular disease in a biological
sample from the subject (e.g., as compared to a subject or
population of subjects having the same cardiovascular disease but
not receiving therapy or receiving a different therapy). The
benefit from exercise therapy can be determined at various time
points in a subject (e.g., after at least 6 months of exercise
therapy, after 1 year of exercise therapy, or after 2 years of
exercise therapy).
Methods of Determining Whether a Subject Should Begin, Continue, or
Discontinue Exercise Therapy
[0079] Also provided are methods of determining whether a subject
having a cardiovascular disease should begin or continue exercise
therapy (e.g., any of the exercise therapy regimes described
herein) that include determining a level of soluble ST2 in a
biological sample from the subject, wherein a decreased (e.g., a
significant or detectable decrease) level of soluble ST2 in the
biological sample compared to a risk or efficacy reference level of
soluble ST2 (e.g., any of the reference levels described herein)
indicates that the subject should begin or continue exercise
therapy. Also provided are methods of determining whether a subject
having a cardiovascular disease should not begin or discontinue
exercise therapy (e.g., any of the exercise therapy regimes
described herein) that include determining a level of soluble ST2
in a biological sample from the subject, where an elevated (e.g., a
significant or detectable increase) level of soluble ST2 in the
biological sample compared to a risk or efficacy reference level of
soluble ST2 (e.g., any of the reference levels of soluble ST2
described herein) indicates that the subject should not begin or
discontinue exercise therapy.
[0080] Also provided are methods of determining whether a subject
having a cardiovascular disorder should discontinue or avoid
exercise therapy (e.g., any of the exercise therapy regimes
described herein) that include determining a level of soluble ST2
in a biological sample from the subject at a first time point
before or after the start of exercise therapy, and determining a
level of soluble ST2 in a biological sample from the subject
undergoing (performing) exercise therapy at a second time point
after the start of exercise therapy and after the first time point,
where an increase (e.g., a significant or detectable increase) in
the level of soluble ST2 in the biological sample of the second
time point compared to the level of soluble ST2 in the biological
sample at the first time point indicates that the subject should
discontinue or avoid exercise therapy. Also provided are methods of
determining whether a subject having a cardiovascular disorder
should continue exercise therapy (e.g., any of the exercise therapy
regimes described herein) that include determining a level of
soluble ST2 in a biological sample from the subject at a first time
point before or after the start of exercise therapy, and
determining a level of soluble ST2 in a biological sample from the
subject undergoing (performing) exercise therapy at a second time
point after the start of exercise therapy and after the first time
point, where a decrease (e.g., a significant or detectable
decrease) or no change (e.g., no significant change) in the level
of soluble ST2 in the biological sample of the second time point
compared to the level of soluble ST2 in the biological sample at
the first time point indicates that the subject should continue
exercise therapy.
[0081] Also provided are methods of determining whether a subject
having a cardiovascular disorder should continue exercise therapy
(e.g., any of the exercise therapy regimes described herein) that
include determining a level of soluble ST2 in a biological sample
from the subject at a first time point before or after the start of
exercise therapy, and instructing the subject to begin or continue
exercise therapy if the level of soluble ST2 is below a risk or
efficacy reference level; and determining a level of soluble ST2 in
a biological sample from the subject undergoing (performing)
exercise therapy at a second time point after the start of exercise
therapy and after the first time point, and instructing the subject
to continue the exercise therapy if the level at the second time
point is still below the risk or efficacy reference level, or to
stop the exercise therapy if the level at the second time point is
above the risk or efficacy reference level.
[0082] In some embodiments, one or more additional levels of
soluble ST2 can be determined in the subject (e.g., determined in
biological samples obtained at one or more additional time points
after the second time point). In some embodiments, the level of
soluble ST2 is determined in a biological sample obtained from the
subject having cardiovascular disease at least every month (e.g.,
at least every two months, at least every three months, at least
every four months, at least every five months, or at least every
six months) during the performance of a exercise therapy regime. In
such embodiments, an increase (e.g., a significant or detectable
increase) in the level of soluble ST2 in a biological sample taken
at a later time point compared to the level of soluble ST2 in a
biological sample taken at an earlier time point (e.g., the
immediately prior biological sample), or the presence of a level
above a risk or efficacy reference level, indicates that the
subject should discontinue exercise therapy, and a decrease (e.g.,
a significant or detectable decrease) or no change (e.g., no
significant change) in the level of soluble ST2 in a biological
sample taken at a later time point compared to the level of soluble
ST2 in a biological sample taken at an earlier time point (e.g.,
the immediately prior biological sample), or the presence of a
level below a risk or efficacy reference level, indicates that the
subject should continue exercise therapy. In some embodiments of
these methods, the subjects are monitored by a health care
professional (e.g., a physician, a physical therapist, a nurse, a
nurse's assistant, a physician's assistant, or a laboratory
technician).
[0083] In some embodiments, the biological sample is collected from
a subject within 2 years of diagnosis with a cardiovascular
disease, a myocardial infarction, or heart failure. The level of
soluble ST2 in the biological sample can be determined using any of
the methods described herein, and the biological sample can be any
of the biological samples described herein. These methods can
reduce (e.g., a significant reduction) in the risk of death or an
adverse outcome (e.g., any of the adverse outcomes described
herein) in the subject, reduce the number of symptoms of a
cardiovascular disease, reduce (e.g., a detectable or observable
reduction) in the intensity, frequency, or duration in one or more
symptoms of a cardiovascular disease, or reduce (e.g., detectable
reduction) in the level of at least one marker (e.g., any of the
markers described herein) of a cardiovascular disease in a
biological sample from the subject (e.g., as compared to a subject
or population of subjects having the same cardiovascular disease
but not receiving therapy or receiving a different therapy).
Methods of Reducing the Risk of an Adverse Outcome in a Subject
[0084] Also provided herein are methods of reducing (e.g., a
significant reduction) the risk of an adverse outcome (e.g., risk
of death) in a subject having a cardiovascular disease that include
determining a level of soluble ST2 in a biological sample from the
subject, identifying a subject that has a decreased (e.g., a
significant or detectable decrease) level of soluble ST2 in the
biological sample compared to a risk reference level of soluble ST2
(e.g., as described herein), and selecting the identified subject
for exercise therapy (e.g., any of the exercise therapy regimes
described herein). Also provided are methods of reducing (e.g., a
significant reduction) the risk of an adverse outcome (e.g., risk
of death) in a subject having a cardiovascular disease that include
determining a level of soluble ST2 in a biological sample from the
subject, identifying a subject that has an elevated (e.g., a
significant or detectable increase) level of soluble ST2 in the
biological sample compared to a risk reference level of soluble ST2
(e.g., as described herein), and instructing the identified subject
to avoid or discontinue exercise therapy (e.g., any of the exercise
therapy regimes described herein).
[0085] In some embodiments, the adverse outcome can be one or more
of: death, organ failure, organ transplantation, hospitalization or
rehospitalization, recurrence of one or more symptoms of a
cardiovascular disease, development of one or more additional
symptoms of a cardiovascular disease, an increase in the frequency,
intensity, or duration of one or more symptoms of a cardiovascular
disease experienced by the subject, or a first or subsequent
myocardial infarction. In some embodiments, the biological sample
is collected from a subject within 2 years of diagnosis with a
cardiovascular disease, a myocardial infarction, or heart failure.
Any of these methods can be performed by a health care professional
(e.g., a physician, a physical therapist, a nurse, a nurse's
assistant, a physician's assistant, or a laboratory
technician).
Methods of Predicting the Efficacy of Exercise Therapy
[0086] Also provided are methods of predicting the efficacy of
exercise therapy (e.g., any of the exercise therapy regimes
described herein) in a subject having a cardiovascular disease.
These methods include determining a level of soluble ST2 in a
biological sample from the subject, and comparing the level of
soluble ST2 in the biological sample to an efficacy reference level
of soluble ST2 (e.g., any of the reference levels of soluble ST2
described herein), wherein a decreased (e.g., a significant or
detectable decrease) level of soluble ST2 in the biological sample
compared to the efficacy reference level of soluble ST2 (e.g., as
described herein) indicates that exercise therapy will be effective
in the subject, and an elevated (e.g., a significant or detectable
increase) level of soluble ST2 in the biological sample compared to
the efficacy reference level of soluble ST2 (e.g., as described
herein) indicates that the exercise therapy will not be effective
in the subject. In some embodiments, the efficacy reference level
of soluble ST2 is a threshold soluble ST2 level of 28.6 ng/mL, less
than or equal to 35 ng/mL, about 28 ng/mL to about 35 ng/mL (e.g.,
the entire range or any level between 28 to 35 ng/mL), 35 ng/mL,
about 35 ng/mL to about 45 ng/mL (e.g., the entire range or any
level between 35 to 45 ng/mL), about 45 ng/mL to about 55 ng/mL
(e.g., the entire range or any level between 45 to 55 ng/mL), about
35 ng/mL to about 55 ng/mL (e.g., the entire range or any level
between 35 to 55 ng/mL), or the range of 55 to 60 ng/mL (e.g., the
entire range or any level between 55 to 60 ng/mL) (e.g., determined
using the antibodies described in U.S. patent application Ser. No.
13/083,333 and PCT Application No. PCT/US2011/031801). In some
embodiments, the biological sample is collected from a subject
within 2 years of diagnosis with a cardiovascular disease, a
myocardial infarction, or heart failure. The level of soluble ST2
in the biological sample can be determined using any of the methods
described herein, and the biological sample can be any of the
biological samples described herein.
[0087] In some embodiments, the efficacy of exercise therapy can be
one or more of the following: a reduction (e.g., a significant
decrease) in the risk of an adverse outcome (e.g., any of the
adverse outcomes described herein) in the subject, a reduction in
the number of symptoms of a cardiovascular disease, a reduction
(e.g., a detectable or observable decrease) in the intensity,
frequency, or duration of one or more symptoms of a cardiovascular
disease, or a reduction (e.g., detectable decrease) in the levels
of at least one marker of a cardiovascular disease (e.g., any of
the markers described herein or known in the art) in a biological
sample from the subject (e.g., as compared to a subject or
population of subjects having the same cardiovascular disease but
not receiving therapy or receiving a different therapy). The
efficacy of exercise therapy can be determined at various time
points in a subject (e.g., after at least 6 months of exercise
therapy, after 1 year of exercise therapy, or after 2 years of
exercise therapy).
Additional Therapeutic Markers
[0088] Any of the methods described herein can further include
determining the level of at least one additional marker (e.g., at
least one additional marker of a cardiovascular disease) in a
biological sample from a subject. In some embodiments, the
biological sample used to determine the level of the at least one
additional marker may be the same sample(s) that is used to
determine a level of soluble ST2 in a subject. In some embodiments,
the biological sample used to determine the level of the at least
one additional marker is a different sample than the sample(s) used
to determine a level of soluble ST2 in a subject. The biological
sample can be any of the biological samples described herein.
[0089] The additional marker can be any protein, nucleic acid,
lipid, or carbohydrate, or a combination (e.g., two or more)
thereof, that is diagnostic of the presence of a particular disease
(e.g., diagnostic of a cardiovascular disease). Several additional
markers useful for the diagnosis of a cardiovascular disease are
known in the art, and include, without limitation, cardiac troponin
I, B-type natriuretic peptide (e.g., proBNP, NT-proBNP, and BNP),
atrial natriuretic peptide (e.g., proANP, NT-proANP, and ANP),
troponin, C-reactive protein, creatinine, Blood Urea Nitrogen
(BUN), liver function enzymes, albumin, and bacterial endotoxin.
Additional non-limiting markers of a cardiovascular disease are
described in U.S. Patent Application Publication Nos.:
2007/0248981; 2011/0053170; 2010/0009356; 2010/0055683; and
2009/0264779 (each of which is hereby incorporated by reference).
Additional markers of a cardiovascular disease are known in the
art.
[0090] Methods for determining the level of the above described
markers of a cardiovascular disease are known in the art.
Diagnostic tests for determining the level of several of these
markers are commercially available. For example, diagnostic tests
for determining the level of C-reactive protein (e.g., Exocell),
B-type natriuretic peptide (e.g., Alpco Immunoassays), atrial
natriuretic peptide (e.g., Cusabio Biotech Co., Ltd.), and cardiac
troponin I (e.g., Calbiotech Inc.) are commercially available.
Additional Therapeutic Treatments
[0091] In any of the methods described herein, the subject can
further be administered an additional therapeutic treatment (e.g.,
at least one therapeutic treatment in addition to exercise
therapy). In some embodiments of the methods described herein, the
subject can be receiving at least one therapeutic treatment at the
time the exercise therapy begins. In some embodiments, a health
care professional may adjust (e.g., increase or decrease) the
dosage or frequency of administration of at least one therapeutic
agent administered to the subject prior to the start of exercise
therapy or at a time point during the exercise therapy. In some
embodiments of the methods described herein, the efficacy of the
exercise therapy allows for a decrease in the number of therapeutic
agents or allows for a decrease in the dose or frequency of
administration of one or more therapeutic agents to a subject
having a cardiovascular disease.
[0092] Non-limiting examples of therapeutic treatment of a
cardiovascular disease (in addition to exercise therapy) include
the administration of one of more of the following agents: statins,
anti-inflammatory agents, anti-thrombotic agents, anti-coagulants,
anti-platelet agents, lipid-reducing agents, direct thrombin
inhibitors, glycoprotein IIb/IIIb receptor inhibitors, calcium
channel blockers, beta-adrenergic receptor blockers,
cyclooxygenase-2 inhibitors, and renin-angiotensin-aldosterone
system (RAAS) inhibitors.
[0093] Non-limiting examples of lipid-reducing agents that can be
used to treat a cardiovascular disease in a subject (alone or in
combination any other therapy, including exercise therapy) include:
a statin, gemfibrozil, cholystyramine, colestipol, nicotinic acid,
and probucol. Statins are molecules that are capable of inhibiting
the activity of HMG-CoA reductase. Non-limiting examples of statins
that can be administered to a subject having a cardiovascular
disease (alone or in combination with any other therapy, including
exercise therapy) include: atorvastatin, cirivastatin, fluvastatin,
lovastatin, pitavastatin, pravastatin, rosuvastatin, and
simvastatin. Additional examples of statins and other
lipid-reducing agents are known in the art.
[0094] Non-limiting examples of anti-inflammatory agents that can
be used to treat a cardiovascular disease in a subject (alone or in
combination any other therapy, including exercise therapy) include:
Alclofenac, Alclometasone Dipropionate, Algestone Acetonide, Alpha
Amylase, Amcinafal, Amcinafide, Amfenac Sodium, Amiprilose
Hydrochloride, Anakinra, Anirolac, Anitrazafen, Apazone,
Balsalazide Disodium, Bendazac, Benoxaprofen, Benzydamine
Hydrochloride, Bromelains, Broperamole, Budesonide, Carprofen,
Cicloprofen, Cintazone, Cliprofen, Clobetasol Propionate,
Clobetasone Butyrate, Clopirac, Cloticasone Propionate,
Cormethasone Acetate, Cortodoxone, Deflazacort, Desonide,
Desoximetasone, Dexamethasone Dipropionate, Diclofenac Potassium,
Diclofenac Sodium, Diflorasone Diacetate, Diflumidone Sodium,
Diflunisal, Difluprednate, Diftalone, Dimethyl Sulfoxide,
Drocinonide, Endrysone, Enlimomab, Enolicam Sodium, Epirizole,
Etodolac, Etofenamate, Felbinac, Fenamole, Fenbufen, Fenclofenac,
Fenclorac, Fendosal, Fenpipalone, Fentiazac, Flazalone, Fluazacort,
Flufenamic Acid, Flumizole, Flunisolide Acetate, Flunixin, Flunixin
Meglumine, Fluocortin Butyl, Fluorometholone Acetate, Fluquazone,
Flurbiprofen, Fluretofen, Fluticasone Propionate, Furaprofen,
Furobufen, Halcinonide, Halobetasol Propionate, Halopredone
Acetate, Ibufenac, Ibuprofen, Ibuprofen Aluminum, Ibuprofen
Piconol, Ilonidap, Indomethacin, Indomethacin Sodium, Indoprofen,
Indoxole, Intrazole, Isoflupredone Acetate, Isoxepac, Isoxicam,
Ketoprofen, Lofemizole Hydrochloride, Lornoxicam, Loteprednol
Etabonate, Meclofenamate Sodium, Meclofenamic Acid, Meclorisone
Dibutyrate, Mefenamic Acid, Mesalamine, Meseclazone,
Methylprednisolone Suleptanate, Morniflumate, Nabumetone, Naproxen,
Naproxen Sodium, Naproxol, Nimazone, Olsalazine Sodium, Orgotein,
Orpanoxin, Oxaprozin, Oxyphenbutazone, Paranyline Hydrochloride,
Pentosan Polysulfate Sodium, Phenbutazone Sodium Glycerate,
Pirfenidone, Piroxicam, Piroxicam Cinnamate, Piroxicam Olamine,
Pirprofen, Prednazate, Prifelone, Prodolic Acid, Proquazone,
Proxazole, Proxazole Citrate, Rimexolone, Romazarit, Salcolex,
Salnacedin, Salsalate, Salycilates, Sanguinarium Chloride,
Seclazone, Sermetacin, Sudoxicam, Sulindac, Suprofen, Talmetacin,
Talniflumate, Talosalate, Tebufelone, Tenidap, Tenidap Sodium,
Tenoxicam, Tesicam, Tesimide, Tetrydamine, Tiopinac, Tixocortol
Pivalate, Tolmetin, Tolmetin Sodium, Triclonide, Triflumidate,
Zidometacin, Glucocorticoids, and Zomepirac Sodium. One preferred
anti-inflammatory agent is aspirin. Additional examples of
anti-inflammatory agents are known in the art.
[0095] Non-limiting examples of anti-thrombotic agents that can be
used to treat a cardiovascular disease in a subject (alone or in
combination with any other therapy, including exercise therapy)
include: plasminogen proactivator, tissue plasminogen activator,
Anisoylated Plasminogen-Streptokinase Activator Complex,
Pro-Urokinase, (Pro-UK), rTPA (recombinant alteplase or activase),
recombinant Pro-UK, Abbokinase, Eminase, Sreptase Anagrelide
Hydrochloride, Bivalirudin, Dalteparin Sodium, Danaparoid Sodium,
Dazoxiben Hydrochloride, Efegatran Sulfate, Enoxaparin Sodium,
Ifetroban, Ifetroban Sodium, Tinzaparin Sodium, Retaplase,
Trifenagrel, Warfarin, and Dextrans. Additional examples of
anti-thrombotic agents are known in the art.
[0096] Non-limiting examples of anti-coagulants that can be used to
treat a cardiovascular disease in a subject (alone or in
combination with any other therapy, including exercise therapy)
include: Ancrod, Anticoagulant Citrate Dextrose Solution,
Anticoagulant Citrate Phosphate Dextrose Adenine Solution,
Anticoagulant Citrate Phosphate Dextrose Solution, Anticoagulant
Heparin Solution, Anticoagulant Sodium Citrate Solution, Ardeparin
Sodium, Bivalirudin, Bromindione, Dalteparin Sodium, Desirudin,
Dicumarol, Heparin Calcium, Heparin Sodium, Lyapolate Sodium,
Nafamostat Mesylate, Phenprocoumon, Tinzaparin Sodium, and Warfarin
Sodium. Additional examples of anti-coagulants are known in the
art.
[0097] Non-limiting examples of anti-platelet agents that can be
used to treat a cardiovascular disease in a subject (alone or in
combination with any other therapy, including exercise therapy)
include: Clopridogrel, Sulfinpyrazone, Aspirin, Dipyridamole,
Clofibrate, Pyridinol Carbamate, Prostaglandin E, Glucagon,
Antiserotonin drugs, Caffeine, Theophyllin Pentoxifyllin,
Ticlopidine, and Anagrelide. Additional examples of anti-platelet
agents are known in the art.
[0098] Non-limiting examples of direct thrombin inhibitors that can
be used to treat a cardiovascular disease in a subject (alone or in
combination with any other therapy, including exercise therapy)
include: hirudin, hirugen, hirulog, agatroban, PPACK, and thrombin
aptamers. Additional examples of thrombin inhibitors are known in
the art.
[0099] Non-limiting examples of glycoprotein IIb/IIIb receptor
inhibitors that can be used to treat a cardiovascular disease in a
subject (alone or in combination with any other therapy, including
exercise therapy) include: ReoPro (abcixamab), lamifiban, and
tirofiban. Additional examples of glycoprotein IIb/IIIb receptor
inhibitors are known in the art.
[0100] Non-limiting examples of calcium channel blockers that can
be used to treat a cardiovascular disease in a subject (alone or in
combination with any other therapy, including exercise therapy)
include: dihydropyridines, such as nifedipine; phenyl alkyl amines,
such as verapamil; and benzothiazepines, such as diltiazem.
Additional non-limiting examples of calcium channel blockers
include amrinone, amlodipine, bencyclane, felodipine, fendiline,
flunarizine, isradipine, nicardipine, nimodipine, perhexilene,
gallopamil, tiapamil, tiapamil analogues (such as 1993RO-11-2933),
phenytoin, barbiturates, and the peptides dynorphin,
omega-conotoxin, and omega-agatoxin, and the like and/or
pharmaceutically acceptable salts thereof. Additional examples of
calcium channel blockers are known in the art.
[0101] Non-limiting examples of beta-adrenergic receptor blockers
that can be used to treat a cardiovascular disease in a subject
(alone or in combination with any other therapy, including exercise
therapy) include: atenolol, acebutolol, alprenolol, befunolol,
betaxolol, bunitrolol, carteolol, celiprolol, hedroxalol,
indenolol, labetalol, levobunolol, mepindolol, methypranol,
metindol, metoprolol, metrizoranolol, oxprenolol, pindolol,
propranolol, practolol, practolol, sotalolnadolol, tiprenolol,
tomalolol, timolol, bupranolol, penbutolol, trimepranol,
2-(3-(1,1-dimethylethyl)-amino-2-hydroxypropoxy)-3-pyridenecarbonitril
HC1, 1-butylamino-3-(2,5-dichlorophenoxy)-2-propanol,
1-isopropylamino-3-(4-(2-cyclopropylmethoxyethyl)phenoxy)-2-propanol,
3-isopropylamino-1-(7-methylindan-4-yloxy)-2-butanol,
2-(3-t-butylamino-2-hydroxy-propylthio)-4-(5-carbamoyl-2-thienyl)thiazol,
and 7-(2-hydroxy-3-t-butylaminpropoxy)phthalide. The above
beta-adrenergic receptor blockers can be used as isomeric mixtures,
or in their respective levorotating or dextrorotating form.
Additional examples of beta-adrenergic receptor blockers are known
in the art.
[0102] Non-limiting examples of cyclooxygenase-2 inhibitors that
can be used to treat a cardiovascular disease in a subject (alone
or in combination with any other therapy, including exercise
therapy) include those described in U.S. Pat. Nos. 5,474,995;
5,521,213; 5,536,752; 5,550,142; 5,552,422; 5,604,253; 5,604,260;
5,639,780; 5,677,318; 5,691,374; 5,698,584; 5,710,140; 5,733,909;
5,789,413; 5,817,700; 5,849,943; 5,861,419; 5,922,742; 5,925,631;
5,643,933; 5,474,995; and 5,543,297; WO 95/00501, and WO 95/18799
(each of which is incorporated herein by reference). Additional
examples of cyclooxygenase-2 inhibitors are known in the art.
[0103] Renin-angiotensin-aldosterone system (RAAS) inhibitors can
be used to treat a cardiovascular disease in a subject (alone or in
combination with any other therapy, such as exercise therapy). RAAS
inhibitors include agents that interfere with the function and
synthesis or catabolism of angiotensin II. RAAS agents include, but
are not limited to, angiotensin-converting enzyme (ACE) inhibitors,
angiotensin II receptor blockers, agents that activate the
catabolism of angiotensin II, agents that prevent the synthesis of
angiotensin I (from which angiotensin II is ultimately derived),
and aldosterone antagonists. The RAAS is involved in the regulation
of hemodynamics and water and electrolyte balance. Factors that
lower blood volume, renal perfusion pressure, or the concentration
of Na.sup.+ in plasma tend to activate the system, while factors
that increase these parameters tend to suppress its function. RAAS
inhibitors are compounds that act to interfere with the production
of angiotensin II from angiotensinogen or angiotensin I or
interfere with the activity of angiotensin II. Such inhibitors are
well known in the art and include compounds that act to inhibit the
enzymes involved in the ultimate production of angiotensin II,
including renin and ACE. They also include compounds that interfere
with the activity of angiotensin II, once produced.
[0104] Angiotensin II receptor blockers include angiotensin II
antagonists which interfere with the activity of angiotensin II by
binding to angiotensin II receptors and interfere with their
activity. Angiotensin II receptor blockers are well known and
include peptide compounds and non-peptide compounds. Most
angiotensin II receptor blockers are slightly modified congeners in
which agonist activity is attenuated by replacement of
phenylalanine in position 8 with some other amino acid. Examples of
angiotensin II receptor blockers include: peptidic compounds (e.g.,
saralasin, [(San1)(Val5)(Ala8)] angiotensin-(1-8) octapeptide, and
related analogs); N-substituted imidazole-2-one (U.S. Pat. No.
5,087,634); imidazole acetate derivatives, including
2-N-butyl-4-chloro-1-(2-chlorobenzile), imidazole-5-acetic acid
(see, Long et al., J. Pharmacol. Exp. Ther. 247:1-7, 1988);
4,5,6,7-tetrahydro-1H-imidazo [4,5-c] pyridine-6-carboxylic acid,
and analog derivatives thereof (U.S. Pat. No. 4,816,463);
N2-tetrazole beta-glucuronide analogs (U.S. Pat. No. 5,085,992);
substituted pyrroles, pyrazoles, and tryazoles (U.S. Pat. No.
5,081,127); phenol and heterocyclic derivatives, such as 1,
3-imidazoles (U.S. Pat. No. 5,073,566); imidazo-fused 7-member ring
heterocycles (U.S. Pat. No. 5,064,825); peptides (e.g., U.S. Pat.
No. 4,772,684); antibodies to angiotensin II (e.g., U.S. Pat. No.
4,302,386); and aralkyl imidazole compounds, such as
biphenyl-methyl substituted imidazoles (e.g., EP 253,310);
N-morpholinoacetyl-(-1-naphthyl)-L-alanyl-(4, thiazolyl)-L-alanyl
(35, 45)-4-amino-3-hydroxy-5-cyclo-hexapentanoyl-N-hexylamide;
SKF108566 (E-alpha-2[2-butyl-1-(carboxyphenyl)methyl]
1H-imidazole-5-yl[methylane]-2-thiophenepropanoic acid); Losartan;
Remikirin; and A2 agonists.
[0105] Non-limiting examples of ACE inhibitors include acylmercapto
and mercaptoalkanoyl prolines, such as captopril (U.S. Pat. No.
4,105,776) and zofenopril (U.S. Pat. No. 4,316,906); carboxyalkyl
dipeptides, such as enalapril (U.S. Pat. No. 4,374,829), lisinopril
(U.S. Pat. No. 4,374,829), quinapril (U.S. Pat. No. 4,344,949),
ramipril (U.S. Pat. No. 4,587,258), and perindopril (U.S. Pat. No.
4,508,729); carboxyalkyl dipeptide mimics, such as cilazapril (U.S.
Pat. No. 4,512,924) and benazapril (U.S. Pat. No. 4,410,520); and
phosphinylalkanoyl prolines, such as fosinopril (U.S. Pat. No.
4,337,201) and trandolopril.
[0106] Additional non-limiting examples of RAAS inhibitors include:
derivatives of peptides (U.S. Pat. No. 5,116,835); amino acids
connected by nonpeptide bonds (U.S. Pat. No. 5,114,937); di- and
tri-peptide derivatives (U.S. Pat. No. 5,106,835); amino acids and
derivatives thereof (U.S. Pat. Nos. 5,104,869 and 5,095,119); diol
sulfonamides and sulfinyls (U.S. Pat. No. 5,098,924); modified
peptides (U.S. Pat. No. 5,095,006); peptidyl beta-aminoacyl
aminodiol carbamates (U.S. Pat. No. 5,089,471); pyrolimidazolones
(U.S. Pat. No. 5,075,451); fluorine and chlorine statine, or
statone containing peptides (U.S. Pat. No. 5,066,643); peptidyl
amino diols (U.S. Pat. Nos. 5,063,208 and 4,845,079); N-morpholino
derivatives (U.S. Pat. No. 5,055,466); pepstatin derivatives (U.S.
Pat. No. 4,980,283); N-heterocyclic alcohols (U.S. Pat. No.
4,885,292); monoclonal antibodies to renin (U.S. Pat. No.
4,780,401); and a variety of other peptides and analogs thereof
(U.S. Pat. Nos. 5,071,837, 5,064,965, 5,063,207, 5,036,054,
5,036,053, 5,034,512, and 4,894,437) (each of which is incorporated
by reference).
[0107] Additional examples of RAAS inhibitors include aldosterone
antagonists. Non-limiting examples of aldosterone antagonists
include: Spironolactone, Eplerenone, Canrenone (canrenoate
potassium), Prorenone (prorenoate potassium), and Mexrenone
(mexrenoate potassium).
EXAMPLES
[0108] The invention is further described in the following
examples, which do not limit the scope of the invention described
in the claims.
Example 1
Soluble ST2 Levels are Predictive of Mortality and Adverse Events
in Heart Failure Patients
[0109] Analysis was performed on the samples and data collected
from 2331 heart failure patients enrolled in the HF-ACTION study. A
total of 2329 of the patients underwent baseline exercise testing
and were randomized to exercise therapy or normal clinical therapy.
Of these patients, blood samples were collected from 912 patients
representing both arms of the study, 453 were in the exercise arm
and 459 were in the normal treatment arm. Nine hundred and ten of
these patients had a sufficient sample size for soluble ST2
measurement. The median soluble ST2 level in this cohort was 23.7
ng/ml, and ranged from 2.2 ng/mL to 344.2 ng/ml. As in the
previously published heart failure cohorts, soluble ST2 levels were
predictive of death for the full duration of the follow-up period
(up to 1460 days). The prognostic value of soluble ST2 levels for
risk of death in heart failure patients during the entire follow-up
period (up to 1460 days) is illustrated in FIG. 1. Patients in the
highest soluble ST2 level group (soluble ST2 levels of greater than
28.6 ng/mL) have the greatest risk of mortality, with this risk
presenting early in the follow-up period. The increased risk of
mortality for those patients in the highest soluble ST2 level group
is maintained throughout the entire follow-up period.
[0110] The predictive strength of soluble ST2 levels was also
assessed by Cox proportional hazards analysis, using soluble ST2
level as both a log (1n)-transformed continuous variable (HR 3.38,
p<0.0001), as well as a dichotomous variable at a concentration
of 35 ng/ml (HR 2.59, p<0.0001). FIG. 2 shows the surviving
portion of heart failure patients over time for subjects having ST2
concentrations above or below a level of 35 ng/mL.
Example 2
Subjects with Elevated Levels of Soluble ST2 Performing an Exercise
Therapy Regime have an Increased Risk of Death
[0111] As reported in O'Connor et al. (JAMA 301(14):1439-1450,
2009) there was a modest, but insignificant, decrease in mortality
rate in heart failure patients who underwent exercise therapy
relative to those who received standard care. An assessment of
soluble ST2 levels in this cohort shows that the therapeutic
efficacy of exercise therapy is different in patients having a high
versus low level of soluble ST2, with more benefit, e.g., lower
mortality rate, observed in heart failure patients with low soluble
ST2 levels. This correlation is illustrated in a Kaplan-Meier
analysis of the data from the following heart failure patient
groups: patients having a level of soluble ST2 less than or equal
to 35 ng/mL and performing an exercise therapy regime (line 1, top
line); patients having a level of soluble ST2 less than or equal to
35 ng/nL and not performing an exercise therapy regime (line 2,
second line from the top); patients having a level of soluble ST2
greater than 35 ng/mL and not performing an exercise therapy regime
(line 3, second line from the bottom); and patients having a level
of soluble ST2 greater than 35 ng/mL and performing an exercise
therapy regime (line 4, bottom line) (FIG. 3). In both treatment
arms (i.e., those performing an exercise therapy regime or those
receiving standard care (not performing an exercise therapy
regime)), heart failure patients with low soluble ST2 levels have
better survival over the 4 year follow-up period than patients with
elevated soluble ST2 levels. By 1 year, the patients with low
soluble ST2 levels who performed an exercise therapy regime had a
significantly lower mortality rate (.about.3%) compared to the
usual care treatment group (not performing an exercise therapy
regime), and this benefit persisted for the full 4-year follow-up
period. Conversely, the data from heart failure patients with
elevated soluble ST2 levels show no survival benefit from the
performance of an exercise therapy regime out to 2 years of
followup. After 2 years, there was an apparent adverse effect
(increased mortality) of performing an exercise treatment regime in
heart failure patients with elevated soluble ST2 levels compared to
the usual care (not performing an exercise therapy regime)
patients.
[0112] The ST2 analysis cutpoint of 35 ng/mL was selected by
choosing a Presage ST2 Assay concentration value above the 90th and
below the 95th percentile of the group. These reference values were
subsequently confirmed to be consistent with an additional 3,450
subjects measured in a large observational population study, the
Framingham
[0113] Offspring Cohort (Wang et al. 2004) by showing that ST2
values are 32.9 ng/ml and 37.3 ng/ml at the 90th and 95th
percentiles respectively, bracketing and confirming the selected 35
ng/ml value.
[0114] The relationship between the mortality risk of performing an
exercise therapy regime and soluble ST2 levels in heart failure
patients is also illustrated in FIG. 4. The data in FIG. 4 show the
calculated hazard ratio for mortality within 1 year in heart
failure subjects performing an exercise treatment regime to heart
failure subjects not performing an exercise treatment regime having
different soluble ST2 levels. These data show that, as soluble ST2
levels increase there is a steady increase in the hazard ratio,
reflecting worse survival, and that a level of soluble ST2 between
55 and 60 ng/mL has a hazard ratio of 1.0. These data indicated
that heart failure patients with soluble ST2 levels below 55-60
ng/mL are likely to benefit from performing an exercise therapy
regime, with greater benefit achieved at lower soluble ST2 levels.
Heart failure patients with soluble ST2 levels above 55-60 ng/mL
are not likely to achieve a therapeutic benefit from performing an
exercise therapy regime and are at increased risk of experiencing
an adverse outcome (e.g., mortality).
Other Embodiments
[0115] It is to be understood that while the invention has been
described in conjunction with the detailed description thereof, the
foregoing description is intended to illustrate and not limit the
scope of the invention, which is defined by the scope of the
appended claims. Other aspects, advantages, and modifications are
within the scope of the following claims.
Sequence CWU 1
1
41328PRTHomo sapiens 1Met Gly Phe Trp Ile Leu Ala Ile Leu Thr Ile
Leu Met Tyr Ser Thr1 5 10 15 Ala Ala Lys Phe Ser Lys Gln Ser Trp
Gly Leu Glu Asn Glu Ala Leu 20 25 30 Ile Val Arg Cys Pro Arg Gln
Gly Lys Pro Ser Tyr Thr Val Asp Trp 35 40 45 Tyr Tyr Ser Gln Thr
Asn Lys Ser Ile Pro Thr Gln Glu Arg Asn Arg 50 55 60 Val Phe Ala
Ser Gly Gln Leu Leu Lys Phe Leu Pro Ala Ala Val Ala65 70 75 80 Asp
Ser Gly Ile Tyr Thr Cys Ile Val Arg Ser Pro Thr Phe Asn Arg 85 90
95 Thr Gly Tyr Ala Asn Val Thr Ile Tyr Lys Lys Gln Ser Asp Cys Asn
100 105 110 Val Pro Asp Tyr Leu Met Tyr Ser Thr Val Ser Gly Ser Glu
Lys Asn 115 120 125 Ser Lys Ile Tyr Cys Pro Thr Ile Asp Leu Tyr Asn
Trp Thr Ala Pro 130 135 140 Leu Glu Trp Phe Lys Asn Cys Gln Ala Leu
Gln Gly Ser Arg Tyr Arg145 150 155 160 Ala His Lys Ser Phe Leu Val
Ile Asp Asn Val Met Thr Glu Asp Ala 165 170 175 Gly Asp Tyr Thr Cys
Lys Phe Ile His Asn Glu Asn Gly Ala Asn Tyr 180 185 190 Ser Val Thr
Ala Thr Arg Ser Phe Thr Val Lys Asp Glu Gln Gly Phe 195 200 205 Ser
Leu Phe Pro Val Ile Gly Ala Pro Ala Gln Asn Glu Ile Lys Glu 210 215
220 Val Glu Ile Gly Lys Asn Ala Asn Leu Thr Cys Ser Ala Cys Phe
Gly225 230 235 240 Lys Gly Thr Gln Phe Leu Ala Ala Val Leu Trp Gln
Leu Asn Gly Thr 245 250 255 Lys Ile Thr Asp Phe Gly Glu Pro Arg Ile
Gln Gln Glu Glu Gly Gln 260 265 270 Asn Gln Ser Phe Ser Asn Gly Leu
Ala Cys Leu Asp Met Val Leu Arg 275 280 285 Ile Ala Asp Val Lys Glu
Glu Asp Leu Leu Leu Gln Tyr Asp Cys Leu 290 295 300 Ala Leu Asn Leu
His Gly Leu Arg Arg His Thr Val Arg Leu Ser Arg305 310 315 320 Lys
Asn Pro Ser Lys Glu Cys Phe 325 22542DNAHomo sapiens 2gaggagggac
ctacaaagac tggaaactat tcttagctcc gtcactgact ccaagttcat 60cccctctgtc
tttcagtttg gttgagatat aggctactct tcccaactca gtcttgaaga
120gtatcaccaa ctgcctcatg tgtggtgacc ttcactgtcg tatgccagtg
actcatctgg 180agtaatctca acaacgagtt accaatactt gctcttgatt
gataaacaga atggggtttt 240ggatcttagc aattctcaca attctcatgt
attccacagc agcaaagttt agtaaacaat 300catggggcct ggaaaatgag
gctttaattg taagatgtcc tagacaagga aaacctagtt 360acaccgtgga
ttggtattac tcacaaacaa acaaaagtat tcccactcag gaaagaaatc
420gtgtgtttgc ctcaggccaa cttctgaagt ttctaccagc tgcagttgct
gattctggta 480tttatacctg tattgtcaga agtcccacat tcaataggac
tggatatgcg aatgtcacca 540tatataaaaa acaatcagat tgcaatgttc
cagattattt gatgtattca acagtatctg 600gatcagaaaa aaattccaaa
atttattgtc ctaccattga cctctacaac tggacagcac 660ctcttgagtg
gtttaagaat tgtcaggctc ttcaaggatc aaggtacagg gcgcacaagt
720catttttggt cattgataat gtgatgactg aggacgcagg tgattacacc
tgtaaattta 780tacacaatga aaatggagcc aattatagtg tgacggcgac
caggtccttc acggtcaagg 840atgagcaagg cttttctctg tttccagtaa
tcggagcccc tgcacaaaat gaaataaagg 900aagtggaaat tggaaaaaac
gcaaacctaa cttgctctgc ttgttttgga aaaggcactc 960agttcttggc
tgccgtcctg tggcagctta atggaacaaa aattacagac tttggtgaac
1020caagaattca acaagaggaa gggcaaaatc aaagtttcag caatgggctg
gcttgtctag 1080acatggtttt aagaatagct gacgtgaagg aagaggattt
attgctgcag tacgactgtc 1140tggccctgaa tttgcatggc ttgagaaggc
acaccgtaag actaagtagg aaaaatccaa 1200gtaaggagtg tttctgagac
tttgatcacc tgaactttct ctagcaagtg taagcagaat 1260ggagtgtggt
tccaagagat ccatcaagac aatgggaatg gcctgtgcca taaaatgtgc
1320ttctcttctt cgggatgttg tttgctgtct gatctttgta gactgttcct
gtttgctggg 1380agcttctctg ctgcttaaat tgttcgtcct cccccactcc
ctcctatcgt tggtttgtct 1440agaacactca gctgcttctt tggtcatcct
tgttttctaa ctttatgaac tccctctgtg 1500tcactgtatg tgaaaggaaa
tgcaccaaca accgtaaact gaacgtgttc ttttgtgctc 1560ttttataact
tgcattacat gttgtaagca tggtccgttc tatacctttt tctggtcata
1620atgaacactc attttgttag cgagggtggt aaagtgaaca aaaaggggaa
gtatcaaact 1680actgccattt cagtgagaaa atcctaggtg ctactttata
ataagacatt tgttaggcca 1740ttcttgcatt gatataaaga aatacctgag
actgggtgat ttatatgaaa agaggtttaa 1800ttggctcaca gttctgcagg
ctgtatggga agcatggcgg catctgcttc tggggacacc 1860tcaggagctt
tactcatggc agaaggcaaa gcaaaggcag gcacttcaca cagtaaaagc
1920aggagcgaga gagaggtgcc acactgaaac agccagatct catgagaagt
cactcactat 1980tgcaaggaca gcatcaaaga gatggtgcta aaccattcat
gatgaactca cccccatgat 2040ccaatcacct cccaccaggc tccacctcga
atactgggga ttaccattca gcatgagatt 2100tgggcaggaa cacagaccca
aaccatacca cacacattat cattgttaaa ctttgtaaag 2160tatttaaggt
acatggaaca cacgggaagt ctggtagctc agcccatttc tttattgcat
2220ctgttattca ccatgtaatt caggtaccac gtattccagg gagcctttct
tggccctcag 2280tttgcagtat acacactttc caagtactct tgtagcatcc
tgtttgtatc atagcactgg 2340tcacattgcc ttacctaaat ctgtttgaca
gtctgctcaa cacgactgca agctccatga 2400gggcagggac atcatctctt
ccatctttgg gtccttagtg caatacctgg cagctagcca 2460gtgctcagct
aaatatttgt tgactgaata aatgaatgca caaccaaaaa aaaaaaaaaa
2520aaaaaaaaaa aaaaaaaaaa aa 25423556PRTHomo sapiens 3Met Gly Phe
Trp Ile Leu Ala Ile Leu Thr Ile Leu Met Tyr Ser Thr1 5 10 15 Ala
Ala Lys Phe Ser Lys Gln Ser Trp Gly Leu Glu Asn Glu Ala Leu 20 25
30 Ile Val Arg Cys Pro Arg Gln Gly Lys Pro Ser Tyr Thr Val Asp Trp
35 40 45 Tyr Tyr Ser Gln Thr Asn Lys Ser Ile Pro Thr Gln Glu Arg
Asn Arg 50 55 60 Val Phe Ala Ser Gly Gln Leu Leu Lys Phe Leu Pro
Ala Ala Val Ala65 70 75 80 Asp Ser Gly Ile Tyr Thr Cys Ile Val Arg
Ser Pro Thr Phe Asn Arg 85 90 95 Thr Gly Tyr Ala Asn Val Thr Ile
Tyr Lys Lys Gln Ser Asp Cys Asn 100 105 110 Val Pro Asp Tyr Leu Met
Tyr Ser Thr Val Ser Gly Ser Glu Lys Asn 115 120 125 Ser Lys Ile Tyr
Cys Pro Thr Ile Asp Leu Tyr Asn Trp Thr Ala Pro 130 135 140 Leu Glu
Trp Phe Lys Asn Cys Gln Ala Leu Gln Gly Ser Arg Tyr Arg145 150 155
160 Ala His Lys Ser Phe Leu Val Ile Asp Asn Val Met Thr Glu Asp Ala
165 170 175 Gly Asp Tyr Thr Cys Lys Phe Ile His Asn Glu Asn Gly Ala
Asn Tyr 180 185 190 Ser Val Thr Ala Thr Arg Ser Phe Thr Val Lys Asp
Glu Gln Gly Phe 195 200 205 Ser Leu Phe Pro Val Ile Gly Ala Pro Ala
Gln Asn Glu Ile Lys Glu 210 215 220 Val Glu Ile Gly Lys Asn Ala Asn
Leu Thr Cys Ser Ala Cys Phe Gly225 230 235 240 Lys Gly Thr Gln Phe
Leu Ala Ala Val Leu Trp Gln Leu Asn Gly Thr 245 250 255 Lys Ile Thr
Asp Phe Gly Glu Pro Arg Ile Gln Gln Glu Glu Gly Gln 260 265 270 Asn
Gln Ser Phe Ser Asn Gly Leu Ala Cys Leu Asp Met Val Leu Arg 275 280
285 Ile Ala Asp Val Lys Glu Glu Asp Leu Leu Leu Gln Tyr Asp Cys Leu
290 295 300 Ala Leu Asn Leu His Gly Leu Arg Arg His Thr Val Arg Leu
Ser Arg305 310 315 320 Lys Asn Pro Ile Asp His His Ser Ile Tyr Cys
Ile Ile Ala Val Cys 325 330 335 Ser Val Phe Leu Met Leu Ile Asn Val
Leu Val Ile Ile Leu Lys Met 340 345 350 Phe Trp Ile Glu Ala Thr Leu
Leu Trp Arg Asp Ile Ala Lys Pro Tyr 355 360 365 Lys Thr Arg Asn Asp
Gly Lys Leu Tyr Asp Ala Tyr Val Val Tyr Pro 370 375 380 Arg Asn Tyr
Lys Ser Ser Thr Asp Gly Ala Ser Arg Val Glu His Phe385 390 395 400
Val His Gln Ile Leu Pro Asp Val Leu Glu Asn Lys Cys Gly Tyr Thr 405
410 415 Leu Cys Ile Tyr Gly Arg Asp Met Leu Pro Gly Glu Asp Val Val
Thr 420 425 430 Ala Val Glu Thr Asn Ile Arg Lys Ser Arg Arg His Ile
Phe Ile Leu 435 440 445 Thr Pro Gln Ile Thr His Asn Lys Glu Phe Ala
Tyr Glu Gln Glu Val 450 455 460 Ala Leu His Cys Ala Leu Ile Gln Asn
Asp Ala Lys Val Ile Leu Ile465 470 475 480 Glu Met Glu Ala Leu Ser
Glu Leu Asp Met Leu Gln Ala Glu Ala Leu 485 490 495 Gln Asp Ser Leu
Gln His Leu Met Lys Val Gln Gly Thr Ile Lys Trp 500 505 510 Arg Glu
Asp His Ile Ala Asn Lys Arg Ser Leu Asn Ser Lys Phe Trp 515 520 525
Lys His Val Arg Tyr Gln Met Pro Val Pro Ser Lys Ile Pro Arg Lys 530
535 540 Ala Ser Ser Leu Thr Pro Leu Ala Ala Gln Lys Gln545 550 555
42058DNAHomo sapiens 4aaagagaggc tggctgttgt atttagtaaa gctataaagc
tgtaagagaa attggctttc 60tgagttgtga aactgtgggc agaaagttga ggaagaaaga
actcaagtac aacccaatga 120ggttgagata taggctactc ttcccaactc
agtcttgaag agtatcacca actgcctcat 180gtgtggtgac cttcactgtc
gtatgccagt gactcatctg gagtaatctc aacaacgagt 240taccaatact
tgctcttgat tgataaacag aatggggttt tggatcttag caattctcac
300aattctcatg tattccacag cagcaaagtt tagtaaacaa tcatggggcc
tggaaaatga 360ggctttaatt gtaagatgtc ctagacaagg aaaacctagt
tacaccgtgg attggtatta 420ctcacaaaca aacaaaagta ttcccactca
ggaaagaaat cgtgtgtttg cctcaggcca 480acttctgaag tttctaccag
ctgcagttgc tgattctggt atttatacct gtattgtcag 540aagtcccaca
ttcaatagga ctggatatgc gaatgtcacc atatataaaa aacaatcaga
600ttgcaatgtt ccagattatt tgatgtattc aacagtatct ggatcagaaa
aaaattccaa 660aatttattgt cctaccattg acctctacaa ctggacagca
cctcttgagt ggtttaagaa 720ttgtcaggct cttcaaggat caaggtacag
ggcgcacaag tcatttttgg tcattgataa 780tgtgatgact gaggacgcag
gtgattacac ctgtaaattt atacacaatg aaaatggagc 840caattatagt
gtgacggcga ccaggtcctt cacggtcaag gatgagcaag gcttttctct
900gtttccagta atcggagccc ctgcacaaaa tgaaataaag gaagtggaaa
ttggaaaaaa 960cgcaaaccta acttgctctg cttgttttgg aaaaggcact
cagttcttgg ctgccgtcct 1020gtggcagctt aatggaacaa aaattacaga
ctttggtgaa ccaagaattc aacaagagga 1080agggcaaaat caaagtttca
gcaatgggct ggcttgtcta gacatggttt taagaatagc 1140tgacgtgaag
gaagaggatt tattgctgca gtacgactgt ctggccctga atttgcatgg
1200cttgagaagg cacaccgtaa gactaagtag gaaaaatcca attgatcatc
atagcatcta 1260ctgcataatt gcagtatgta gtgtattttt aatgctaatc
aatgtcctgg ttatcatcct 1320aaaaatgttc tggattgagg ccactctgct
ctggagagac atagctaaac cttacaagac 1380taggaatgat ggaaagctct
atgatgctta tgttgtctac ccacggaact acaaatccag 1440tacagatggg
gccagtcgtg tagagcactt tgttcaccag attctgcctg atgttcttga
1500aaataaatgt ggctatacct tatgcattta tgggagagat atgctacctg
gagaagatgt 1560agtcactgca gtggaaacca acatacgaaa gagcaggcgg
cacattttca tcctgacccc 1620tcagatcact cacaataagg agtttgccta
cgagcaggag gttgccctgc actgtgccct 1680catccagaac gacgccaagg
tgatacttat tgagatggag gctctgagcg agctggacat 1740gctgcaggct
gaggcgcttc aggactccct ccagcatctt atgaaagtac aggggaccat
1800caagtggagg gaggaccaca ttgccaataa aaggtccctg aattctaaat
tctggaagca 1860cgtgaggtac caaatgcctg tgccaagcaa aattcccaga
aaggcctcta gtttgactcc 1920cttggctgcc cagaagcaat agtgcctgct
gtgatgtgca aaggcatctg agtttgaagc 1980tttcctgact tctcctagct
ggcttatgcc cctgcactga agtgtgagga gcaggaatat 2040taaagggatt caggcctc
2058
* * * * *