Dipeptidyl Peptidase-4 Regulation of SDF-1/CXCR4 Axis: Implications for Cardiovascular Disease

Zhong, Jixin; Rajagopalan, Sanjay

del of HF, delivery of a plasmid SDF-1 with an endomyocardial injection catheter demonstrated safety at doses up to 100 mg while improving cardiac function and vasculogenesis up to 90 days post-injection at doses of 7.5 and 30 mg (59) . In a Phase I dose escalation study with 12 months follow-up in ischemic cardiomyopathy, 17 subjects in New York Heart Association class III heart failure, with an ejection fraction ≤40% on stable medical therapy, were enrolled to receive 5, 15, or 30 mg of plasmid SDF-1 via endomyocardial injection. The primary end points for safety and efficacy were at 1 and 4 months, respectively. The primary safety end point was a major adverse cardiac event while efficacy end points were changes in quality of life, New York Heart Association (NYHA) class, 6-min walk distance, single photon emission computed tomography, N-terminal pro-brain natruretic peptide, and echocardiography at 4 and 12 months. The primary safety end point was met. At 4 months, all of the cohorts demonstrated improvements in 6-min walk distance, quality of life, and NYHA class (93) . Stromal cell-derived factor-1 plasmid treatment for patients with heart failure (STOP-HF) was a Phase II, double-blind, randomized, placebo-controlled trial to evaluate safety and efficacy of a single treatment of plasmid SDF-1 delivered via endomyocardial injection to patients with ischemic heart failure. The primary endpoint was a composite of change in 6 min walking distance and Minnesota Living from Heart Failure Questionnaire from baseline to 4 months follow-up. The primary endpoint was not met (P = 0.89). For the patients treated with pSDF-1, there was a trend toward an improvement in left ventricular ejection fraction at 12 months (placebo vs. 15 vs. 30 mg ΔLVEF: −2 vs. −0.5 vs. 1.5%, P = 0.20). Patients in the first tertile of EF (<26%) that received 30 mg of pSDF-1 demonstrated a 7% increase in EF compared with a 4% decrease in placebo (ΔLVEF = 11%, P = 0.01) at 12 months (94) . Although the reasons for the overall failure are currently unclear, the differential benefit in those with advanced left ventricle dysfunction raises the possibility of differential mechanisms that would be operational in more advanced patients. These include the possible overexpression of CXCR4 in cardiac myocytes in the infarct border leading to a negative inotropic state (95) . The transient overexpression of SDF-1 in ischemic cardiomyopathy has been shown to lead to long-term down-regulation of cardiac myocyte CXCR4 expression, re-recruiting the contractile function of the border zone (61) . Patients with greater left ventricle dysfunction are likely to have a greater volume of myocardial tissue under stress; therefore, a greater demonstrable response to SDF-1 overexpression. Another important reason could be that the upregulation of DPP4 in the border zone of the infarct or around ischemic areas may have resulted in rapid degradation of SDF-1 limiting the efficacy of such an approach. Since both the Phase I and Phase II studies were performed in the absence of DPP4 inhibition, it could be speculated that the results may have been different if the trials had been performed either in the presence of a DPP4 inhibitor.