Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure

1. Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Adrian F. Hernandez, MD On behalf of the ASCEND-HF Committees, Investigators and Study Coordinators

2. Disclosure Information Adrian F. Hernandez, MD ASCEND-HF Trial FINANCIAL DISCLOSURE: Trial Sponsor: Scios Inc Research funding from Johnson & Johnson Honorarium from Amgen, Corthera Full listing of disclosures at dcri.org UNLABELED or UNAPPROVED USE: None

3. Study organization Sponsor SciosInc. Executive Committee Chair: Rob Califf Chris O’Connor (Co-PI), Randy Starling (Co-PI) Paul Armstrong, Kenneth Dickstein, Michel Komajda, Barry Massie, John McMurray, Markku Nieminen, Jean Rouleau, Karl Swedberg, Vic Hasselblad Independent DSMB Chair: Sidney Goldstein Salim Yusuf, David DeMets, Milton Packer, John Kjekshus Clinical Event Committee Chair: John McMurray International Steering Committee ROW: Johnson & JohnsonGlobal Clinical Operations Coordinating center: DCRI Adrian Hernandez, Craig Reist, Gretchen Heizer North America Academic Consortium: (DCRI, C5, Jefferson, Henry Ford, Canadian VIGOUR Centre) >800 Investigators and Study Coordinators at 398 Sites

4. Background • Acute heart failure is a major health problem responsible for several million hospitalizations worldwide each year. • Standard therapy has not changed since 1970s and includes diuretics and variable use of vasodilators or inotropes. • In 2001, nesiritide was approved by the FDA to reduce PCWP and improve dyspnea, based on efficacy at 3 hrs. • However, in 2005 two meta-analyses raised concerns regarding the risks of mortality and renal injury. • Subsequently, an independent panel* was convened by Scios Inc and recommended that a clinical trial be conducted to definitively answer the question of nesiritide’s safety and efficacy. *chaired by Eugene Braunwald

5. Design of ASCEND-HF: Guiding principles • Independent framework • Pragmatic trial model • Focused • Efficient study design • Streamlined procedures • Simple follow-up • Permissive enrollment criteria for broad population • Meaningful outcomes • Standard of care per local practice (“real world”)

6. Co-Primary objectives To assess whether nesiritide vs placebo, in addition to standard care provides: • Reduction in rate of HF rehospitalization or all-cause mortality through Day 30 • Significant improvement in self-assessed dyspnea at 6 or 24 hrs using 7-point Likert scale 60 Markedly Better 40 Moderately Better Minimally Better 20 No Change % Subjects 0 Minimally Worse 20 Moderately Worse 40 Markedly Worse

7. Secondary and safety objectives • Secondary endpoints: • Overall well-being at 6 and 24 hours • Persistent or worsening HF and all-cause mortality from randomization through discharge • Number of days alive and outside of the hospital • Cardiovascular rehospitalization and cardiovascular mortality • Safety endpoints: • All cause mortality • Renal: 25% decrease in eGFR at any time from study drug initiation through Day 30 • Hypotension: As reported by investigator as symptomatic or asymptomatic

8. Study design and drug procedures Nesiritide • Double – blind placebo controlled • IV bolus (loading dose) of 2 µg/kg nesiritide or placebo • Investigator’s discretion for bolus • Followed by continuous IV infusion of nesiritide 0.01 µg/kg/min or placebo for up to 7 days • Usual care per investigators including diuretics and/or other therapies as needed • Duration of treatment per investigator based on clinical improvement Acute HF < 24 hrs from IV RX 24–168 hrs Rx Placebo Co-primary endpoint: Dyspnea relief at 6 and 24 hrs Co-primary endpoint: 30-day death or HF rehosp All-cause mortality at 180 days

9. Inclusion and exclusion criteria Key inclusion criteria Key exclusion criteria • Hospitalized for ADHF <24 hrs from IV treatment • Dyspnea at rest or with minimal activity • 1 clinical sign: • Respiratory rate ≥ 20 breaths per min • Rales >1/3 bases • 1 objective measure: • CXR with pulmonary edema • BNP ≥400 pg/mL or NT-proBNP≥1000 pg/mL • Prior EF <40% within 12 months • PCWP > 20 mmHg • Hypotension at baseline (SBP <100 mm Hg or SBP<110 mm Hg with IV vasodilator) • Significant lung disease that could interfere with interpretation of dyspnea • Acute coronary syndrome • Severe anemia or active bleeding • Treatment with levosimendan or milrinone • Unstable doses of IV vasoactive medication within 3 hours

10. Statistical methods • Study population: modified intention-to-treat based on receiving study drug • Primary analysis: • Co-primary endpoints tested using Bonferroni approach • Composite of HF rehospitalization and all-cause mortality tested at 0.045 significance level • Dyspnea tested at 0.005 level using Hochberg method: • Significant if both 6- and 24-hr assessment P values ≤0.005; or • If either 6- or 24-hr assessment P values ≤0.0025 • Sample size determination: • Based on composite endpoint: 89% power with 7000 patients using chi-square test, assuming a placebo event rate of 14% and a relative risk reduction of 18.6%

11. Enrollment 7141 patients 30 Countries & 398 Sites Western Europe = 7% 35 sites North America = 45% 214 sites Central Europe = 14% 48 sites Asia-Pacific = 25% 62 sites Latin America = 9% 39 sites >800 Investigators and Study Coordinators

12. Study population Randomized (n=7141) • Placebo (n=3577) • Did not receive study drug (n=66) • Hypotension (n=28) • Exclusion criteria (n=8) • Physician decision (n=6) • Participant withdrew consent (n=14) • Other reason (n=10) • Nesiritide (n=3564) • Did not receive study drug (n=68) • Hypotension (n=26) • Exclusion criteria identified (n=9) • Physician decision (n=6) • Participant withdrew consent (n=16) • Other reason (n=11) Placebo MITT=3511 Nesiritide MITT=3496

13. Baseline characteristics Continuous variables as median (IQR 25th, 75th); MITT population

14. Baseline characteristics Continuous variables as median (IQR 25th, 75th); MITT population

15. Co-Primary outcome: 30-day all-cause mortality or HF rehospitalization P=0.31 Hazard Ratio 0.93 (95% CI: 0.8,1.08) 12 10.1 9.4 10 Placebo Nesiritide 8 6.1 6.0 % 6 4.0 3.6 4 2 0 30-day Death/HF Rehospitalization 30-day Death HF Rehospitalization Risk Diff (95 % CI) -0.7 (-2.1; 0.7) -0.4 (-1.3; 0.5) -0.1 (-1.2; 1.0)

16. 30 day death/HF readmission subgroups Risk Difference <0: Favors Nesiritide; Risk Difference >0: Favors Placebo Difference (%) and 95% Confidence Interval

17. 30 day death/HF readmission subgroups Risk Difference <0: Favors Nesiritide; Risk Difference >0: Favors Placebo Difference (%) and 95% Confidence Interval

18. Co-Primary Endpoint: 6 and 24 hour dyspnea 6 Hours 24 Hours 70 68.2% P=0.007 70 66.1% P=0.030 60 60 42.1% 44.5% 50 27.5 30.4 50 40 40 15.0 13.4 30 30 % Subjects 20 % Subjects 20 38.6 37.8 29.5 28.7 10 10 0 0 10 10 22.1 21.2 32.8 34.1 20 20 8.6 9.5 30 30 40 40 3398 Placebo 3371 Nesiritide 20.3 21.7 50 60 3416 Nesiritide 3444Placebo Markedly Better Moderately Better No Change Minimally Better Minimally Worse Moderately Worse Markedly Worse

19. Dyspnea at 6 and 24 HoursOdds for Marked-Moderate Improvement 6 hours 24 hours OR <1: Favors Placebo; OR >1: Favors Nesiritide; Odds Ratio of Markedly/Moderately vs. Other

20. Dyspnea at 6 and 24 HoursOdds for Marked-Moderate Improvement 6 hours 24 hours OR <1: Favors Placebo; OR >1: Favors Nesiritide; Odds Ratio of Markedly/Moderately vs. Other

21. Secondary endpoints *Combined response for moderately/markedly better

22. Renal Safety Placebo Nesiritide End of Treatment Creatinine Discharge or 10 day Creatinine 1.0 1.0 0.9 0.9 0.8 0.8 0.7 0.7 0.6 0.6 Cum Dist Cum Dist 0.5 0.5 0.4 0.4 0.3 0.3 0.2 0.2 0.1 0.1 0 0 0 0 2 2 4 4 6 6 8 8 Creatinine (mg/dL) Creatinine (mg/dL)

23. Hypotension

24. 30-day mortality meta-analysis Odds Ratio (95% CI) Mills (N=163) 0.38 (0.05, 2.74) Efficacy (N=127) 1.24 (0.23, 6.59) Comparative (N=175) 1.43 (0.50, 4.09) 0.59 (0.18, 2.01) PRECEDENT (N=147) VMAC (N=498) 1.63 (0.77, 3.44) PROACTION (N=237) 6.93 (0.89, 53.91) ASCEND-HF (N=7007) 0.89 (0.69, 1.14) COMBINED 30 day w/out ASCEND 1.28 (0.73, 2.25) COMBINED with ASCEND 1.00 (0.76, 1.30) 1 10 0.1

25. Conclusions • Nesiritide did not reduce the rate of recurrent heart failure hospitalization or death at 30 days. • Nesiritide reduced dyspnea to a modest degree, consistent with previous findings but did not meet pre-specified protocol criteria for statistical significance at 6 and 24 hours. • Nesiritide did not affect 30-day all cause mortality nor did it worsen renal function as had been suggested by prior meta-analyses of smaller studies.

26. Implications • Nesiritide can now be considered a safe therapy in patients with acute heart failure. • Further analysis of ASCEND-HF is likely to permit better understanding of acute heart failure and patient profiles that may potentially benefit from nesiritide. • Our results from this large randomized trial emphasize both the challenges of making therapeutic decisions on inadequate evidence as well as the urgent need for large, well-conducted trials capable of informing clinical practice

27. Steering Committee North America: Kirkwood F. Adams Jr MD; Javed Butler, MD;Maria Rosa Costanzo, MD; Mark E. Dunlap, MD; Justin A. Ezekowitz, MBBCh, MSc; David Feldman, MD, PhD; Gregg C. Fonarow, MD; Stephen S. Gottlieb, MD, MHS; James A. Hill, MD, MS; Judd E. Hollander, MD; Jonathan G. Howlett, MD; Michael Hudson, MD; Mariell L. Jessup, MD; Serge Lepage, MD; Wayne C. Levy, MD; Naveen Pereira, MD; W.H. Wilson Tang, MD; John R. Teerlink, MD; David J. Whellan, MD; Clyde W. Yancy, MD Europe: Stefan D. Anker, MD, PhD; Dan Atar, MD; Alexander Battler, MD; Ulf Dahlstrom, MD, PhD; Aleksandras Laucevicius, MD; Marco Metra, MD; Alexander Parkhomenko, MD; Piotr Ponikowski, MD, PhD; Jindrich Spinar, MD; Svetla Torbova, MD; Filippos Triposkiadis, MD;Vyacheslav Mareev, MD; Adriaan A. Voors, MD, PhD; Faiez Zannad, MD, PhD Latin America: Rodrigo Botero, MD; Nadine Clausell, MD; Ramón Corbalán, MD; Rafael Diaz, MD; Gustavo Méndez Machedo Asia Pacific: Ping Chai, MD; Wen-Jone Chen, MD; Henry Krum, MBBS, PhD; Sanjay Mittal, MD; Byung Hee Oh, MD; Supachai Tanomsup, MD; Richard W. Troughton, MD, PhD; YueJin Yang, MD;