What is G-CSF?

1. STEM-AMI OUTCOME TRIALSTem cElls Mobilization in Acute Myocardial Infarction Outcome TrialA national, multicentre, randomised, open-label, Phase III studyDott. Luca DeferrariU.O. CardiologiaIRCCS San Martino, Genova

2. What is G-CSF? • Granulocyte Colony Stimulating Factor • Glycoprotein • Growth factor • Cytokine • Produced by endothelium, macrophages and other immune cells • G-CSF receptor present on precursor cells in the bone marrow • Initiates proliferation and differentiation into mature granulocytes • Stimulates bone marrow cell release into circulation

3. Two important G-CSF uses • MOST COMMON: Post chemotherapy febrile neutropenia • Potent inducer of hematopoietic stem cell mobilization for stem cell transplantation

4. Side effects associated with G-CSF

5. STEM–AMI Outcome trial: rationale

6. STEM–AMI Outcome trial: rationale

7. STEM–AMI Outcome trial: rationale

8. STEM –AMI Outcome trial: rationale

9. STEM–AMI Outcome trial: rationale

10. STEM–AMI Outcome trial: rationale

11. STEM–AMI Outcome trial: rationale

12. STEM-AMI OUTCOME TRIAL STUDY OBJECTIVES To demonstrate that G-CSF in addition to state of the art treatment is safe and significantly improves clinical outcome in patients with reduced left ventricular EF (≤45%) after successful reperfusion for large anterior acute myocardial infarction

13. STEM-AMI OUTCOME TRIAL DESIGN Phase III, randomized, open label. 1530Patients (50 centres) will be randomized to standard therapy + G-CSF or standard therapy alone in 1:1 ratio. Accrual time 3 years. Follow-up time 2 years. TREATMENT FILGRASTIM 5 µg/kg will be administered subcutaneouslybis in die for 6 days (from Day 1 to Day 6), starting within 24 h after PCI and reperfusion.

14. STEM-AMI OUTCOME TRIAL PRIMARY EFFICACY END POINT Clinical outcome will be assessed by the composite endpoint of: • death or • recurrence of MI or • hospitalization due to heart failure SAFETY ENDPOINTS • Incidence and severity of bleeding complications • Incidence of malignancy • Incidence and intensity of AEs and SAEs

15. STEM-AMI OUTCOME TRIAL INCLUSION CRITERIA • Patients affected by acute anterior STEMI undergoing primary PCI (or PCI-rescue with persistent occlusion of coronary artery) • Time symptom-to-balloon ≥3 h and ≤12h (or ≤24 h if symptoms persist) • TIMI flow post PCI ≥2 • Evidence of LV dysfunction (EF biplane ≤ 45%) ≤ 24 h after revascularization • Men and women aged ≥18 years and ≤ 75 years, • Informed consent must be signed before proceeding with any study procedure.

16. STEM-AMI OUTCOME TRIAL EXCLUSION CRITERIA • PreviousanteriorMI • Recent MI (within 1 month) • Known previous LV dysfunction (EF <45%), • Angiographic evidence of coronary anatomy not suitable for PCI • Valve disease requiring surgical correction • History of previous cardiac surgery or PCI on LAD within 6 months • Previous or current documented history of leukemia, myeloproliferativeor myelodisplastic disorder, malignant disease • Haemoglobin<10 mg/dl • White blood cells (WBC) >25.000 mm3 • Platelet<50.000 mm3 • Sepsis • KnownHIV infection • Immune systemdiseases • Interstitiallungdisease • Serious concomitant medical conditions (other than ischemic heart disease) • Pregnancyand breastfeeding • Documented alcohol and drug abuse • Anticipatedpoorcompliance • Current participation in a clinical trial with other investigational products or celltherapy • ANAMNESI EXTRACARDIACA • Malattie mieloproliferative, leucemia • Neoplasie • HIV • Patologia autoimmune • Interstiziopatia polmonare • Gravidanza o allattamento • Abuso di alcool e/o droghe • Scarsa compliance • ANAMNESI CARDIOLOGICA • Pregresso IMA anteriore • IMA nel mese precedente • Nota disfunzione VSx (FE ≤ 45% ) • Valvulopatia con indicazione CCH • Pregressa CCH nei 6 mesi precedenti • Pregressa PCI su IVA nei 6 mesi precedenti • EMOCROMO • Hb <10 g/dl • Globuli bianchi >25.000/mm3 • Piastrine <50.000/mm3

17. STEM-AMI OUTCOME TRIAL Assessment I Assessment II Assessment III Assessment IV Assessment V Assessment VI Day -1/0 In hospital phase 1 month 6 months 12 months 24 months

18. STEM-AMI OUTCOME TRIAL ASSESMENT I DAY -1/0 Screening and randomization • Obtain written informed consent • Documented acute anterior STEMI • Documented primary PCI/PCI-rescue (symptom to ballon time) • TIMI flow post-PCI registration • Evidence of Echo Simpson biplane EF ≤45%, EDV and ESV • Hemochrome (hemoglobin, platelets, WBC) • Pregnancy test (if necessary) • Determine patient’s eligibility for enrollment • Randomization to study treatment group

19. STEM-AMI OUTCOME TRIAL ASSESMENT II DAY 0-7 In Hospital phase • G-CSF administration • Hemochrome (WBC count) • Documentation of ADRs/SAEs • ECG • ECHO: EF (Echo Simpson biplane), EDV and ESV

20. STEM-AMI OUTCOME TRIAL ASSESMENT III DAY 30 1-month visit • Clinical Evaluation • Documentation of ADRs/SAEs • ECG

21. STEM-AMI OUTCOME TRIAL ASSESMENT IV DAY 180 6-months visit • Clinical Evaluation • Documentation of ADRs/SAEs • ECG • ECHO: EF (Echo Simpson biplane), EDV and ESV

22. STEM-AMI OUTCOME TRIAL ASSESMENT V DAY 365 12-months visit • Phone interview • Documentation of ADRs/SAEs

23. STEM-AMI OUTCOME TRIAL ASSESMENT V DAY 730 24-months visit • Clinical Evaluation • Documentation of ADRs/SAEs • ECG • ECHO: EF (Echo Simpson biplane), EDV and ESV

24. STEM-AMI OUTCOME TRIAL Egregi Dottori, Con la presente, comunichiamo che oggi, 8 novembre 2013, è stato arruolato il primo paziente dello Studio STEM-AMI Outcome dall'Ospedale San Gerardo di Monza. CordialmenteSegreteria OrganizzativaCentro di Coordinamento Centro Studi ANMCO Grazie per l’attenzione