Pharmacogenetics-guided dalcetrapib therapy after an acute coronary syndrome: the dal-GenE trial

Abstract

Aims: In a retrospective analysis of dal-Outcomes, the effect of dalcetrapib on cardiovascular events was influenced by an adenylate cyclase type 9 (ADCY9) gene polymorphism. The dal-GenE study was conducted to test this pharmacogenetic hypothesis.

Methods and results: dal-GenE was a double-blind trial in patients with an acute coronary syndrome within 1-3 months and the AA genotype at variant rs1967309 in the ADCY9 gene. A total of 6147 patients were randomly assigned to receive dalcetrapib 600 mg or placebo daily. The primary endpoint was the time from randomization to first occurrence of cardiovascular death, resuscitated cardiac arrest, non-fatal myocardial infarction, or non-fatal stroke. After a median follow-up of 39.9 months, the primary endpoint occurred in 292 (9.5%) of 3071 patients in the dalcetrapib group and 327 (10.6%) of 3076 patients in the placebo group [hazard ratio 0.88; 95% confidence interval (CI) 0.75-1.03; P = 0.12]. The hazard ratios for the components of the primary endpoint were 0.79 (95% CI 0.65-0.96) for myocardial infarction, 0.92 (95% CI 0.64-1.33) for stroke, 1.21 (95% CI 0.91-1.60) for death from cardiovascular causes, and 2.33 (95% CI 0.60-9.02) for resuscitated cardiac arrest. In a pre-specified on-treatment sensitivity analysis, the primary endpoint event rate was 7.8% (236/3015) in the dalcetrapib group and 9.3% (282/3031) in the placebo group (hazard ratio 0.83; 95% CI 0.70-0.98).

Conclusion: Dalcetrapib did not significantly reduce the risk of occurrence of the primary endpoint of ischaemic cardiovascular events at end of study. A new trial would be needed to test the pharmacogenetic hypothesis that dalcetrapib improves the prognosis of patients with the AA genotype.

Clinical trial registration: Trial registration dal-GenE ClinicalTrials.gov Identifier: NCT02525939.

Keywords: Adenylate cyclase type 9 (ADCY9); Atherosclerosis; CETP; Genetics; Myocardial infarction; Precision medicine.

Conflict of interest statement

Conflict of interest: J.C.T. has received research grant and honoraria from Amarin; research grant from AstraZeneca; research grant, honoraria, and minor equity interest from DalCor; research grant from Esperion; research grant from Ionis; research grant and honoraria from Sanofi; research grant and honoraria from Servier; a patent on pharmacogenomics-guided CETP inhibition was obtained, and J.C.T. and M.P.D. are mentioned as authors. M.P.D. has a minor equity interest in DalCor and has received honoraria from DalCor. M.A.P. receives research support from Novartis; he serves as a consultant for AstraZeneca, Corvidia, DalCor, GlaxoSmithKline, Jazz, MyoKardia, Novartis, Novo Nordisk, Roche, Sanofi, Servier, and Takeda; and has equity in DalCor. D.D.W. has received remuneration for participation in clinical trial committees from CSL Ltd, Daiichi Sankyo, DalCor, the Medicines Company, Novo Nordisk, Regeneron, Resverlogix, and Sanofi, and honoraria for lectures from DalCor and Pfizer. W.K. reports personal fees (consulting) from DalCor and consulting fees from AstraZeneca, Novartis, Pfizer, The Medicines Company, Kowa, a Corvidia, Esperion, Genentech, Omeicos, Novo Nordisk, Daiichi Sankyo, and Amgen; personal fees (honorarium for lectures) from AstraZeneca, Novartis, Amgen, Sanofi, Bristol-Myers-Squibb, and Berlin-Chemie; grants and non-financial support (provision of reagents for biomarker measurements free of charge) from Roche Diagnostics, Beckmann, Singulex, and Abbott, outside the submitted work. A.P.M. has received personal fees for participation in study committee from DalCor, and personal fees for participation in study committees from AstraZeneca, Bayer, Novartis, and Fresenius. J.J.V.M. reports grants paid to his institution and fees as steering committee member from DalCor Pharma UK for the Dal-GenE study, during the conduct of the study; grants paid to his institution and fees as steering committee member from Oxford University and Bayer; grants paid to his institution from Theracos; grants paid to his institution and fees as steering committee from Abbvie; grants paid to his institution from Pfizer, Merck AstraZeneca, GlaxoSmithKline, and Novartis. J.W.J. and his department have received research grants from and/or was speaker (with or without lecture fees) in CME-accredited meetings sponsored by Amgen, Athera, Biotronik, Boston Scientific, Dalcor, Daiichi Sankyo, Lilly, Medtronic, Merck-Schering-Plough, Novartis, Novo Nordisk, Pfizer, Roche, Sanofi-Aventis, The Medicine Company, The Netherlands Heart Foundation, CardioVascular Research The Netherlands (CVON), The Netherlands Heart Institute and the European Community Framework KP7 Programme. H.D.W. reports grants paid to his institution and fees as steering committee member from DalCor Pharma UK for the Dal-GenE study, during the conduct of the study; grants paid to his institution and fees as steering committee member from Sanofi-Aventis, Regeneron Pharmaceutics, National Institutes of Health (USA), CSL Behring, American Regent, Sanofi-Aventis Australia Pty Ltd, and Esperion Therapeutics Inc, outside the submitted work. F.L.T., T.H., and D.M.B. are employed by and have minor equity interest in DalCor. Other authors report no conflicts of interest.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.

Figures

Structured Graphical Abstract

Dalcetrapib in patients with AA genotype at variant rs1967309 in theADCY9 gene. CI, confidence interval; CV, cardiovascular; HR, hazard ratio.

Figure 1

dal-GenE trial: patient disposition.

Figure 2

Kaplan–Meier curves for the primary efficacy endpoint at end of study.

Figure 3

Efficacy results in pre-specified subgroups at end of study.