Applications of Biotechnology
in Cardiovascular Therapeutics

Applications
of Biotechnology
in Cardiovascular
Therapeutics
Kewal K. Jain MD, FRACS, FFPM
Jain PharmaBiotech, Basel, Switzerland
Kewal K. Jain
Jain PharmaBiotech
Blaesiring 7
Basel 4057
Switzerland

ISBN 978-1-61779-239-7 e-ISBN 978-1-61779-240-3
DOI 10.1007/978-1-61779-240-3
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011931532
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physicians, surgeons, and scientists working on cardiovascular disorders. It will be
useful for those working in life sciences and pharmaceutical industries, and some
basics of cardiovascular diseases are included for nonmedical readers.
A major application of biotechnology is in therapeutic delivery to the cardiovas-
cular system. Routes of drug delivery and applications to various diseases are
described. Formulations for drug delivery to the cardiovascular system range from
controlled release preparations to delivery of proteins and peptides. Various methods
of improving systemic administration of drugs for cardiovascular disorders are
described including the use of nanotechnology.
Cell-selective-targeted drug delivery has emerged as one of the most significant
areas of biotechnology engineering research to optimize the therapeutic efficacy of
a drug by strictly localizing its pharmacological activity to a pathophysiologically
relevant tissue system. These concepts have been applied to targeted drug delivery
to the cardiovascular system. Finally, devices for drug delivery to the cardiovascular
system are described. A full chapter is devoted to drug-eluting stents used for treat-
ment of restenosis following stenting of coronary arteries. This is one of the biggest
segments of the cardiovascular drug delivery market with 15 companies involved in
developing and producing stents.
Cell and gene therapies, including antisense and RNA interference, are described
in full chapters as they are the most innovative methods of delivery of therapeutics.
New cell-based therapeutic strategies are being developed in response to the short-
comings of available treatments for heart disease. Potential repair by cell grafting or
mobilizing endogenous cells holds particular attraction in heart disease, where the
meager capacity for cardiomyocyte proliferation likely contributes to the irrevers-
ibility of heart failure. Cell therapy approaches include attempts to reinitiate cardio-
myocyte proliferation in the adult, conversion of fibroblasts to contractile myocytes,
viii Preface
conversion of bone marrow stem cells into cardiomyocytes, and transplantation of
myocytes or other cells into injured myocardium.
Advances in molecular pathophysiology of cardiovascular diseases have brought

several other countries. He passed specialist examinations in neurosurgery in USA,
Canada, and Australia. Currently, he is a Fellow of the Royal Australasian College
of Surgeons and a Fellow of the Faculty of Pharmaceutical Medicine of the Royal
College of Physicians of UK. Prof. Jain is the author of 425 publications including
18 books (2 as editor) and 49 special reports, which have covered important areas
in neurosciences, biomedicine, biotechnology, cell/gene therapy, and biopharma-
ceuticals. In the 1970s, he developed a technique for sutureless microvascular
anastomosis using lasers described in his Handbook of Laser Neurosurgery pub-
lished by Charles C Thomas in 1984. His Textbook of Gene Therapy was translated
into Chinese language in 2000. The Textbook of Hyperbaric Medicine (5th Ed
2009) has been a standard reference on the subject for the past two decades and
contains a chapter on cardiovascular disorders.
Prof. Jain has edited Drug Delivery Systems (2008) and Drug Delivery to the
Central Nervous System (2010), both published by Humana/Springer. His other
recent books include Handbook of Nanomedicine (Springer/Humana 2008),
Textbook of Personalized Medicine (Springer 2009), Handbook of Biomarkers
(Springer 2010), and Handbook of Neuroprotection (Springer 2011).
About the Author

xiii
Contents
1 Cardiovascular Therapeutics 1
Introduction 1
History of Cardiovascular Therapy 1
Overview of Cardiovascular Disease 2
Epidemiology of Cardiovascular Disease 2
Management of Acute Coronary Occlusive Disease 3
Limitations of Current Therapies for Myocardial Ischemic Disease 3
Angina Pectoris 4
Cardiomyopathies 4

Routes of Drug Delivery to the Cardiovascular System 29
Local Administration of Drugs to the Cardiovascular System 29
Intramyocardial Drug Delivery 29
Drug Delivery via Coronary Venous System 30
Intrapericardial Drug Delivery 31
Formulations for Drug Delivery to the Cardiovascular System 31
Sustained and Controlled Release 32
Methods of Administration of Proteins and Peptides 34
Targeted Drug Delivery to the Cardiovascular System 38
Immunotargeting of Liposomes to Activated Vascular
Endothelial Cells 38
PEGylated Biodegradable Particles Targeted
to Inflamed Endothelium 39
Devices for Cardiovascular Drug Delivery 40
Local Drug Delivery by Catheters 41
Micro-Infusion Catheters for Periarterial Injection 42
DDS in the Management of Ischemic Heart Disease 45
Drug Delivery for Cardiac Rhythm Disorders 47
Sustained and Controlled-Release Nitrate for Angina Pectoris 47
Vaccines Delivery for Hypertension 49
Drug Delivery in the Management of Pulmonary Hypertension 50
Anticoagulation in Cardiovascular Disease 51
Thrombolysis for Cardiovascular Disorders 53
Drug Delivery for Peripheral Arterial Disease 54
References 55
3 Role of Nitric Oxide in Cardiovascular Disorders 57
Introduction 57
Role of NO in Physiology of the Cardiovascular System 59
Hemoglobin, Oxygen, and Nitric Oxide 64
NO and Pulmonary Circulation 66

of Cardiovascular Disease 94
Detection of Biomarkers of Myocardial Infarction
in Saliva by a Nanobiochip 94
Metabolomic Technologies for Biomarkers of Myocardial Ischemia 95
Imaging Biomarkers of Cardiovascular Disease 95
Applications of Biomarkers of Cardiovascular Disease 97
Biomarkers for Ischemic Heart Disease and Myocardial Infarction 97
Biomarkers of Congestive Heart Failure 103
Biomarkers for Atherosclerosis 108
Biomarkers of Risk Factors for Coronary Heart Disease 112
Biomarkers for Pulmonary Arterial Hypertension 114
Genetic Biomarkers for Cardiovascular Disease 116
Multiple Biomarkers for Prediction of Death
from Cardiovascular Disease 121
Role of Biomarkers in the Management of Cardiovascular Disease 122
Role of Biomarkers in the Diagnosis/Prognosis
of Myocardial Infarction 122
Role of Biomarkers in the Prevention of Cardiovascular Disease 122
Molecular Signature Analysis in Management
of Cardiovascular Diseases 123
C-Reactive Protein as Biomarker of Response to Statin Therapy 124
xvi Contents
Role of Circulating Biomarkers and Mediators
of Cardiovascular Dysfunction 125
Use of Protein Biomarkers for Monitoring Acute
Coronary Syndromes 125
Use of Biomarkers for Prognosis of Recurrent Atrial Fibrillation 126
Use of Multiple Biomarkers for Monitoring
of Cardiovascular Disease 126
Use of Biomarkers in the Management

6 Nanobiotechnology in Cardiovascular Disorders 145
Introduction 145
Nanotechnology-Based Cardiovascular Diagnosis 146
Nanobiotechnology for Molecular Diagnostics 146
Nanosensors 147
xviiContents
Use of Magnetic Nanoparticles as MRI Contrast Agents
for Cardiac Disorders 148
Use of Perfluorocarbon Nanoparticles in Cardiovascular Disorders 148
Cardiac Monitoring in Sleep Apnea 148
Detection and Treatment of Atherosclerotic Plaques in the Arteries 149
Monitoring for Disorders of Blood Coagulation 149
Nanotechnology-Based Therapeutics for Cardiovascular Diseases 150
Nanolipoblockers for Atherosclerotic Arterial Plaques 150
Nanotechnology-Based Drug Delivery in Cardiovascular Diseases 150
Antirestenosis Drugs Encapsulated in Biodegradable Nanoparticles 152
Controlled Delivery of Nanoparticles to Injured Vasculature 152
IGF-1 Delivery by Nanofibers to Improve Cell Therapy
for Myocardial Infarction 152
Injectable Peptide Nanofibers for Myocardial Ischemia 153
Liposomal Nanodevices for Targeted Cardiovascular Drug Delivery 153
Low Molecular Weight Heparin-Loaded Polymeric Nanoparticles 154
Nanoparticles for Cardiovascular Imaging
and Targeted Drug Delivery 154
Nanofiber-Based Scaffolds with Drug-Release Properties 155
Nanotechnology Approach to the Vulnerable Plaque as Cause
of Cardiac Arrest 155
Nanotechnology for Regeneration of the Cardiovascular System 156
References 157
7 Cell Therapy for Cardiovascular Disorders 159

Transplantation of Myoblasts for Myocardial Infarction 171
Patching Myocardial Infarction with Fibroblast Culture 172
Cardiac Repair with Myoendothelial Cells from Skeletal Muscle 173
Myocardial Tissue Engineering 173
Role of Stem Cells in Repair of the Heart 175
Role of Stem Cells in Cardiac Regeneration Following Injury 175
Cardiomyocytes Derived from Adult Skin Cells 175
Cardiomyocytes Derived from ESCs 176
Studies to Identify Subsets of Progenitor Cells Suitable
for Cardiac Repair 176
Technologies for Preparation of Stem Cells
for Cardiovascular Therapy 178
Role of ESCs in Repair of the Heart 180
Transplantation of Stem Cells for Acute Myocardial Infarction 181
Stem Cell Therapy for Cardiac Regeneration 188
Transplantation of Genetically Modified Cells 191
Transplantation of Genetically Modified MSCs 191
Transplantation of Cells Secreting Vascular Endothelial
Growth Factor 191
Transplantation of Genetically Modified Bone Marrow
Stem Cells 192
Cell Transplantation for Congestive Heart Failure 192
Myoblasts for Treatment of Congestive Heart Failure 193
Injection of Adult Stem Cells for Congestive Heart Failure 193
AngioCell Gene Therapy for Congestive Heart Failure 194
Stem Cell Therapy for Dilated Cardiac Myopathy 195
Role of Cell Therapy in Cardiac Arrhythmias 196
Atrioventricular Conduction Block 196
Ventricular Tachycardia 198
Prevention of Myoblast-Induced Arrhythmias

Direct Plasmid Injection into the Myocardium 220
Catheter-Based Systems for Vector Delivery 221
Ultrasound Microbubbles for Cardiovascular Gene Delivery 221
Vectors for Cardiovascular Gene Therapy 221
Hypoxia-Regulated Gene Therapy for Myocardial Ischemia 224
Angiogenesis and Gene Therapy of Ischemic Disorders 225
Therapeutic Angiogenesis with Vascular Endothelial Growth
Factor Therapy 226
Gene Painting for Delivery of Targeted Gene Therapy to the Heart 226
Gene Delivery to Vascular Endothelium 227
Targeted Plasmid DNA Delivery to the Cardiovascular System
with Nanoparticles 227
Gene Therapy for Genetic Cardiovascular Disorders 229
Genetic Disorders Predisposing to Atherosclerosis 229
Gene Therapy of Familial Hypercholesterolemia 229
Apolipoprotein E Deficiency 231
Hypertension 232
Genetic Factors for Myocardial Infarction 233
Gene Therapy for Acquired Cardiovascular Diseases 233
Coronary Artery Disease with Angina Pectoris 233
Gene Therapy for Improving Long-Term CABG Patency Rates 234
Ischemic Heart Disease with Myocardial Infarction 234
Congestive Heart Failure 237
Gene Therapy for Cardiac Arrhythmias 240
Gene Therapy and Heart Transplantation 242
Gene Therapy for Peripheral Arterial Disease 243
xx Contents
Maintaining Vascular Patency After Surgery 245
Antisense Therapy for Cardiovascular Disorders 245
Antisense Therapy for Hypertension 246

The Ideal DES 282
Companies Developing Drug-Eluting Stents 283
Clinical Trials of Drug-Eluting Stents 284
Comparison of DES with Competing Technologies 291
Cost-Effectiveness of DES 297
Safety Issues of DES 298
Regulatory Issues of DES 303
Future Prospects for Treatment of Restenosis by DES 305
Future Role of DES in Management of Cardiovascular Diseases 305
Stent Cost and Marketing Strategies 306
xxiContents
Improvements in Stent Technology 307
DES Versus Drug-Eluting Balloons 308
References 308
10 Personalized Cardiology 315
Introduction to Personalized Medicine 315
Role of Diagnostics in Personalized Management
of Cardiovascular Disease 316
Testing in Coronary Heart Disease 316
SNP Genotyping in Cardiovascular Disorders 316
Cardiovascular Disorders with a Genetic Component 317
Gene Variant as a Risk Factor for Sudden Cardiac Death 318
KIF6 Gene Test as a Guide to Management of Congestive
Heart Failure 320
SNP Chip for Study of Cardiovascular Diseases 321
Pharmacogenomics of Cardiovascular Disorders 321
Modifying the Genetic Risk for Myocardial Infarction 321
Management of Heart Failure 322
b -Blockers 322
Bucindolol 323

Micro-Infusion catheter for coronary artery injection.
A single injection to the outside of the vessel results in liquid
compounds diffusing around the vessel (circumferentially),
up and down the vessel (longitudinally), and inward through
the vessel layers (transmurally). The microscopic needle
puncture is so small that it heals almost instantly.
Illustrations courtesy of Mercator MedSystems 43
Fig. 3.1 Biosynthesis of nitric oxide (NO). L-arginine is converted
to NO in two successive steps of which a two-electron
oxidation of L-arginine to N-w-hydroxy-L-argininine
is the first, then converted to NO and citrulline, utilizing
one and half NADPH and O
2
. Both steps require Ca
2+

and calmodulin as activators and are accelerated by
tetrahydrobiopterin (©Jain PharmaBiotech) 58
Fig. 3.2 Role of NOS in functions of the cardiac myocyte.
Postsynaptically, acetylcholine (Ach) binds to ACh receptors
(M2) on the sinoatrial-node pacemaker cells and,
via second messenger pathways, modulates ion channels to
reduce heart rate. NO is generated in the pacemaker cell
following M2-receptor activation via caveolin-3 and eNOS
to inhibit flow of Ca
2+
through L-type Ca channels.
When noradrenalin binds to the b1-adrenoceptor, nNOS
localized in the sarcoplasmic reticulum can regulate
Ca

coronary arteries 260
Fig. 9.2 Vicious circle of vascular occlusion following angioplasty
and stenting 263
Fig. 9.3 Medtronic’s Endeavor Sprint Zotarolimus-Eluting
Coronary Stent System 277
Fig. 9.4 Magnetic nanoparticle-coated stent 280
Fig. 10.1 A scheme of personalized approach to
management of hypertension 326