The CANTOS Trial – Is Targeting Inflammation the Solution to Heart Disease?

The recently published results of the long awaited CANTOS trial may forever change our approach to the prevention and treatment of coronary artery disease (1). Inescapably, there is now proof that targeting inflammation, in this case by a drug, significantly improves outcome for certain very high-risk patients.

But, as so often in clinical research, things are not open-and-shut, and the picture is not as lucid as it seems.

The CANTOS Trial - Is Targeting Inflammation the Solution to Heart Disease?
Two or three decades ago, many experts predicted that the modification of risk factors, in particular, the treatment of high blood pressure and lipid disorders, would eliminate CAD in 10 – 20 years. Unfortunately, that prediction turned out to be wrong.

Although the death rate from coronary artery disease has dropped in most countries, the disease remains an important cause of death and disability worldwide. Even more worrying is the rising prevalence of obesity and type 2 diabetes which ultimately reverse the declining trend in mortality from cardiovascular disease.

Current drug therapies designed to slow the atherosclerotic process focus almost exclusively on reducing plasma levels of LDL cholesterol. However, experimental and clinical research supports that additionally targeting inflammation may be beneficial (2).

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What Is Inflammation?

The body’s defenses are controlled by the immune system which is composed of biological structures and mechanisms that continuously protects us against diseases such as infections and cancer.

Inflammation is a protective response to injury or destruction of cells or tissues. It is one of the body’s most important defense mechanism. Without it, we would not be able to fight bacterial infections, injuries, and destruction of tissues.

Inflammation can be both acute and chronic. Acute inflammation is the initial response of the body to harmful stimuli.  Prolonged inflammation or chronic inflammation is characterized by simultaneous destruction and repair.

Inflammation is protective when it is appropriate. However, when inflammation is inappropriate or gets out of hand, it may cause disease.

Autoimmune disorders such as rheumatoid arthritis, Hashimoto’s thyroiditis, systemic lupus erythematosus, and type 1 diabetes are all associated with a dysfunction of the immune system. These disorders are characterized by an inappropriate immune response against cells and tissues in our body causing inflammation of tissues and organs.

Inflammation and Atherosclerosis

Inflammation plays a significant role in atherosclerotic cardiovascular disease (3). Modern theories on the initiation of atherosclerosis suggest that modified lipoproteins, such as oxidized LDL (OxLD), may play a central role in promoting the inflammatory reactions that characterize and drive atherosclerosis (4).

Leukocytes, the type of white blood cells typically involved in most inflammatory reactions in the body, appear to play an important role in atherosclerosis. Leukocyte recruitment to the arterial wall is an important initial step in the formation of atherosclerotic plaques.

Cytokines are small proteins that are important in cell signaling (5). The cytokines interleukin-6 (IL-6), IL-1, and TNFα are elevated in most, if not all, inflammatory states and have been recognized as targets of therapeutic intervention (6).

Interleukin-1β is a cytokine that is central to the inflammatory response and drives the so-called interleukin-6 signaling pathway.

Inflammatory biomarkers are used to determine whether systemic inflammation is present or not. Many observational and clinical studies have used high-sensitivity C-reactive protein (hs-CRP)  to test the relationship between inflammation and cardiovascular disease (7).

CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study)

The CANTOS trial examined whether reducing inflammation with canakinumab in patients with a history of a prior heart attack can decrease the risk of another cardiovascular event happening in the future.

Canakinumab is a human monoclonal antibody that neutralizes interleukin-1β (8). It is approved in the United States and Europe as a treatment for several rare inflammatory diseases and has proven to be well-tolerated in people with diabetes or arthritis.

A total of 10.061 patients with a history of myocardial infarction (heart attack) and an hs-CRP equal to or above 2 mg/L were included in the CANTOS trial. Patients with a history of chronic or recurrent infections and cancer were excluded from the trial. The median follow-up was 3.7 years.

Patients with a history of chronic or recurrent infections and cancer were excluded from the trial.

The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every three months) with placebo. Enrollment began in April 2011 and was completed in March 2014. The median follow-up was 3.7 years.

The CANTOS Trial Population

The mean age of the participants who underwent randomization was 61 years, 25.7% of the patients were women.

The median body mass of the participants was 29.9, 40.0% had diabetes, 79.9% had hypertension, and 93.4% were on lipid-lowering therapy.

Median LDL cholesterol was 82.0 mg/dl (2.1 mmol/L), median HDL cholesterol was 43.7 mg/dL (1.1 mmol/L), and median triglyceride level was 139 mg/dL (1.56 mmol/L).

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The CANTOS Trial Results

Canakinumab reduced the hs-CRP level, compared to placebo, by 26% to 41% depending on the dose administered. Similar effects were observed for the interleukin-6 level.

Canakinumab did not reduce lipid levels from baseline although a slight reduction in triglycerides was found.

Here’s how the main results are reported in the paper (you’ll find an easier version below if you read further):

At a median follow-up of 3.7 years, the incidence rate for the primary end point (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the group that received the 50-mg dose of canakinumab, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group.

No significant effect, as compared with placebo, was observed with regard to the primary end point in the 50-mg group (hazard ratio, 0.93; P=0.30). By contrast, a significant effect for the primary end point was observed in the 150-mg group (hazard ratio vs. placebo, 0.85; P=0.02075, with a threshold P value of 0.02115). In the 300-mg group, the hazard ratio was similar to that in the 150-mg group, but the P value did not meet the prespecified threshold for significance (hazard ratio vs. placebo, 0.86; P=0.0314, with a threshold P value of 0.01058).

For the key secondary cardiovascular end point (the components of the primary end point plus hospitalization for unstable angina that led to urgent revascularization), the incidence rate was 5.13 events per 100 person-years in the placebo group, 4.56 events per 100 person-years in the group that received the 50-mg dose of canakinumab, 4.29 events per 100 person-years in the 150-mg group, and 4.25 events per 100 person-years in the 300-mg group. In the group that received the 150-mg dose of canakinumab (for which the P value met the significance threshold for the primary end point), the hazard ratio versus placebo for the secondary cardiovascular end point was 0.83 (P=0.00525, with a threshold P value of 0.00529).

No significant differences in the number of cardiovascular deaths or total mortality were observed between canakinumab and placebo.

Significantly more deaths were attributed to infection or sepsis in the pooled canakinumab groups than in the placebo group. Cancer mortality was significantly lower with canakinumab than with placebo.

Interestingly, the CANTOS group has in a separate paper published in the Lancet, published data suggesting that canakinumab could significantly reduce incident lung cancer and lung cancer mortality (9).

The CANTOS Trial - Is Targeting Inflammation the Solution to Heart Disease?
The event rate for the primary endpoint was 14.2% on canakinumab and  16.0% on placebo. This corresponds to an absolute risk reduction of 1.8% and a relative risk reduction of 11.3%. The number needed to treat (NNT) based on all dose groups vs. placebo is 56. Hence, 56 patients need to be treated with canakinumab for a median of 3.7 years to prevent one primary end-point event.

The Final Verdict

There are three important issues I want to highlight, not only because they tend to be overlooked, but because they provide the key to understanding the implications of the CANTOS trial.

The first issue deals with the study population, the second has to do with the statistical methods used, and the third will take us back to the real world to understand if and how the results will affect current clinical practice.

Who Are the CANTOS Patients?

The CANTOS trial was not a simple study of a pharmacological intervention in patients with coronary artery disease. It was a study of patients with a history of myocardial infarction on top of a chronic low-grade systemic inflammation. That is a huge difference.

But why do some patients with coronary artery disease have chronic low-grade inflammation whereas others don’t? Interestingly, the answer may be found by looking closer at the CANTOS study population.

Most patients included in the CANTOS trial were overweight, almost half of them may be defined as obese based on body mass index criteria, a high proportion had diabetes, HDL cholesterol levels were low, and triglycerides were high. So, to a large extent, these were patients with metabolic syndrome and insulin resistance.

Patients with metabolic syndrome have visceral obesity reflected by increased waist circumference, they have low HDL cholesterol and high triglycerides, they have prediabetes or diabetes, and they often have hypertension. Furthermore, the prevalence of obstructive sleep apnea and atrial fibrillation is high.

Adipose tissue (fat tissue) produces a number of bioactive substances, known as adipokines, which during fat tissue expansion may trigger chronic low-grade inflammation and interact with a range of processes in many different organs. Although the precise mechanisms are still unclear, dysregulated production or secretion of these adipokines caused by excess fat mass and adipose tissue dysfunction can contribute to the development of obesity-related metabolic diseases (10).

Unraveling the Statistics

Interestingly, the authors of the CANTOS trial decided to present the incidence rates in the study as events per 100 person years. In many studies, the length of exposure to the treatment is different for different subjects, and the person-year statistic is one way of dealing with this issue (11). However, it may make it hard to figure out the absolute risk reduction as well as the number needed to treat (NNT) which are numbers we usually want to see as well.

Person years is the summing of the results of events divided by time. The calculation of events per patient-year is the number of incident cases divided by the amount of person-time at risk. For example, if 1000 patients are followed for five years, there are 5.000 years of follow-up. If there are 100 events in the group, the rate would be 100 events per 5.000 patient years or 2 events per 100 patient years.

But, let’s figure out the absolute risk reduction for the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) in the CANTOS trial.

A total of 955 events were reported for the primary endpoint in the canakinumab group (all doses) and 535 in the placebo group. The total number of patients on canakinumab was 6.717 and 3.344 on placebo.

Hence, it can be calculated that the event rate for the primary endpoint was 14.2% on canakinumab and 16.0% on placebo. This corresponds to an absolute risk reduction of 1.8% and a relative risk reduction of 11.3%. However, the authors report a 15% relative risk reduction by looking solely at patients in the 150-mg group.

I have calculated that the corresponding number needed to treat (NNT) based on all dose groups vs. placebo is 56. Hence, 56 patients need to be treated with canakinumab for a median of 3.7 years to prevent one primary end-point event.

Does anybody doubt that the juice ain’t worth the squeeze?

The Clinical Implications

The CANTOS Trial is a landmark study because it tested for the first time the hypothesis that blocking an important component of the inflammatory cascade involved in atherosclerotic heart disease will be translated into an improved outcome.

The positive results of the study certainly open new doors to the prevention and treatment of cardiovascular disease.

The data suggesting that canakinumab may reduce incident lung cancer and lung cancer mortality are of great interest but need to be confirmed by further studies.

However, the modest absolute clinical benefit and the high price of canakinumab can hardly justify its routine use in patients with coronary artery disease. Furthermore, more data is needed to understand the safety trade-offs involved in the long-term use of the drug.

Interestingly, the CANTOS trial has defined a high-risk subgroup of patients with coronary artery disease and metabolic abnormalities characterized by visceral obesity, insulin resistance, inflammation and adipocyte dysfunction.

The results of the study inevitably raise the question whether reducing inflammation by improving diet and lifestyle will provide similar results as treatment with an expensive drug with potential side effects.

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12 thoughts on “The CANTOS Trial – Is Targeting Inflammation the Solution to Heart Disease?”

  1. “The results of the study inevitably raise the question whether reducing inflammation by improving diet and lifestyle will provide similar results as treatment with an expensive drug with potential side effects.” I guess I thought this was already fact. Good article and synopsys, thanks

    • When it comes to reducing LDL, the answer was that no, doing it by lifestyle changes is somehow not as good as taking statins. Since the cholesterol story could not be completely discarded, there was much finessing to make that point. I suspect something similar will happen in this case.

  2. Cardiac rehab exercise reduces MI rate by about 1/3 after first MI. Statins do the same.
    Daily Meditation reduces risk by 48% in secondary prophylaxis. All these exceed the relative risk reduction of 11.3% found in Cantos.
    Few cardiologists prescribe meditation. Here is an excerpt from the abstract.

    Stress reduction in the secondary prevention of
    cardiovascular disease: randomized, controlled trial of transcendental meditation
    and health education in Blacks.

    Circ
    Cardiovasc Qual Outcomes. 2012 Nov;5(6):750-8. doi:

    10.1161/CIRCOUTCOMES.112.967406.
    Epub 2012 Nov 13.

    PMID:23149426

    This was a randomized, controlled
    trial of 201 black men and women with coronary heart disease who were
    randomized to the TM (transcendental meditation) program or health education. The
    primary end point was the composite of all-cause mortality, myocardial
    infarction, or stroke.
    Secondary end points included the
    composite of cardiovascular mortality, revascularizations, and cardiovascular
    hospitalizations; blood pressure; psychosocial stress factors; and lifestyle
    behaviors. During an average follow-up of 5.4
    years, there was a 48% risk reduction in the primary end point in the TM group
    (hazard ratio, 0.52; 95% confidence interval, 0.29–0.92; P=0.025). The TM group also showed a 24% risk reduction in the
    secondary end point (hazard ratio, 0.76; 95% confidence interval, 0.51–0.1.13; P=0.17).
    There were reductions of 4.9 mmHg in systolic blood pressure (95% confidence
    interval −8.3 to –1.5 mmHg; P=0.01) and anger expression (P<0.05
    for all scales). Adherence was associated with survival.

  3. Dear Dr. Sigurdsson,

    I have been reading your website and have learn a lot from you. Thank you so much for such an insightful website. I think you are a great cardiologist taking good care of patients.

    If I live in Iceland I would definitely come to see you about my heart problems. However I live in Taiwan and therefore would not be able to see you. May I please seek your expertise on the following questions:

    I am a skinny Asian female age 67 years old, I am fit and have never had an heart attack nor stroke, no family history of vascular disease, a non-smoker, normal blood pressure, not diabetic but have high cholesterol and have plaque in my coronary arteries as follows:

    Calcium Score = 87

    Total Cholesterol: 7.4 mmol/L
    HDL: 1.9 mmol/L
    LDL: 5 mmol/L
    Triglycerides: 0.6 mmol/L

    Apo-B: 1.20 g/L
    Apo-A1: 1.84 g/L
    Apo-B / Apo-A1 ratio: 0.65

    hs-CRP: 0.2 mg/L

    Question 1:
    Do you think I need to take a statin?

    Question 2:
    Is my Apo-B (1.20 g/L) too high or ok? Does it indicate low risk or high risk?

    Question 3:
    Is my Apo-B / Apo-A1 ratio (0.65) too high or ok? Does it indicate low risk or high risk?

    Thank you very much for your expertise and highly appreciated for your time and attention. I sincerely look forward to hear from you.

    Kind Regards,

    Gloria

    • Hi Gloria

      Thank you for the kind words.

      I usually avoid individual advice because it’s a tricky business and probably not ethically correct under these circumstances.

      But, I guess some guidance might okay as long as you don’t take it too seriously. And, of course, you should rather listen to your own doctor.

      1. You don’t need to take a statin. Nobody does. But it is an option and may reduce risk primarily among people with underlying cardiovascular disease. I would probably not recommend it in your case because considering everything your risk is still relatively low. Statin treatment will probably only have a tiny effect on your risk of developing a cardiovascular event. So, the risk/benfit ratio of such treatment in your case is probably relatively high.
      2. Your Apo-B suggests medium risk.
      3. Your Apo-B / Apo-A1 suggests medium risk.

      Best wishes
      Axel

      p.s. Your focus on healthy eating and exercise is great and probably what matters most.

      • Dear Dr. Sigurdsson,

        Thank you very much for your kind reply. I will take your guidance as a precious opinion in addition to the advice from my own doctor and cardiologist.

        May I please seek your guidance to the following questions? This will be the last set of questions. Many thanks again and your time and attention is highly appreciated.

        My LDL is 5 mmol/L and the LDL particle size are large (Type A pattern). I am a skinny (underweight) female age 67 years old: Height: 5’1′, Weight: 85 pounds.

        I eat 2 small bowls of “Whole Grains” consisting of a combination of a bit of brown rice, barley, buckwheat and red & black beans per day and 1 bowl of oat meal everyday.
        I am going to adapt to a Mediterranean Diet from now on with intake of mono-unsaturated fat (3 tea spoons of extra virgin olive oil and 1 avocado per day)

        QUESTION 1:

        Will elimination of eating all the above “Whole Grains” have a significant or tiny impact on:

        1). improving my cholesterol profile (i.e. reducing LDL and increasing HDL) ?

        2). reducing overall risk (heart attack, fatty liver, gut health) ?

        QUESTION 2:

        Will eating a Mediterranean Diet (plenty of vegetables, fruits, nuts, salmon, olive oil, green tea and whole grains), with the addition of taking supplements of Omega 3 fish oil (EPA), Vitamin K2, Vitamin D3 and Ubiquinol:

        1). help to slow down the progression of plaque build up in my coronary arteries?

        2). help to minimize my risk of heart attack and stroke (i.e. stay at low risk) in the coming years even if my LDL (5 mmol/L) and HDL (1.9 mmol/L) remains unchanged in the coming years?

        QUESTION 3:

        Eating 1 avocado per day is healthy or too much?

        QUESTION 4:

        As my LDL (5 mmol/L) is high, is it likely or unlikely that I have Familial Hypercholesterolemia?

        QUESTION 5:

        Am I insulin resistant? (my HDL is 1.9 mmol/L)

        Thank you very much for your kind guidance and highly appreciated for your time and attention. I sincerely look forward to hear from you.

        Kind Regards,

        Gloria

  4. Dear Dr. Sigurdsson,

    I have been sincerely waiting with great interest to hear from you for a week. I have simplified the previous questions to TWO questions as shown below for your convenience. Would you please be able to reply? Your reply would be highly appreciated and many many thanks.

    QUESTION 1:

    Will eating a Mediterranean Diet according to the PREDIMED recipe help to minimize my risk of heart attack and stroke (i.e. stay at low risk) in the coming years even if my non-HDL (5.5 mmol/L) and HDL (1.9 mmol/L) remain unchanged in the coming years?

    As Mediterranean Diets won’t have much impact on lipids, I can still be at low risk even with a constantly high non-HDL of 5.5 mmol/L and HDL of 1.9 mmol/L in the future? (assuming all other risk factors such as blood pressure etc remains normal in the future)

    QUESTION 2:

    I am a 67 year old female.

    1). Based on my standard lipid profile only:

    Triglyceride: 0.6 mmol/L
    non-HDL: 5.5 mmol/L
    HDL: 1.9 mmol/L
    LDL: 5 mmol/L

    Is this medium risk or high risk given my age is 67?

    2). If the above standard lipid profile represents high risk, and as my Apo-B / Apo-A1 ratio = 0.65 represents medium risk, is my overall lipids at medium risk? (the Apo-B / Apo-A1 ratio is more accurate than HDL and non-HDL so it wins)

    3). My Calcium Score is 87 at my age of 67, is this low risk or medium risk?

    Thank you very much for your kind guidance and highly appreciated for your time and attention. I sincerely look forward to hear from you.

    Kind Regards,

    Gloria

      • Dear Dr. Sigurdsson,

        Thank you very much for your kind reply.

        I have tried several of the calculators before but they give different results, and therefore I am confused. Also they did not incorporate Calcium Scoring (my Calcium Score is 87).

        I prefer to trust you as from reading your website and replies, I know that you are very knowledgeable and kind and caring. I really look up to you and treasure your guidance.

        Can you please reply “YES” or “NO” to the following 2 questions:

        QUESTION 1:

        As a 67 year old female, is my risk for heart attack and stroke relatively low? My cardiac information as follows:

        1). Calcium Score = 87
        2). non-HDL= 5.5 mmol/L; HDL= 1.9 mmol/L; Trigly= 0.6 mmol/L
        3). Palpitations sometimes
        4). Never had an heart attack nor stroke
        5). No family history of heart disease
        6). Normal blood pressure
        7). Normal thyroid
        8). Not diabetic
        9). Non-smoker
        10). Skinny and underweight

        QUESTION 2:

        1). According to the QRISK2017 calculator, my 10 year risk = 6%.
        Will eating a Mediterranean Diet according to the PREDIMED recipe reduce my 10 year risk to less than 6% ? (assuming my non-HDL of 5.5 mmol/L and HDL of 1.9 mmol/L remain unchanged in the next 10 years)

        2). If the answer is “YES”, lets say the Mediterranean Diet reduced my 10 year risk to 5%. Hypothetically my 10 year risk can stay at 5% even with a constantly high non-HDL of 5.5 mmol/L and HDL of 1.9 mmol/L in the next 10 years ? (assuming hypothetically that aging has no impact on risk and all the risk factors in QUESTION 1 remain unchanged)

        Thank you very much for your kind guidance and highly appreciated for your time and attention. I sincerely look forward to hear from you.

        Kind Regards,

        Gloria

      • Hi Gloria
        When it comes to reducing cardiovascular risk, a Mediterranean type diet is probably one of the best options you have. However, it is not possible to quantify exactly how much it will influence individual risk.
        The second question is difficult to answer because age itself is a risk factor as you mention. However, if age stays the same (which it never does of course), your risk will remain the same if all other factors remain constant.

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