AU2012203219B2 - Induction of arteriogenesis - Google Patents

Abstract

Abstract The present invention inter alia relates to a method of promoting collateral circulation comprising the step of exposing a subject to a therapeutically effective amount of an NO 5 donor wherein the therapeutically effective amount of the NO donor promotes arteriogenesis sufficient to augment collateral circulation in a physiological or pathological condition.

Description

AUSTRALIA Regulation 3.2 Patents Act 1990 Complete Specification Standard Patent APPLICANT: G. Pohl-Boskamp GmbH & Co. KG Invention Title: INDUCTION OF ARTERIOGENESIS The following statement is a full description of this invention, including the best method of performing it known to me: Induction of Arteriogenesis The present invention relates to methods of treating or preventing an arterial insufficiency by the administration of a NO (nitric oxide) donor. The reference to any prior art in this 5 specification is not, and should not be taken as an acknowledgement or any form of suggestion that such art forms part of the common general knowledge Cardiovascular diseases as well as other diseases involving a cardiovascular and, more specifically, arterial insufficiency have an enormous economic importance. In Germany, 10 for example, about 280000 patients suffer every year from a cardiac infarct, while about 65000 patients die. One important reason for a cardiovascular disease is the partial or complete occlusion of arterial vessels resulting in a reduced supply of oxygen and nutrients of the tissue supplied by the arterial vessel. 15 Angina pectoris, the chest pain, is a clinical syndrome reflecting inadequate oxygen supply for myocardial metabolic demands with resultant ischemia and is generally caused by obstruction (stenosis) or spasm of coronary arteries. Arteriogenesis is a process in which already pre-existing small arteriolar collaterals can 20 develop to full functional conductance arteries which bypass the site of an arterial occlusion and/or compensate blood flow to ischemic territories supplied by the insufficient artery. Consequently, arteriogenesis is a highly effective endogenous mechanism for the maintenance and regeneration of the blood flow after an acute or chronic occlusive event in an arterial vessel. In this case the collaterals can function as natural bypasses. 25 Arteriogenesis is a process distinct from angiogenesis or neovascularization, where a de novo formation of arterial vessels occur (Buschmann and Schaper, Journal of Pathology 2000, 190:338-342). 30 Nitroglycerin (glyceryl trinitrate) is used since decades as a vasodilatating agent in cardiovascular diseases as coronary artery disease (CAD, also ischemic heart disease or coronary artery disease), which is the leading cause of death and disability worldwide. Nitroglycerin has been solely used to treat the symptoms of these diseases e.g. stable angina pectoris due to its vasodilating effect on veins and arteries, resulting in a reduced 35 workload and energy consumption of the heart (by decreasing preload and afterload) as well as an increased myocardial oxygen supply (by dilating the coronary arteries). These symptoms include chest pain, pressure, discomfort, or dyspnea. However, nitroglycerin has not been used for curing the underlying disease or improving its prognosis.

-2 Consequently, nitroglycerin has been and is primarily used for the acute relief or prophylaxis of angina pectoris attacks, the most common symptom of CAD. In the art, it has been described that nitroglycerin is not able to induce angiogenesis 5 (neovascularisation) or arteriogenesis in a setting where this substance has been administered continuously (Hopkins et al. Journal of Vascular Surgery 27:886-894 (1998); Troidl et al. Journal of Cardiovascular Pharmacology 55: 153-160 (2010)). There is a need for providing agents for promoting collateral circulation. 10 In a first aspect, the present invention relates to a method of treating or preventing an arterial insufficiency, wherein an NO donor is administered in an intermitting manner to a subject in an amount effective for the induction of arteriogenesis. 15 In the context of the present invention, it has been surprisingly found that NO donors are effective in the induction of arteriogenesis even if they are not administered constantly but in a manner where plasma levels are only elevated for a short time (see the example section). Consequently, the present invention provides effective agents for the promotion of collateral circulation. Based on the finding that NO donors are capable of inducing 20 arteriogenesis, the present invention now provides an effective tool for preventing and treating an arterial insufficiency. According to the present invention, the term "treatment" or "prevention" means that not only symptoms of the disease are relieved but that also the disease itself is treated or 25 prevented. In a preferred embodiment, the term "treatment" means improving the prognosis of said disease. According to the invention, the term "arterial insufficiency" refers to any insufficient blood or oxygen supply or any other insufficient supply of a tissue which is provided by an 30 artery. This insufficient supply can be overcome by the methods and uses of the present invention wherein an NO donor is used to increase the supply of a given tissue. The arterial insufficiency may occur both during physical rest or during an exercise. In a preferred embodiment of the present invention, the arterial insufficiency is due to 35 insufficient oxygen or blood supply of a tissue supplied by the artery or a bypass or shunt during physical rest or exercise.

According to a further preferred embodiment, the arterial insufficiency is due to an increased demand of oxygen or blood flow of a tissue supplied by the artery or a bypass or shunt. 5 This increased demand of oxygen or blood flow can have several reasons including but not limited to increased sport or physical activity, and increased mental activity or a disease requiring an increased demand of oxygen or blood flow. According to a further preferred embodiment, the arterial insufficiency is characterized by 10 a partial (stenosis) or complete occlusion of an arterial vessel. In the context of the present invention, the term "partial occlusion" is equivalent to a stenosis. The partial or complete occlusion of an arterial vessel is a well-known phenomenon. It can have various reasons including but not limited to deposition of material in the blood 15 vessels (including non-revascularisable stenoses), compression from external tissue or fluid next to the vessel or a dysfunction of the endothelium of the vessel resulting in a paradoxic vasoconstriction during exercise. In a preferred embodiment, the arterial insufficiency is due to the deposition of material in 20 the blood vessels. The deposition of materials in the blood vessels is a well-known phenomenon resulting e.g. in atherosclerosis. 25 In a further preferred embodiment, the arterial insufficiency is due to an external or internal compression of an artery. An internal compression of an artery may be due to an edema but also to a tumor putting pressure on the artery. Furthermore, this includes a vasospastical constriction of the artery 30 as e.g. in Prinzmetal's angina. In addition, this also includes the paradoxic vasoconstriction which e.g. sometimes occur in an endothelial dysfunction. An external compression may be due to an accident or any external force which can put pressure on an artery. 35 In a further preferred embodiment, the arterial insufficiency is a vascular disease.

-4 According to a further preferred embodiment, the arterial insufficiency is a disease selected from the group consisting of atherosclerosis, an ischemic disease and a further chronic arterial disease. 5 In a further preferred embodiment, the arterial insufficiency is a coronary arterial insufficiency. In a preferred embodiment, the coronary insufficiency is an atherosclerotic coronary arterial insufficiency, in particular coronary artery disease (coronary heart disease or 10 ischemic heart disease), stable angina pectoris, unstable angina pectoris, myocardial ischemia or chronic myocardial ischemia, acute coronary syndrome, or myocardial infarct (heart attack or ischemic myocardial infarct). In a further preferred embodiment, the coronary insufficiency is a non-atherosclerotic, in 15 particular coronary microvascular disease or small vessel disease, Prinzmetal's angina and cardiac syndrome X. In a further preferred embodiment, the arterial insufficiency is a cerebral arterial insufficiency. 20 In a preferred embodiment, the cerebral arterial insufficiency is an atherosclerotic cerebral arterial insufficiency, in particular cerebral ischemia, pre-stroke, transient ischemic attack (mini stroke), stroke, vascular dementia, ischenic brain disease, or ischemic cerebrovascular disease. 25 The cerebral arterial insufficiency may also be ischemic microvascular brain disease, small vessel vascular dementia, subcortical arteriosclerotic encephalopathy (Binswanger's disease), Alzheimer's disease, or Parkinson's disease. 30 In a preferred embodiment, the arterial insufficiency is a peripheral arterial insufficiency. In a preferred embodiment, the peripheral arterial insufficiency is an atherosclerotic peripheral arterial insufficiency, in particular peripheral vascular disease (peripheral artery disease (PAD) or peripheral artery occlusive disease (PAOD)). 35 In a preferred embodiment, the peripheral arterial insufficiency is an non-atherosclerotic peripheral arterial insufficiency, in particular Raynaud's syndrome (vasospasmatic), thrombangiitis obliterans, endangitis obliterans or Buerger's disease (recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet), vascular inflammatory disease (vasculitis), diabetic ischemia, diabetic neuropathy and compartment syndromes. 5 In a further preferred embodiment, the arterial insufficiency may be an intestinal arterial insufficiency, in particular an atherosclerotic intestinal arterial insufficiency, in particular ischemic bowel disease, mesenteric ischemia, or mesenteric infarction. In a further preferred embodiment, the arterial insufficiency may be an urogenital arterial 10 insufficiency, in particular an atherosclerotic urogenital arterial insufficiency, in particular erectile dysfunction, renal artery disease, renal ischemia, or renal infarction. In a further preferred embodiment, the arterial insufficiency may be a nerval arterial insufficiency, in particular tinnitus. 15 Furthermore, the arterial insufficiency may be in the context of scleroderma (systemic sclerosis). In a preferred embodiment, the arterial insufficiency is a central retinal artery 20 insufficiency, in particular an atherosclerotic central retinal artery insufficiency, in particular ocular arterial insufficiency. In a further preferred embodiment, the arterial insufficiency is characterized by an absence of an endothelial dysfunction. 25 The endothelial dysfunction is a well-known systemic pathological state of the endothelium and can be broadly defined as an imbalance between vasodilating and vasoconstricting substances produced by or acting on the endothelium. 30 In a further preferred embodiment, the arterial insufficiency is a chronic arterial insufficiency. In the context of the present invention, the term "chronic arterial insufficiency" means that the course of the arterial insufficiency is chronic and often progredient. 35 According to a further preferred embodiment, the chronic arterial insufficiency includes endothelial dysfunction, atherosclerosis, coronary artery disease (coronary heart disease or ischemic heart disease), stable angina pectoris, coronary microvascular disease or small vessel disease, Prinzmetal's angina and cardiac syndrome X, vascular dementia, ischemic -6 brain disease, or ischemic cerebrovascular disease, ischemic microvascular brain disease, small vessel vascular dementia, subcortical atherosclerotic encephalopathy (Binswanger's disease), Alzheimer's disease, Parkinson's disease, peripheral vascular disease (peripheral artery disease (PAD) or peripheral artery occlusive disease (PAOD), thrombangiitis 5 obliterans, endangitis obliterans or Buerger's disease, vascular inflammatory disease (vasculitis), diabetic ischemia, diabetic neuropathy, ischemic bowel disease, erectile dysfunction, renal artery disease, tinnitus, and scleroderma (systemic sclerosis). According to the invention, the term "NO donor" refers to either to nitric oxide itself or 10 any molecule which is capable to release NO after having been administered to a subject. Preferably, the NO donor is nitric oxide, sodium nitroprusside, nitroglycerin (glyceryl trinitrate), isosorbide mononitrate, isosorbide dinitrate, pentaerythritol tetranitrate (PETN), molsidomin, amyl nitrite or nicorandil. 15 In a preferred embodiment, the NO donors may be selected from the following: Anorganic: nitric oxide 20 nitrite nitrate Organic nitrates: GTN (glyceryl trinitrate; nitroglycerin) 25 PETN (pentaerythritol tetranitrate) ISDN (isosorbide dinitrate) ISMN (isosorbide mononitrate) Nicorandil 30 Organic nitrites: IAN (isoamyl nitrite; amyl nitrite) IBN (isobutyl nitrite) N-nitroso compounds: 35 N-Nitrosamines: Dephostatin NDMA derivates of N-methyl-N-nitrosourea -7 N-Hydroxy-Nitrosamines: Dopastin Cupferron 5 Alanosine N-Nitrosimines N-Diazeniumdiolates (NONOate): 10 spermine NONOate DEA-NONOate DETA-NONOate S-Nitrosothiols: 15 S-nitroso-N-acetylpenicillamine (SNAP) S-nitrosoglutathione Metal-NO-complexes: Iron complexes: 20 Nitroprusside (sodium nitroprusside) Dinitrosyl-iron complexes Iron-Sulfur Cluster Nitrosyls (as e.g. Roussin's Red Salt, Roussin's Black Salt, Roussin's Red Ester) 25 Ruthenium complexes NO releasing heterocycles: Heterocyclic N-oxides: Furoxans 30 Mesoionic Heterocycles: Sydnonimines (as e.g. molsidomine, linsidomine (SIN-]), ciclosidomine, pirsidomine, marsidomine) Mesoionic oxatriazoles 35 Guanidines and N-hydroxyguanidines: L-arginine L-homoarginine N-hydroxy-L-arginine N-hydroxy-L-homoarginine Other: Alkyl C-nitroso compounds 5 Aryl C-nitroso compounds Oximes N-hydroxyureas In a preferred embodiment, the NO donor is an organic nitrate with a glycerol backbone. 10 In a further preferred embodiment, the NO donor is selected from the group consisting of nitroglycerin (glyceryl trinitrate), glycerol-1,2-dinitrate (1,2-GDN) and glycerol-1,3 dinitrate (1,3-GDN), glycerol-I-nitrate (1-GMN) and glycerol-2-nitrate (2-GMN). 15 In a particular preferred embodiment, the NO donor is nitroglycerin. Preferably, the NO donor is a short acting NO donor. According to the invention, the term "short acting NO donor" refers either to NO itself or to an NO donor which releases NO shortly, with a short half life time of less then e.g. 45, 30 or preferably 15 minutes, after 20 having been administered to a subject. Examples of short acting NO donors are nitroglycerin (glyceryl trinitrate), amyl nitrite and sodium nitroprusside. Nitroglycerin is an especially preferred example of such a short acting NO donor. 25 According to the invention, the NO donor is administered in an amount capable of inducing arteriogenesis. The skilled person will appreciate that this amount will depend on the subject to which the NO donor is administered. Generally, the amount to be administered may be between 0.1 and 8 mg per day, but this can vary due to the weight of the subject, its hemodynamic response to the NO donor and/or the severity of the disease. 30 In a preferred embodiment, the amount of the NO donor is applied in a dosage of 0.2 up to 0.8 mg (0.2, 0.3, 0.4, 0.6, 0.8) for at least I- up to maximal 4-times daily, resulting in a maximal daily dosage of 3.2 mg. These numbers especially apply in cases where the NO donor is nitroglycerin. 35 According to the invention, the term "administration of an NO donor" means that a given dosage of the NO donor is administered. Depending on the way of administration, the skilled person will appreciate that the administration may take some time. In a preferred -'9 embodiment, the NO donor is administered in form of a spray, chewable capsule, inhalable gas, inhalable aerosol or powder, granules, powder or a tablet, which means that the administration may be completed within seconds. However, the administration of the NO donor may also take longer, e.g. if the NO donor is administered to the patient by way of 5 infusion or by ointment or patch. Modes of administration of the NO donor are further discussed below. Furthermore, according to the invention, the NO donor is administered in a manner capable of inducing arteriogenesis. 10 As shown in the examples, the inventors of the present invention have surprisingly found out that an NO donor is capable of inducing arteriogenesis when administered in an intermitting manner. 15 According to the invention, the term "intermitting manner" means that the NO donor is administered in a way that its plasma levels are only elevated in a short-term manner after the administration of the NO donor but then again decline. This can be achieved for example if the NO donor is a short acting NO donor as defined above and the administration of the short acting NO donor is followed by a time period without 20 administration and then the NO donor is again administered to the subject. Furthermore, this way of administration avoids that the subject is developing tolerances against the effect of NO. However, it is equally possible that the NO donor is a long acting NO donor. In this case, 25 however, in order to achieve the decline in plasma levels, care has to be taken that the administration of the long acting NO donor is only shortly and that the plasma levels obtained are not too high. In a preferred embodiment, the plasma levels of the NO donor are elevated for not more 30 that 180, 120, or 60 minutes, or for not more than 50, 40, 30, 15, 10 or 5 minutes. Furthermore, this also implies that the NO donor can be administered in chronical manner, i.e. without taking account of disease developments implying an acute treatment with the NO donor. Furthermore, it also implies that a therapy plan can be established without 35 taking account of disease developments implying an acute treatment with the NO donor. In the context of the present invention, the NO donor is inter alia administered to induce arteriogenesis. This implies that the NO donor can also be administered at time points or - 1u time periods where there is no need for vasodilation and such a relief of symptoms like pain relief. This is in contrast to past applications where the NO donor, e.g. nitroglycerin, has been 5 used to achieve a relief or acute (i.e. immediate) prevention of the symptoms of a corresponding disease. These symptoms for example include pain and/or dyspnea in the case of a cardiovascular disease, and the relief or acute prevention of the symptoms was achieved by vasodilation and resulting pain and/or dyspnea relief. However, the purpose of the administration of the NO donor was, as discussed above, not the treatment of the 10 underlying disease, because it was well known that the diseases cannot be treated by vasodilation or pain relief. The identification of an NO donor as a pro-arteriogenic agent, therefore, also makes it possible that the NO donor is administered at time points or time periods where there is no 15 need for such a relief of symptoms like pain relief. In a further preferred embodiment, the NO donor can also be administered in cases where there are no corresponding symptoms like dyspnea or pain or in cases where such symptoms are not to be expected. In the context of the present invention, the term "intermittently" also means that the NO 20 donor, in particular the short acting NO donor, is not administered continuously, for example by means of long term intravenous infusion or with the help of an implanted pump which constantly delivers the NO donor to the subject. Rather, this term also means that there is an interval between two administrations of the NO donor, and that the NO donor is given several times, e.g. at least 1, 2, 3, 4, 5, 6, 8, 9, 12 or 16 times a day. 25 As the skilled person will appreciate, one administration of the NO donor may include an administration in one or more dosage forms, e.g. tablets or hubs (puffs) in case of a spray. For example, one administration may include the administration of two tablets or one to three hubs (puffs). 30 As to the schedule of administration, the skilled person will appreciate that there are many ways to achieve this intermitting administration. For example, it is possible to administer the NO donor at least once a day and at least on one day a week for at least two weeks. However, it is equally possible to administer the NO donor for only one week if the NO 35 donor is administered several times during this week.

- 11 Preferable, the NO donor is administered once, twice or three times a day, wherein even more preferred the time period between two administrations of the NO donor is at least 4 hours, in particular 8 hours, in particular at least 10 hours or 12 hours. 5 Although possible, it is not necessary that the time periods between two administrations of the NO donor are the same. Rather, it is preferred that these time periods differ, depending on the individual administration schedule. In a preferred embodiment, the NO donor is administered at least on one day a week. 10 However, the NO donor may also be administered on 2, 3, 4, 5, 6 or 7 days a week. In an especially preferred embodiment, the NO donor is administered at least on 3 or 4 days a week. According to the invention, it is possible to administer the NO donor for a period of several 15 weeks or months. This is particularly preferred in order to induce arteriogenesis efficiently, although also a shorter administration of one of two weeks is possible. In a preferred embodiment, the NO donor is administered for 2 to 8 weeks. It is equally preferred to administer the NO donor for 3 to 6, 3 to 8, 3 to 10 or 4 to 8, 4 to 10 or 4 to 12 20 weeks. These numbers are only examples and may vary depending on the individual schedule of the subject. In a preferred embodiment, the NO donor is taken at least once a week for at least 8 weeks, in particular for at least 12 weeks. 25 In a further preferred embodiment, the NO donor is taken not longer than 6, 8 or 12 months. However, it is also possible to take the NO donor for 2, 3 or even more years. Furthermore, it is also possible that the NO donor is administered for decades or even through the whole life of the subject. 30 In the context of such long-term administrations, it is preferred that the NO donor is administered once or twice a week or at least once or twice a week. It has been described previously that an exogenous stimulation of pulsatile shear forces in 35 an individual may result in arteriogenesis. Furthermore, it has been described how the pulsatile shear forces can be measured (W02010/072416).

- 12 Consequently, in a preferred embodiment, the NO donor is administered in conjunction with an exogenous stimulation of the pulsatile shear forces in the artery. With respect to said embodiment of the invention, the NO donor should be administered in 5 a way that it is active in the body of the subject when the exogenous stimulation is applied. In this context, active means that either the NO release is not yet terminated or the NO released from the NO donor is still present and active. Depending on the specific NO donor to be used, its physiological halftime in the subject and its formulation, the skilled person will be capable of determining when the NO donor has to be administered to the subject in 10 order to ensure that it is active upon the exogenous stimulation. In the case of nitroglycerin, the halftime and its persistence in the body of the subject has been intensively studied, see e.g. Armstrong et al. Circulation 59:585-588 (1979) or Armstrong et al. Circulation 62:160-166 (1980). 15 In general, the halftime of nitroglycerin is 2 to 5 minutes. In a preferred embodiment, the NO donor is administered in the time period of 30 minutes before the onset of the exogenous stimulation until 30 minutes after the termination of the 20 exogenous stimulation. More preferably, the NO donor is administered in the time period of 15 minutes, preferably 5 minutes, more preferably 2 minutes minutes before the exogenous stimulation until 30, preferably 15, more preferably 5 minutes after the onset of the exogenous stimulation. 25 In a further preferred embodiment, the NO donor is administered once a day, five times a week for 6 weeks 2-5 minutes before the exogenous stimulation. The exogenous stimulation of the pulsatile shear forces may be achieved by any known 30 way. This includes a stimulation with the help of medicaments like medicaments which increase the blood pressure. In a preferred embodiment, said stimulation is achieved by physical exercise or the application of an endogenous force to the arterial vessel. 35 According to the invention, the term "physical exercise" means any training of the subject, including but not limited to training in exercise rooms, jogging, walking, nordic walking, swimming, dancing, cycling and hiking. The skilled person will appreciate that any - 13 exercise will be helpful in the context of the invention, provided that it is performed in conjunction with the administration of the NO donor. Preferably, the term "physical exercise" does not include unsupervised, unprescribed routine movements like casual walking or house work. 5 As discussed above, it has been found in the context of the present invention that an NO donor is capable of inducing arteriogenesis. This enables not only the treatment of an already existing disease. Rather, in the context of the present invention, it is also possible to prevent the disease. Consequently, in a preferred embodiment of the present invention, 10 the method aims at the prevention of said arterial insufficiency. As shown in the example section, in the context of the present invention, it has been possible to reduce the infarct size in case of an already existing occlusion. Furthermore, it has been possible to reduce arrhythmias in the subjects. Consequently, in a preferred 15 embodiment of the present invention, the method results in a reduction of the infarct size, in reduced arrhythmias or in a decreased ST segment elevation. The NO donor can be administered in any suitable way so that it can be incorporated into the subject. This includes an oral, parenteral or intravenous administration as well as the 20 injection of the NO donor into the body of the subject, but also an administration to a mucous membrane of the subject. Consequently, in a preferred embodiment of the present invention, the NO donor is administered lingually, sublingually, inhalatively, bucally, transmucosally or 25 oromucosally. In case of a lingual, sublingual or oromucosal administration, it is preferred that the NO donor, preferably nitroglycerin, is administered with the help of a spray, a chewable capsule or in the form of a tablet, powder or granules or even by an inhalator device, from 30 which the NO donor can be easily inhaled and adsorbed. It is equally preferred that the NO donor is administered in the form of an inhalable gas, aerosol or powder. Preferably, the administration of the NO donor is a non-topical administration, i.e., that the NO donor is not administered to the skin of the subject. In the context of the present 35 invention, the term "skin" excludes mucous membranes of the subject.

The NO donor can be formulated in any suitable way for the above mentioned administration modes. Such formulations are known to the person skilled in the art and include the formulation in suitable buffers, in a gas, aerosol, as tablets, powder or granules. 5 In a preferred embodiment, the NO donor is formulated in a way that allows a fast release of the NO donor from the formulation. This includes e.g. formulations which do not hold back the NO donor for a longer time period, but which release the NO donor within e.g. 45, 30 or 15, 10, 5 minutes or 1 minute. 10 Through the invention, it is preferred that the subject to which the NO donor is applied is a human subject. In a further aspect, the present invention also relates to an NO donor for use in a method for the prevention or treatment of an arterial insufficiency, wherein the NO donor is 15 administered in an amount and manner effective for the induction of arteriogenesis. All features and preferred embodiments discussed above for the method of treating or preventing an arterial insufficiency also apply to the NO donor for use according to this aspect of the invention. 20 In another aspect, the present invention also relates to a method of the suppression of negative effects associated with any treatment of an arterial insufficiency which is anti ateriogenic or inhibiting arteriogenesis, comprising administering to a subject subjected to said treatment an NO donor in an amount and manner effective for the induction of arteriogenesis. Throughout this specification and the claims, unless the context requires 25 otherwise, the word "comprise" and its variations, such as "comprises" and "comprising," will be understood to imply the inclusion of a stated integer or step or group of integers or steps but not the exclusion of any other integer or step or group of integers or steps. In a preferred embodiment, said treatment is an acetyl salicylic acid (ASA), 30 glycoproteinllbllla antagonists, or etanercept (soluble tumor necrosis factor alpha receptor) treatment. It is known in the art that ASA is an inhibitor of arteriogenesis (Singer et al., Vasa 2006, 35:174-177). Consequently, the ASA treatment of cardiovascular diseases, although being a standard therapy, has significant side effects and disadvantages. In the context of the present invention, it has been found that NO donors are capable of 35 overcoming the genitive effects associated with an ASA treatment (see example section). Based on these findings, the inventors conclude that also the negative side effects associated with other medications like glycoproteinIlbIlla antagonists or etanercept treatment can also be diminished.

- 15 Furthermore, the present invention also relates to an NO donor for use in a method of the suppression of negative effects associated with any treatment of an arterial insufficiency which is anti-ateriogenic or inhibiting arteriogenesis, wherein the NO donor is administered to a subject subjected to said treatment in an amount and manner effective for 5 the induction of arteriogenesis. In a preferred embodiment, said treatment is an acetyl salicylic acid (ASA), glycoproteinIlbIlla antagonists, or etanercept (soluble tumor necrosis factor alpha receptor) treatment. 10 All features and preferred embodiments discussed above for the method of treating or preventing an arterial insufficiency also apply to the method for the suppression of negative effects according to this aspect of the invention or to said NO donor for use according to this aspect of the invention. 15 In a further aspect, the present invention also relates to a method for the prevention or treatment of a cardiac arrhythmia, wherein an NO donor is administered to a subject in an amount and manner effective for the treatment of said cardiac arrhythmia. Furthermore, the present invention also relates to an NO donor for use in a method for the prevention or 20 treatment of a cardiac arrhythmia, wherein the NO donor is administered to a subject in an amount and manner effective for the treatment of said cardiac arrhythmia. In the context of the present invention, the inventors have found that NO donors are capable to prevent and treat arrhythmias (see the example section). 25 All features and embodiments defined above with respect to the NO donor and its formulation and administration also apply to this method or NO or donor for use according to the invention. 30 The present invention also relates to a method of promoting collateral circulation comprising the step of exposing a subject to a therapeutically effective amount of an NO donor wherein the therapeutically effective amount of the NO donor promotes arteriogenesis sufficient to augment collateral circulation in a physiological or pathological condition. 35 The term collateral circulation describes the circulation of blood through so-called collateral vessels. These vessels are small arterioles, which are part of a network that interconnects perfusion territories of arterial branches. In the case that the main artery itself - 16 is not capable of sufficiently supplying a tissue, e.g. due to an arterial occlusion, these collateral vessels are recruited and can develop to large conductance arteries, to bypass the site of an arterial occlusion and/or to compensate blood flow to ischemic territories supplied by the or insufficient artery. In the context of the present invention, the promotion 5 of collateral circulation occurs via arteriogenesis. According to the invention, the term "physiological condition" denotes any condition of the subject which is not related to any disease. 10 According to the invention, the term "pathological condition" denotes any condition of the subject which is related to a disease. Preferably, the subject suffers from an arterial insufficiency. 15 All features and preferred embodiments discussed above for the method of treating or preventing an arterial insufficiency also apply to the method of promoting collateral circulation. With respect to the aspects defined above where the NO donor is administered in a manner 20 sufficient to induce arteriogenesis this manner is preferably an intermitting manner as defined above. The invention is further described by the attached figures and examples, which are intended to illustrate, but not to limit the invention. 25 - 17 Short Description of the Figures Figure 1: Course of the ST segment elevation per beat after FPO (=final occlusion to induce infarct) of 5- and 10-days-control-groups. ECG graph in middle grey indicates 5 5 DAYS RIP PBS, n=8: 0.104 ± 0.016 mV; ECG graph in black indicates 5 DAYS SHAM PBS, n=8: 0.134 ± 0.034 mV; ECG graph in light grey indicates 10 DAYS RIP PBS, n=7: 0.055 ± 0.033 mV; ECG graph in dark grey indicates 10 DAYS SHAM PBS, n=7: 0.124 0.039 mV. ECG was recorded 90 minutes after FPO. Course of the ST segment elevation per beat at 1o first 8 minutes revealed no differences between 5- and 10-days-sham-groups and 5-days RIP-group. Only in the 10-days-RIP-group a lower ST segment elevation was observed. Figure 2: ST segment elevation of 5- and 10-days-control-groups. Column I shows ST segment elevation of 5 DAYS SHAM PBS group; column 2 shows ST segment elevation 15 of 5 DAYS RIP PBS group; column 3 shows ST segment elevation of 10 DAYS SHAM PBS group; column 4 shows ST segment elevation of 10 DAYS RIP PBS group; standard deviation is indicated in error bars; asterisk indicates significant compared to 10 DAYS SHAM PBS (nominal p value <0.025); double asterisk indicate significant compared to 10 DAYS RIP PBS (nominal p value < 0.025). 20 Diagram shows mean of ST segment elevation maximum per group. After 5 days there was no significant difference found between RIP and SHAM. After 10 days in the RIP group ST segment elevation maximum was significantly lower compared to sham (*) and 5-day RIP control (**) (*nominal p-value < 0.025). 25 Figure 3: Course of the ST segment elevation per beat after FPO (module 1: Sham operation without the RIP). ECG graph in black indicates 5 DAYS SHAM PBS, n=8: 0.134 ± 0.034 mV; ECG graph in light grey indicates 5 DAYS SHAM NTG, n=7: 0.124 ± 0.058 mV; ECG graph in middle grey indicates 5 DAYS SHAM NTG-PLACEBO, n=6: 0.131 ±0.043 mV. 30 The course of the ST segment elevation per beat after FPO revealed no differences between sham control and treated groups after 5 days.

- Is Figure 4: ST segment elevation (module 1: Sham operation without the RIP). Column I shows 5 DAYS SHAM PBS; column 2 shows 5 DAYS SHAM NTG-Placebo; column 3 shows 5 DAYS SHAM NTG; standard deviation is indicated by error bars. No difference in ST segment elevation maximum was found between sham control and 5 treated groups. Figure 5: Course of the ST segment elevation per beat after FPO (module 2: NO intermittent (NTG)). ECG graph in light grey indicates 5 DAYS RIP PBS, n=8: 0.104 ± 0.0 16 mV; ECG graph in middle grey indicates 5 DAYS NTG-PLACEBO, n=6; 0.096 ± 10 0.061 mV; ECG graph in black indicates 5 DAYS RIP NTG, n=7: 0.052 ± 0.030 mV. Compared to control treatment with PBS or NTG-Placebo a lower ST segment elevation course was detected after NTG treatment 5 days after RIP. In the NTG group ("5 DAYS RIP NTG") ST segment elevation is significantly decreased compared to the PBS group. There is no significance between the PBS and NTG 15 PLACEBO-group. Figure 6: ST segment elevation (module 2: NO intermittent (NTG)). Column 1 shows 5 DAYS RIP PBS; column 2 shows 5 DAYS NTG-PLACEBO; column 3 shows 5 DAYS RIP NTG; standard deviation is indicated by error bars, asterisk indicates significant 20 decrease of ST segment elevation compared to PBS group (nominal p-value < 0.017). After treatment with NTG, the ST segment elevation maximum was significantly decreased compared to PBS and NTG-Placebo treatment 5 days after RIP (*nominal p value < 0.017). 25 Figure 7: Course of the ST segment elevation per beat after FPO (module 3: NO continuous (ISDN retard)). ECG graph in light grey indicates 5 DAYS RIP PBS, n=8: 0.104 ± 0.016 mV; ECG graph in middle grey indicates 5 DAYS ISDN-PLACEBO, n=7: 0.110 ± 0.069 mV; ECG graph in black indicates 5 DAYS RIP ISDN, n=7: 0.062 ± 0.027 mV. 30 Compared to control treatment with PBS or ISDN-Placebo a lower ST segment elevation course was detected after ISDN treatment 5 days after RIP. ST segment elevation in the ISDN group ("5 DAYS RIP ISDN") is decreased compared to the PBS group but there is no significance as well as between the PBS and ISDN PLACEBO-group.

- 19 Figure 8: ST segment elevation (module 3: NO continuous (ISDN retard)). Column I shows 5 DAYS RIP PBS; column 2 shows 5 DAYS RIP ISDN-PLACEBO; column 3 shows 5 DAYS RIP ISDN; standard deviation is indicated by error bars. 5 After treatment with ISDN, the ST segment elevation maximum was non-significantly decreased compared to PBS and ISDN-Placebo treatment 5 days after RIP (nominal p value < 0.017). Figure 9: Course of the ST segment elevation per beat after FPO (module 4: NO 10 intermittent plus ASA). ECG graph in light grey indicates 5 DAYS RIP PBS, n=8; 0.104 ± 0.016 mV; ECG graph in middle grey indicates 5 DAYS RIP ASA + PBS, n=7: 0.138 ± 0.098 mV; ECG graph in dark grey indicates 5 DAYS RIP ASA + NTG-PLACEBO, n=6: 0.144 ± 0.091 mV; ECG graph in black indicates 5 DAYS RIP NTG + ASA, n=7: 0.088 0.071mV. 15 Treatment with NTG+ASA was compared to with PBS+ASA, NTG-Placebo+ASA and PBS. In general, all curves overlay at the same range. ST segment elevation in the group treated with PBS and ASA is higher compared to the PBS control group, but there is no significance as well as between the ASA + NTG PLACEBO-group. In the ASA + NTG-group ST segment elevation is decreased compared 20 to the group treated with ASA and PBS. Figure 10: ST segment elevation (module 4: NO intermittent plus ASA). Column 1 shows 5 DAYS RIP PBS; column 2 shows 5 DAYS RIP PBS+ASS; column 3 shows 5 DAYS RIP NTG-PLACEBO; column 4 shows 5 DAYS RIP NTG-PLACEBO+ASS; column 5 25 shows 5 DAYS RIP NTG; column 6 shows 5 DAYS RIP NTG+ASS; standard deviation is indicated by error bars. Treatment with NTG+ASA was compared to PBS+ASA, NTG-Placebo+ASA and PBS. Furthermore, all ASA groups (PBS+ASA, NTG-Placebo+ASA, NTG+ASA) were compared to their controls (PBS, NTG-Placebo, NTG). No significant differences were 30 detected. Figure 11: Arrhythmias during FPO (module 1: Sham Operation (without the RIP)). Numbers of columns are given in consecutive order of the columns in group IVb. Column - 20 I shows 5 DAYS SHAM PBS; column 2 shows 5 DAYS SHAM NTG-PLACEBO; column 3 shows 5 DAYS SHAM NTG. In accordance with Lown classification, all sham groups were predominantly scaled into grade IVa. 5 In the "5 DAYS SHAM PBS" group 87.5% of the rats have class IVb arrhythmias and 12.5% class IVa. In the "5 DAYS SHAM NTG-PLACEBO" group 83.3% have IVb arrhythmias and 16.7% class IVa and in the "5 DAYS SHAM NTG" group 85.7% have IVb arrhythmias and 14.3% class Illa arrhythmias. 10 Figure 12: Arrhythmias during FPO (module 2: NO intermittent (NTG)). Numbers of columns are given in consecutive order of the columns in group IVb. Column I shows 5 DAYS RIP PBS; Column 2 shows 5 DAYS RIP NTG-PLACEBO; Column 3 shows 5 DAYS RIP NTG. While arrhythmias in both control groups, PBS and NTG-Placebo, were predominantly 15 scaled into grade IVa, the NTG treated group was more often scaled into grade 0. In the "5 DAYS RIP PBS" group, 75.0% of the rats have class IVb arrhythmias, 12.5% IVa and 12.5% class 0. Regarding the "5 DAYS RIP NTG-PLACEBO" group, 66.7% of the rats showed class IVb arrhythmias, 16.7% IVa and 16.7% class IlIb arrhythmias. Interestingly, the "5 DAYS RIP NTG" group shows 42.9% class IVb arrhythmias and 20 57.1% class 0 arrhythmias. Figure 13: Arrhythmias during FPO (module 3: NO continuous (ISDN retard)). Numbers of columns are given in consecutive order of the columns in group IVb. Column I shows 5 DAYS RIP PBS; column 2 shows 5 DAYS RIP ISDN-PLACEBO; column 3 shows 5 25 DAYS RIP ISDN. In all groups, arrhythmias were similarly more often scaled into grade IVa. In the "5 DAYS ISDN-PLACEBO" group, 57.1% of the rats have class IVb arrhythmias, 14.3% class IVa and 28.6% class IIb. The "5 DAYS RIP ISDN" group shows less severe arrhythmias with 57.1% class IVb, 28.6 % class IVa and 14.3% class 0 arrhythmias. 30 Figure 14: Arrhythmias during FPO (module 4: NO intermittent plus ASA). Numbers of columns are given in consecutive order of the columns in group IVb. Column I shows 5 DAYS RIP ASS + PBS; column 2 shows 5 DAYS RIP ASS + NTG-PLACEBO; column 3 shows 5 DAYS RIP ASS + NTG.

- 21 Arrhythmias were similarly scaled more into grade IVa in all groups. In the "5 DAYS RIP ASS + PBS" group, in the group treated with ASS + NTG PLACEBO and in the "5 DAYS RIP ASS + NTG" group 83.3% of the rats posses class lVb arrhythmias and 16.7% class IIIa. 5 Figure 15: VPB-Score. Column I shows SHAM PBS; Column 2 shows SHAM NTG Placebo; Column 3 shows SHAM NTG; Column 4 shows RIP PBS; Column 5 shows RIP NTG-Placebo; Column 6 shows RIP NTG; Column 7 shows RIP PBS; Column 8 shows RIP ISDN-CC; Column 9 shows RIP ISDN; Column 10 shows RIP PBS + ASS; Column 1o I I shows RIP NTG-CC + ASS; Column 12 shows RIP NTG + ASS. The VBP score shows the percentage of each Lown grade of every group. The Sham groups have higher VBP-scores. Compared to the group with an ischemic protocol (control group, treated with PBS), more rats show severe arrhythmias. The treatment with NTG reveals reduced arrhythmias, and consequently a lower VPB-Score. The VPB-Score in 15 groups treated with ASA alone or NTG + ASA is higher compared to the controls (treated with PBS). Regarding the percentage of each Lown grade of every group, a VBP score can be ascertained. The more animals show a higher grade, the higher is the VBP score. 20 Figure 16: Infarct size of 5-days- and 10-days-control-groups. Column I shows 5 DAYS SHAM PBS, n=8: 13.36 ± 5.22%; column 2 shows 5 DAYS RIP PBS, n=8: 11.05 ± 5.12%; column 3 shows 10 DAYS SHAM PBS, n=7: 13.71 ± 6.06%; column 4 shows 10 DAYS RIP PBS, n=6: 6.57 ± 3.26%; standard deviation is indicated by error bars; asterisk indicates significant compared to 10 DAYS SHAM PBS (nominal p-value <0.013). 25 After an ischemic protocol of 5 days there is no significantly smaller infarct size measurable, but after a RIP of 10 days the infracted area is significantly decreased (nominal p-value < 0.013). After 90 minutes of LAD occlusion and 20 minutes reperfusion, infarct size was analyzed. The "10 DAYS RIP PBS" group has a significantly smaller infarct area compared to the 30 "10 DAYS SHAM PBS" group. There is no significance between both 5 DAYS groups. Figure 17: Infarct size (module 1: Sham Operation (without the RIP)). Column I shows 5 DAYS SHAM PBS, n=8: 13.36 ± 5.22mV; column 2 shows 5 DAYS SHAM NTG- - 22 PLACEBO, n=6: 14.21 ± 5.79 mV; column 3 shows 5 DAYS SHAM NTG, n=7: 14.09 5.18 mV; standard deviation is indicated by error bars. The infarct size shows no difference between the SHAM groups. There is no significance between the three SHAM-groups. 5 Figure 18: Infarct size (module 2: NO intermittent (NTG)). Column I shows 5 DAYS RIP PBS, n=8: 11.05 ± 5.12%; column 2 shows 5 DAYS NTG-PLACEBO: n=6; 9.80 ± 6.79 mV; column 3 shows 5 DAYS RIP NTG, n=7: 3.61 ± 2.08%; standard deviation is indicated by error bars, asterisk indicates significant compared to 5 DAYS RIP PBS 10 (nominal p-value < 0.017). The infarct size is significantly smaller after treatment with NTG compared to controls (treated with PBS) (nominal p-value < 0.0 17). Compared to the "5 DAYS RIP PBS", a significantly smaller infarct area is observed in the "5 DAYS RIP NTG" group. There is no significance between the PBS and NTG 15 PLACEBO-group. Figure 19: Infarct size (module 3: NO continuous (ISDN retard)). Column 1 shows 5 DAYS RIP PBS, n=8: 11.05 ± 5.12%; column 2 shows 5 DAYS ISDN-PLACEBO, n=6: 9.97 ± 3.65 %; column 3 shows 5 DAYS RIP ISDN, n=7: 7.59 ± 4.38%; standard 20 deviation is indicated by error bars. The infarct size after treatment with ISDN is smaller compared to controls (treated with PBS or ISDN-Placebo), but there is no significance. The infarct size in the ISDN group ("5 DAYS RIP ISDN") is smaller compared to the PBS group, as well as the ISDN-PLACEBO-group. 25 Figure 20: Infarct size (module 4: NO intermittent plus ASS). Column 1 shows 5 DAYS RIP PBS, n=8; 11.05 ± 5.12%; Column 2 shows 5 DAYS RIP ASS + PBS, n=6: 12.51 ± 3.05%; Column 3 shows 5 DAYS NTG-PLACEBO: n=6; 9.80 ± 6.79 %; Column 4 shows 5 DAYS RIP NTG-PLACEBO + ASS, n=6: 13.92 ± 1.71%; Column 5 shows 5 DAYS 30 RIP NTG, n=7: 11.05 ± 5.12%; Column 6 shows 5 DAYS RIP NTG + ASS, n=6: 13.00 ± 3.82%;standard deviation is indicated by error bars, asterisk indicates significant compared to 5 DAYS RIP NTG (nominal p-value < 0.017). The infarct size after treatment with NTG plus ASS is significantly increased compared to the treatment with NTG alone (nominal p-value < 0.017).

- 23 The infarct size in the group treated with ASA ("5 DAYS ASS + PBS") is minimally increased compared to the PBS control group, as well as the ASS + NTG-PLACEBO group. There is no difference between the ASS + NTG-group and the group treated with ASS and PBS. However, the infarct area in the NTG group is significantly smaller 5 compared to the ASA + NTG group. Figure 21: TTC-staining. The pictures shows slices of three levels. Infarcted tissue stains a pale-white since they lack the enzymes with which the TTC reacts. Thus the areas of necrosis are clearly discernible and quantifiable. 10 Figure 22: Collateral diameters of ROI (module 1: Sham Operation (without the RIP)). Column I shows 5 DAYS SHAM PBS, n=3: 82.7 ± 3.7 jim; column 2 shows 5 DAYS SHAM NTG-PLACEBO, n=3: 89.6 pm ± 10.6 pm; column 3 shows 5 DAYS SHAM NTG, n=3: 86.8 ± 9.0 jim; standard deviation is indicated by error bars. 15 There is no growth of collaterals and no differences measurable between the SHAM groups. There is no significance between the three SHAM-groups. Figure 23: Collateral diameters of ROI (module 2: NO intermittent (NTG)). Column 1 20 shows 5 DAYS RIP PBS, n=3: 129.8 ± 6.9 pm; column 2 shows 5 DAYS RIP NTG PLACEBO: n=3; 127.0 ± 12.1 pm; column 3 shows 5 DAYS RIP NTG, n=3: 158.4 ± 9.2 pm; standard deviation is indicated by error bars, asterisk indicates significant compared to 5 DAYS RIP NTG (nominal p-value < 0.033). Diameters of collaterals are significantly increased by treatment with NTG compared to 25 controls (treated with PBS or NTG-Placebo) (nominal p-value < 0.033). Compared to the "5 DAYS RIP PBS", the diameters of the collaterals in the ROI in the "5 DAYS RIP NTG" group are significantly increased. There is no difference between the PBS and NTG-PLACEBO-group. 30 Figure 24: Collateral diameters of ROI (module 3: NO continuous (ISDN retard)). Column I shows 5 DAYS RIP PBS, n=3: 129.8 ± 6.9 pm; column 2 shows 5 DAYS ISDN PLACEBO, n=3: 133.0± 11.5 pm; column 3 shows 5 DAYS RIP ISDN, n=3: 148.2± 11.3 pm; standard deviation is indicated by error bars.

No differences are measurable in the diameter of collaterals after treatment with ISDN or ISDN-Placebo. The diameters of the collaterals in the ISDN group ("5 DAYS RIP ISDN") are enhanced compared to the PBS group, as well as compared to the ISDN-PLACEBO group. 5 Figure 25: Collateral diameter of ROI (module 4: NO intermittent plus ASA). Column 1 shows 5 DAYS RIP PBS, n=3; 129.8 ± 6.9 im; column 2 shows 5 DAYS RIP PBS + ASS, n=3: 102.5 ± 8.0 Im; column 3 shows 5 DAYS RIP NTG-PLACEBO: n=3; 127.0 ± 12.1 pm; column 4 shows 5 DAYS NTG-PLACEBO + ASS, n=3: 97.1 ± 8.61 pm; column 5 10 shows 5 DAYS RIP NTG, n=3: 158.4 ± 9.2 4m; column 6 shows 5 DAYS RIP ASS + NTG, n=3: 124.4 ± 5.6 pm; standard deviation is indicated by error bars, one asterisk indicates significant compared to 5 DAYS RIP PBS (nominal p-value < 0.039); double asterisk indicate significant compared to 5 DAYS RIP ASS + NTG (nominal p-value < 0.039). 15 Diameters of collaterals are significantly smaller after treatment with ASA compared to controls (treated with PBS). An additional treatment with NTG abolished the inhibiting effect of ASS. NTG-treatment alone shows significantly increased diameter compared to controls (treated with PBS) (nominal p-value < 0.039). The diameters in the group treated with PBS and ASS are significantly smaller compared 20 to the PBS control group as well as the ASS + NTG-PLACEBO-group, but there is no significance. In the ASA + NTG -group diameter are increased compared to the group treated with PBS and ASA. Figure 26: MicroCT imaging of the "ROI": (A) "5DAYS SHAM PBS"; (B) "5DAYS 25 SHAM NTG"; (C) "5DAYS RIP ISDN"; (D) "5DAYS RIP PBS"; (E) DAYSS RIP NTG"; (F) "5DAYS RIP ASS + PBS; (G) "5DAYS RIP ASS + NTG". The pictures show the growth of the collateral diameter in the region of interest by the ischemic protocol treated with PBS (D), NTG (E), or ISDN (C) compared to SHAM treated with PBS (A) or NTG (B). Inhibition of collateral growth by treatment with ASA 30 (F) is partially abolished by additional treatment with NTG (G). Figure 27: Study Flow Chart. Duration of the baseline period is estimated to be approximately 2 weeks. Duration of the intervention period will be six weeks. The follow up period will include an immediate investigation (one day up to maximal three days after the intervention period) and a long-term follow up investigation (1 month after intervention period). 5 - 26 Example 1 Pre-Clinical Study 5 1. INTRODUCTION One important mechanism of arteriogenesis is the induction of shear stress across recruited collateral arteries. 10 NO plays a fundamental role in this scenario, since it regulates the vasodilatory capability of the artery as well as therapeutic proliferation aspects on the smooth muscle cells of collateral arteries. 15 Here we evaluated the effects of Nitrolingual akut* Spray (G. Pohl-Boskamp GmbH & Co.KG, Hohenlockstedt, Germany; U.S. American brand name Nitrolingual* Pumpspray) in a unique non-myocardial infarct arteriogenesis model. Collateral growth in this model is induced via repetitive occlusion of the left anterior descending coronary artery (LAD). Infarct size in these animals was measured as the endpoint at the end of the experiment. 20 Thus, no interference between myocardial infarction and arteriogenesis has weaken the experiment. Moreover we evaluated the effect of acetyl salicylic acid (ASA) in this model of repetitive coronary occlusion as a possible inhibitor of arteriogenesis. We evaluated whether a concomitant application of NO (intermittent use of nitroglycerin) may compensate for this negative effect of ASA. 25 2. MATERIALS AND METHODS 1.1. Animal Preparation 30 Male Sprague-Dawley rats (300 g body weight at study start; n = 182) are used for experiments. For surgery (day 0), rats are premedicated (ketamine 50 mg/mI plus xylazine 4 mg/ml intraperitoneal) and intubated. Oral intubation (14-G polyethylene tubing) is done under direct observation of the vocal cords with an otoscope. General anesthesia is introduced and maintained by isoflurane inhalation (1.0% to 2.0%, with 100% oxygen). 35 Body temperature is controlled at 37 *C by an electric heating table. Surgery is performed using aseptic technique. The animal is initially placed on its dorsal side and cutaneous clips are fixed. With a BioAmp differential amplifier coupled to a PowerLab data acquisition system (AD Instruments) ECG parameters (heart rate) are monitored and recorded during - 21 surgery. The heart is exposed by left thoracotomy. A mini-pneumatic snare occluder (see the Mini-Pneumatic Snare Occluder section for details) is implanted around the mid to proximal left anterior descending coronary artery (LAD). Confirmation that the occluder is functional, i.e., producing myocardial ischemia, is determined initially by observation of 5 blanching and hypokinesis of the left ventricle (LV) and by observation of the electrocardiogram (ST elevation) during inflation. Rats are randomly divided into 4 therapeutic modules: Module 1: Sham Operation 10 Module 2: NO intermittent (nitroglycerin) Module 3: NO continuous (retard preparation of isosorbide dinitrate) Module 4: NO intermittent plus ASA After instrumentation and measurements, the chest is closed under positive end-expiratory 15 pressure, and the thoracic cavity is evacuated of air. The occluders are tunneled subcutaneously and exteriorized between the scapulae. These catheters are protected by a stainless steel spring coil connected to a ring that is secured subcutaneously between the scapulae. After the surgery, analgesic (buprenorphine 0.05 mg/kg SC) and antibiotic (enrofloxacin 10 mg/kg SC) are administered. Rats are observed in a recovery cage for 20 2 hours and then transferred to the animal care facility where they are continuously monitored by technicians. For 3 days after the surgery, buprenorphine (0.5 mg/kg SC) is taken for pain. On the third day after the surgery (day 3), ischemic protocol is started. After 5 resp. 10 days (only in module IA and 2B) of the experimental protocol (day 8 resp. day 13), the rats are anesthetized, and the chest is opened by mid thoracotomy. In the micro-CT 25 group, the hearts are immediately excised. For the final infarct size detection the LAD will be permanently occluded (final permanent occlusion, FPO) and infarct size will be measured via TTC staining. 1.2. Mini-Pneumatic Snare Occluder for Rat Heart 30 A mini-pneumatic snare occluder is used consisting of a mini-balloon, sheath tubing, suture, and catheter. The balloon (7 mm long) is made of soft latex membrane and is sufficiently pliable to give negligible physical force on the coronary vessels during balloon deflation. The balloon is mounted within an umbrella sheath (3.2 or 4.8 mm in diameter, 35 12 mm in length; protects the balloon from fibrous infiltration). Prolene (5-0) is passed around the LAD and attached to the sheath, securing the occluder to the heart, so that myocardial ischemia is produced by balloon inflation. Inflation volume is small (0.2 to 0.25 mL air), but occlusion occurs by 2 physical actions: "crimping" the LAD toward upward/outside and compressing the LAD by the inflated balloon/sheath. The balloon is connected to a catheter (PE-50) that is exteriorized. Balloon inflation and deflation are controlled from outside the rat cage. 5 1.3. Measurements of ECG Parameters In all four modules (1-4) we will at the beginning (day 3) and the end (day 8 resp. day 13) of the experimental protocol (RIP) perform the coronary occlusion for 40 seconds (equivalent to an occlusion in the RIP; see page 6) and measure ECG parameters to 10 examine the heart rate and ST elevation. 1.4. Coronary Microvascular Imaging With Micro-CT In addition we propose to use Micro-CT as a further endpoint to image collaterals. One 15 group of rats (3 rats of each group in each module; total of 36 rats) is prepared for coronary vascular visualization via micro-CT. The coronary circulation is filled with contrast medium (yellow microfil) by modification of the methodology for micro-CT study in the rats. The viscosity of the contrast medium enables filling up to coronary arteriolar level with no or minimal filling of capillaries. The excised heart is immediately cannulated by an 20 aortic cannula, and coronary circulation is perfused retrogradely at 85 mm Hg. A perfusate (25 0 C to 27 'C saline with 2% procaine) is used to avoid myocardial metabolic contraction and maximally dilate the coronary vasculature. Polyethylene tubing is inserted into the LV via a left appendage through the mitral valve to unload the LV. Warmed contrast medium (42 'C) is injected at a pressure of 85 mmHg for 3 minutes while 25 perfusion pressure is monitored. The heart is cooled by immersion into cold saline (0 *C to 4 'C) until the (yellow microfil) solidified. Then, the heart is removed and fixed in 4% paraformaldehyde solution (4 'C) overnight. Whole hearts are used for micro-CT imaging of coronary collateral growth. The coronary vasculature is visualized with micro-CT. In brief, the whole heart is scanned in 30 1* increments around 3600 about its apex-to-base longitudinal axis. The spatial resolution selected in the present study has an 18*18*18 m 3 voxel size to focus on the size of collateral vessels and to minimize the signals from smaller vessels. Finally, CT data are reconstructed as 3D images. The main purpose of these images is to establish the presence or absence of arterial-arterial anastomotic connections. Collateral vessels, i.e., arterial 35 arterial anastomotic connections, are counted by independent observers for the groups. 1.5. Experimental Protocol - 29 The repetitive ischemia protocol (RIP) is introduced by automatised inflation of the occluder using the following protocol: 40 seconds of occlusion every 20 minutes for 2 hours 20 minutes, followed by a period of "rest" (deflation) for 5 hours 40 minutes. This 8-hour set is repeated 3 times a day for 5 resp. 10 days (only in module IA and 2A). The 5 LAD is occluded automatically by remote inflation or deflation through the catheter. In sham rats (see module 1), the balloon is implanted, but RIP is not applied. Rats under RI protocol are randomly divided into the three modules 2, 3 and 4. 1.6. Infarct Size Detection 10 Infarct size will be detected by TTC staining after final permanent occlusion. After 5 resp. 10 days (only in module IA and 2A) of the experimental protocol, the occluder is inflated permanently for 90 minutes. Infarct size will be measured by TTC staining (n=10/group). Therefore rats are anaesthesized and undergo again the ECG recording to confirm the 15 occlusion (ST elevation) and to calculate ECG parameters and the numbers of arrhythmias. In animals without collaterals, coronary occlusion causes deterioration of systemic hemodynamics and arrhythmias, including premature ventricular contractions, ventricular tachycardia, and ventricular fibrillation; in animals with well developed collaterals, no such adverse effects are noted. 20 The chest is opened by mid thoracotomy. The heart is immediately excised and sectioned from apex to base in 2-mm-thick transverse slices parallel to the atrioventricular groove. Slices are incubated with 0.09 mol/L sodium phosphate buffer containing 1.0% triphenyl tetrazolium chloride (TTC) and 8% dextran for 20 min. at 37 0 C. Slices are fixed in 10% 25 formaldehyde and then photographed with a digital camera mounted on a stereomicroscope. The infarcted size is quantified using a computerized planmetric program (Adobe Photoshop). The infarcted area is indentified as the TTC-negative tissue and is expressed as a percentage of the area of the left ventricle (LV). 30 1.7. Details Regarding Testing Compounds ASA Merck Chemicals NO intermittent (NTG) nitroglycerin solution; Nitrolingual akut* Spray, G. Pohl-Boskamp GmbH & Co. KG, 35 Hohenlockstedt, Germany NO continuous (ISDN retard) isosorbide dinitrate retard pellets; Nitrosorbon* retard; G. Pohl-Boskamp GmbH & Co. KG, Hohenlockstedt, Germany - JU Carrier compound for NO intermittent (NTG-Placebo) placebo solution of Nitrolingual akut* Spray, Pohl-Boskamp GmbH & Co. KG, Hohenlockstedt, Germany 5 NO continuous Carrier Compound (ISDN-Placebo) neutral pellets of Nitrosorbon* retard; G. Pohl Boskamp GmbH & Co. KG, Hohenlockstedt, Germany 10 Control buffer PBS (phosphate buffered saline) 1.8. Route, Timepoint and Concentration of Delivery to Animals All medication (ASA and NTG and ISDN retard) is given upfront to a following occlusion 15 time of the device. The control buffer (PBS) is given in the same way prior to the first two occlusions. NO intermittent (NTG) A new test solution is prepared every morning at eight o'clock. The solution is taken from 20 the vials via syringes. NO intermittent (NTG) is given twice a day with a time interval of 8 hours. Due to the chronic instrumentation of the rats and to avoid further stress, NTG is given via buccal application. 50 tl of the daily prepared test solution containing 13.3 pg nitroglycerin (equivalent to a human dose of 0.8 mg) is administered per buccal application 25 in module 1, 2 and 4. The time point of application is directly upfront to balloon inflation at 9 a.m. and 5 p.m., thus with maximal effects on recruited collateral arteries. This concentration is taken from the above mentioned reaction vials right before administration. Carrier compound solution is served as a stock solution for the preparation of the test 30 solution. Carrier compound for NO intermittent (NTG-Placebo) Carrier compound is administered in a way identical to NO intermittent. 35 NO continuous (ISDN retard) The medication for prolonged NO delivery (retard preparation isosorbide dinitrate = long acting nitrate ISDN) is delivered as retarded pellets 1x per day.

For the retard preparation ISDN a dosage of 2.6 mg ISDN/rat is chosen. Therefore 13 mg pellets are suspended in 0.5 ml drinking water and are applied via gavage at 9 a.m. every morning (equivalent of a human dose of 2mg/kg/BW). 5 NO continuous Carrier Compound (ISDN-Placebo) Carrier compound is administered in a way identical to NO continuous. No intermittent plus ASA (acetylsalicylic acid) Every morning at 9.30 a.m. 2.22 mg ASA per rat is given dissolved in 0.5 ml drinking 10 water via gavage directly into the stomach. The ASA concentration of 2.22 mg ASA per rat (6.34 mg/kg) correlates with the human dosage of 100 mg/day. 15 1.9. Animals and Groups 10 rats per groups (FPO= final permanent occlusion to induce infarcts) Group d: 3 additional animals are treated with the same medications and ligation scheme like the corresponding groups a, b and c, but without FPO. These 9 animals per module are 20 used for micro CT images. Module 1: Sham Operation (without the RIP): A. Control buffer (phosphate buffered saline PBS) with functional FPO for infarct size detection n=20 25 1. n=10: "5 DAYS SHAM PBS" 2. n=10 "10 DAYS SHAM PBS" B. Carrier compound without NO plus functional FPO for infarct size detection n=10: "5 DAYS SHAM NTG-PLACEBO" C. NTG with functional FPO for infarct size detection 30 n=10: "5 DAYS SHAM NTG" D. Al.) n=3 A2.) n=3 B) n=3 C) n=3 for micro CT images n-12 total: n=52 35 Module 2: NO intermittent: A. intermittent control buffer with functional FPO for infarct size detection n=20 - n2 1. n=10: "5 DAYS RIP PBS" 2. n=10: "10 DAYS RIP PBS" B. intermittent Carrier compound plus functional FPO for infarct size detection n=10: "5 DAYS RIP NTG-PLACEBO" 5 C. Intermittent NTG with functional FPO for infarct size detection n=10: "5 DAYS RIP NTG" D. Al.) n=3 A2.) n=3 B) n=3 C) n=3 for micro CT images n=12 10 total: n=52 Module 3: NO continuous: A. Continuous Control buffer (drinking water) with functional FPO for infarct size detection (n=10): "5 DAYS RIP DW" 15 B. Continuous Carrier compound plus functional FPO for infarct size detection n=10: "5 DAYS RIP ISDN-PLACEBO" C. Continuous NO functional FPO for infarct size detection n=10: "5 DAYS RIP ISDN" D. A.) n=3 B.) n=3 C.) n=3for micro CT images 20 n=9 total: n=(39) 25 Module 4: NO intermittent plus ASA: A. Intermittent Control buffer plus ASA with functional FPO for infarct size detection n=10: "5 DAYS RIP PBS+ASA" B. Intermittent NO Carrier compound plus ASA plus functional FPO for infarct size detection n=10: "5 DAYS RIP NTG-PLACEBO+ASA" 30 C. Intermittent NTG plus ASA functional FPO for infarct size detection n=10: "5 DAYS RIP NTG+ASA" D. A.) n=3 B.) n=3 C.) n=3 for micro CT images n=9 35 total: n=39 -33 3. RESULTS 3.1 Final Permanent Occlusion 5 LAD occlusion allowed a prospective study of the function of collateral vessels. Such vessels can protect myocardial tissue at risk of ischemia after coronary occlusion. At the end of the RMI protocol we performed the permanent LAD occlusion in one subgroup of all groups and measured ECG parameters to examine ST segment elevation 10 and ventricular arrhythmias. After 90 minutes of permanent occlusion we determined the infarcted area. 3.2 ECG Analysis 15 Electrocardiographic manifestations of ischemia initiated by LAD occlusion are less pronounced when collateral vessels are present. 3.3. ST Segment Elevation 20 During LAD occlusion there is an inverse correlation between the magnitude of ST segment elevation and the extent of the collateral supply. Collateral function is an important determinant of the direction of ST segment response to ischemia during acute coronary occlusion. Reversible ST segment elevation during acute 25 LAD occlusion is related to inadequate collateral arterial function. In patients with reversible ST segment depression, coronary collateral function appears to be better and, as a consequence, shows less ischemia results. During a 90 minutes occlusion the ST segment elevation in the "10 DAYS SHAM PBS" is 30 significantly higher compared to the "10 DAYS RIP PBS" group (10 DAYS SHAM, n=7: 0.124 ± 0.039 mV; 10 DAYS RIP, n=7: 0.055 ± 0.033 mV). In contrast, ST segment elevation in the "5 DAYS SHAM PBS" is similar to the "5 DAYS RIP PBS" group (5 DAYS SHAM, n=8: 0.134 ± 0.034 mV; 5 DAYS RIP, n=8: 0.104 ± 0.016 mV) (Figs. 1 and 2). 35 Module 1: Sham Operation (without the RIP) There is no significance between the three SHAM-groups (5 DAYS SHAM PBS, n=8: 0.134 ± 0.034 mV; 5 DAYS SHAM NTG-PLACEBO, n=6: 0.131 ± 0.043 mV; 5 DAYS SHAM NTG, n=7: 0.124 ± 0.058 mV) (Figs. 3 and 4). 5 Module 2: NO intermittent (NTG) In the NTG group ("5 DAYS RIP NTG") ST elevation is significantly decreased 10 compared to the PBS group (5 DAYS RIP PBS, n=8: 0.104 ± 0.016 mV; 5 DAYS RIP NTG, n=7: 0.052 ± 0.030 mV). There is no significance between the PBS and NTG PLACEBO-group (5 DAYS NTG-PLACEBO: n=6; 0.096 ± 0.061 mV) (Figs. 5 and 6). 15 Module 3: NO continuous (ISDN retard) ST segment elevation in the ISDN group ("5 DAYS RIP ISDN") is decreased compared to the PBS group (5 DAYS RIP PBS, n=8: 0.104 ± 0.016 mV; 5 DAYS RIP ISDN, n=7: 0.062 ± 0.027 mV), but there is no significance as well as between the PBS and ISDN 20 PLACEBO-group (5 DAYS ISDN-PLACEBO, n=7: 0.110 ± 0.069 mV) (Figs. 7 and 8). Module 4: NO intermittent plus ASA 25 ST segment elevation in the group treated with PBS and ASA is higher compared to the PBS control group (5 DAYS RIP ASA + PBS, n=7: 0.138 ± 0.098 mV; 5 DAYS RIP PBS, n=8; 0.104 ± 0.016 mV), but there is no significance as well as between the ASA + NTG PLACEBO-group (5 DAYS RIP ASA + NTG-PLACEBO, n=6: 0.144 ± 0.091 mV). In the ASA + NTG-group ST elevation is decreased compared to the group treated with ASA and 30 PBS (5 DAYS RIP NTG + ASA, n=7: 0.088 ± 0.071 mV) (Figs. 9 and 10). 3.4. Ventricular Arrhythmias 35 The importance of ventricular premature beats (VPBs) results from their possible association with an increased risk for cardiac sudden death. VPBs were stratified according to the Lown classification. A high Lown grade has been shown to predict mortality after acute myocardial infarction.

-3*, Grade 0: no ventricular ectopic beats Grade I: occasional, isolated VPB Grade II: frequent VPB (> 1/min or 30/h) Grade III: multiform VPB 5 (a) VPB (b) Bigenimus Grade IV: repetitive VPB (a) Couplets (b) Salvos 10 Grade V: Early VPB Module 1: Sham Operation (without the RIP) 15 In the "5 DAYS SHAM PBS" group 87.5% of the rats have class IVb arrhythmias and 12.5% class IVa. In the "5 DAYS SHAM NTG-PLACEBO" group 83.3% have lVb arrhythmias and 16.7% class IVa and in the "5 DAYS SHAM NTG" group 85.7% have lVb arrhythmias and 14.3% class lIla arrhythmias (Fig. 11). 20 Module 2: NO intermittent (NTG) In the "5 DAYS RIP PBS" group, 75.0% of the rats have class lVb arrhythmias, 12.5% 25 IVa and 12.5% class 0. Regarding the "5 DAYS RIP NTG-PLACEBO" group, 66.7% of the rats showed class IVb arrhythmias, 16.7% iVa and 16.7% class Illb arrhythmias. Interestingly, the "5 DAYS RIP NTG" group shows 42.9% class IVb arrhythmias and 57.1% class 0 arrhythmias (Fig. 12). 30 Module 3: NO continuous (ISDN retard) In the "5 DAYS ISDN-PLACEBO" group, 57.1% of the rats have class IVb arrhythmias, 14.3% class IVa and 28.6% class IlIb. The "5 DAYS RIP ISDN" group shows less severe 35 arrhythmias with 57.1% class IVb, 28.6 % class IVa and 14.3% class 0 arrhythmias (Fig. 13).

- 36 Module 4: NO intermittent plus ASA In the "5 DAYS RIP ASA + PBS" group, in the group treated with ASS + NTG PLACEBO and in the "5 DAYS RIP ASS + NTG" group 83.3% of the rats posses class 5 IVb arrhythmias and 16.7% class Illa. Regarding the percentage of each Lown grade of every group, a VBP score can be ascertained. The more animals show a higher grade, the higher is the VBP score (Fig. 15). 10 Figure 15: VPB-Score

VPB

group Score Module 1 SHAM PBS 5.88 SHAM NTG PLACEBO 5.83 SHAM NTG 5.77 Module 2 RIP PBS 5.10 RIP NTG-PLACEBO 4.84 RIP NTG 3.60 Module 3 RIP PBS 5.10 RIP ISDN-PLACEBO 5.29 RIP ISDN 4.57 Module 4 RIP ASA + PBS 5.50 RIP ASA + NTG PLACEBO 5.50 RIP ASA + NTG 5.50 Table 1: VPB-Score 15 3.5. Infarct Size After 90 minutes of LAD occlusion and 20 minutes reperfusion, infarct size was analyzed.

- 37 The "10 DAYS RIP PBS" group has a significantly smaller infarct area compared to the "10 DAYS SHAM PBS" group (10 DAYS RIP PBS, n=6: 6.57 ± 3.26%; 10 DAYS SHAM PBS, n=7: 13.71 ± 6.06%). There is no significance between both 5 DAYS groups (5 DAYS SHAM PBS, n=8: 13.36 ± 5.22%; 5 DAYS RIP PBS, n=8: 11.05 ± 5.12%) (Fig. 5 16). Module 1: Sham Operation (without the RIP) 10 There is no significance between the three SHAM-groups (5 DAYS SHAM PBS, n=8: 13.36 ± 5.22 mV; 5 DAYS SHAM NTG-PLACEBO, n=6: 14.21 ± 5.79 mV; 5 DAYS SHAM NTG, n=7: 14.09 ± 5.18 mV) (Fig. 17). 15 Module 2: NO intermittent (NTG) Compared to the "5 DAYS RIP PBS", a significantly smaller infarct area is observed in the "5 DAYS RIP NTG" group (5 DAYS RIP PBS, n=8: 11.05 ± 5.12%; 5 DAYS RIP NTG, n=7: 3.61 ± 2.08%). There is no significance between the PBS and NTG 20 PLACEBO-group (5 DAYS NTG-PLACEBO: n=6; 9.80 ± 6.79 mV) (Fig. 18). Module 3: NO continuous (ISDN retard) 25 The infarct size in the ISDN group ("5 DAYS RIP ISDN") is smaller compared to the PBS group (5 DAYS RIP PBS, n=8: 11.05 ± 5.12%; 5 DAYS RIP ISDN, n=7: 7.59 + 4.38%), as well as the ISDN-PLACEBO-group (5 DAYS ISDN-PLACEBO, n=6: 9.97 ± 3.65 %) (Fig. 19). 30 Module 4: NO intermittent plus ASA The infarct size in the group treated with ASA ("5 DAYS ASA + PBS") is minimally 35 increased compared to the PBS control group (5 DAYS RIP ASA + PBS, n=6: 12.51 ± 3.05%; 5 DAYS RIP PBS, n=8; 11.05 ± 5.12%), as well as the ASA + NTG-PLACEBO group (5 DAYS RIP ASA + NTG-PLACEBO, n=6: 13.92 ± 1.71%). There is no difference between the ASA + NTG-group and the group treated with ASA and PBS (Fig. 20).

- 38 However, the infarct area in the NTG group is significantly smaller compared to the ASA + NTG group (5 DAYS RIP NTG, n=7: 11.05 ± 5.12%; 5 DAYS RIP NTG + ASS, n=6: 13.00 ± 3.82%). 5 3.6. Coronary Microvascular Imaging With Micro-CT Collateral arteries are pre-existent vessels running parallel to a major artery. In case the major artery is occluded, even for a short period of time (40 sec during this RIP), 10 collaterals assume the blood supply. As a result, collateral arteries in this area (ROI, region of interest) start to grow in length (clearly visible by the cork screw pattern) and most notably in their diameter. So we measured the diameter of the collaterals in the ROL. Module 1: Sham Operation (without the RIP) 15 There is no significance between the three SHAM-groups (5 DAYS SHAM PBS, n=3: 82.7 ± 3.7 pim; 5 DAYS SHAM NTG-PLACEBO, n=3: 89.6 pm ± 10.6 pim; 5 DAYS SHAM NTG, n=3: 86.8 ± 9.0 pm) (Figs. 22 and 26). 20 Module 2: NO intermittent (NTG) Compared to the "5 DAYS RIP PBS", the diameters of the collaterals in the ROI in the "5 DAYS RIP NTG" group are significantly increased (5 DAYS RIP PBS, n=3: 129.8 ± 6.9 25 pm; 5 DAYS RIP NTG, n=3: 158.4 ± 9.2 jim). There is no difference between the PBS and NTG-PLACEBO-group (5 DAYS NTG-PLACEBO: n=3; 127.0 ± 12.1 jim) (Figs. 23 and 26). 30 Module 3: NO contiin * s (ISDN retard) * The diameter of the collaterals in the ISDN group ("5 DAYS RIP ISDN") are enhanced compared to the PBS group (5 DAYS RIP PBS, n=3: 129.8 ± 6.9 pm; 5 DAYS RIP ISDN, n=3: 148.2 ± 11.3 pm), as well as compared to the ISDN-PLACEBO group (5 DAYS 35 ISDN-PLACEBO, n=3: 133.0 ± 11.5 pim) (Figs. 24 and 26). Module 4: NO intermittent plus ASA - 39 The diameter in the group treated with PBS and ASA are smaller compared to the PBS control group (5 DAYS RIP PBS + ASA, n=3: 102.5 ± 8.0 pm; 5 DAYS RIP PBS, n=3; 129.8 ± 6.9 pm), but there is no significance as well as the ASA + NTG-PLACEBO-group 5 (5 DAYS NTG-PLACEBO + ASA, n=3: 97.1 ± 8.61 pm). In the ASA + NTG -group diameter are increased compared to the group treated with PBS and ASA (5 DAYS RIP ASA + NTG, n=3: 124.4± 5.6 tm) (Figs. 25 and 26). 10 4. Conclusion We examined the groups "10 DAYS SHAM PBS" and "5 DAYS SHAM PBS", each without a RIP (repetitive ischemic protocol) and the groups "10 DAYS RIP PBS" and "5 DAYS RIP PBS", each with a RIP of five and ten days. 15 Measurement of infarct volume after a 90 minute permanent LAD occlusion (FPO, final permanent occlusion) revealed significantly smaller infarcted areas in the 10 DAYS RIP group than in "10 DAYS SHAM" group. In contrast, after a RIP of five days, no differences became apparent in the SHAM and RIP group. Moreover, we used ECG parameters for examinations and evaluation for the first time. We 20 found the maximal ST elevation after FPO of the LAD showed no crucial differences between "5 DAYS RIP PBS" and SHAM groups, yet. However, after 10 days ST elevations were significantly decreased in the RIP group. Aside from ST elevation measurement during FPO, we were able to analyze and evaluate arrhythmias in differentiated way. 25 Based on these novel insights into the characterization of rat RMI model, we decided to use a 5 day RIP in case of an expected stimulation of arteriogenesis. The degree of ST elevation enhancement and the infarct volume after a 10 day RIP can be obtained with pro arteriogenic substances within a 5 day RIP, yet. This provides additional parameters being able to approve our results of infarct volume 30 measurement. The intermittent application of NTG solution (twice daily on buccal mucosa) decreased serious arrhythmias of the rat heart during FPO compared to the control group. Additionally, infarct volume is decreased by more than 50% after 90 minutes FPO 35 compared to the control group. This reduction in infarct size is not even obtainable with controls set to a 10 days RIP. Furthermore, a treatment with NTG solution significantly attenuated ST elevation during FPO. On the basis of the pCT analyses, significantly enlarged collateral arteries were measurable.

- 40 The treatment of the rats with ISDN retard (once daily intragastrally) also led to decreases in ST elevation during FPO, less arrhythmias and reduced infarct volumes. However, these improvements of infarct parameters are less distinct compared with NTG treatment. Moreover, they did not show any significance. 5 Compared to controls, the treatment with ASA showed an impairment of ECG parameters and an increase of infarct volumes due to impaired collateral growth. These negative effects of ASA on arteriogenesis are already known. Interestingly, they can be partly abolished through an additional NTG treatment (twice daily on buccal mucosa). Thus, collateral diameters were enlarged in the ROI and ECG parameters were enhanced. 10 Nevertheless, infarct volumes after FPO showed no reduction. The SHAM groups did not differ among each other. Further on, there were no differences measured between the Placebo groups and their corresponding control groups. 15 In conclusion, the presented results indicate that an intermittent treatment with NTG solution decreases the size of an experimentally induced myocardial infarct. In addition, effects on cardiac rhythm may ameliorate. These insights are of outstanding relevance for clinical aspects.

-41 Example 2 Clinical Study 5 This study aims to investigate the effects of a supervised, physician-controlled standardized exercise program for the symptomatic treatment, functional improvement and an augmentation of the arteriogenic capacity in patients with chronic stable CAD. 10 1 Study Design 1.1 Hypotheses and Study Arms 1.1.1 Hypotheses 15 1 Active physician-controlled exercise training with intermittent application of GTN is superior to active physician-controlled exercise training without GTN. (A+) > (A-) 20 11 Passive physician-controlled exercise training (CardioAccel*) with intermittent application of GTN is superior to passive physician-controlled exercise training without GTN. (P+) > (P-) 25 III Conservative CAD therapy with intermittent application of GTN is superior to conservative CAD therapy without GTN. (C+) > (C-) 1.1.2 Study Arms 30 - 42 A+ Active physician-controlled exercise training with intermittent application of GTN A- Active physician-controlled exercise training P+ Passive physician-controlled exercise training (CardioAccel*) with intermittent application of GTN P- Passive physician-controlled exercise training (CardioAccel*) C+ Conservative CAD therapy with intermittent application of GTN C- Conservative CAD therapy Patients may use GTN in case of angina pectoris, however will be supplied with an additional study GTN for the study use. 5 Active physician-controlled exercise training with intermittent application of GTN. Best medical therapy and usual care as detailed in the current guidelines (AHA, ESC) for the care for patients with chronic stable angina. Daily (Mon-Fri) physical exercise intervals 10 (treadmill) of 30 min (> 1 W/kg bw, following risk stratification and individual calculation and adjustment of training intensity as detailed in the current EACPR guidelines, for a total of six weeks. GTN use for the treatment of angina episodes is permitted. In addition, GTN 0.4 mg is administered 2-5 min before the onset of exercise. 15 Active physician-controlled exercise training. Best medical therapy and usual care as detailed in the current guidelines (AHA, ESC) for the care for patients with chronic stable angina. Daily (Mon-Fri) physical exercise intervals (treadmill) of 30 min (> I W/kg bw), following risk stratification and individual calculation and adjustment of training intensity as detailed in the current EACPR guidelines, for a total of six weeks. GTN use for the 20 treatment of angina episodes is permitted. Passive physician-controlled exercise training (CardioAccel*) with intermittent application of GTN. Best medical therapy and usual care as detailed in the current guidelines (AHA, ESC) for the care for patients with chronic stable angina. Daily (Mon 25 Fri) CardioAccelo treatment intervals of one hour per day for a total of six weeks, as detailed (Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto RW. The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol. 1999 Jun;33(7):1833-40). GTN use for the treatment of angina episodes is permitted. In addition, GTN 0.4 mg is administered 2-5 min before the onset of exercise. 5 GTN use for the treatment of angina episodes is permitted. Passive physician-controlled exercise training (CardioAccel*). Best medical therapy and usual care as detailed in the current guidelines (AHA, ESC) for the care for patients with chronic stable angina. Daily (Mon-Fri) CardioAccel* treatment intervals of one hour 10 per day for a total of six weeks, as detailed (Arora et al., supra). GTN use for the treatment of angina episodes is permitted. Conservative CAD therapy with intermittent application of GTN. Best medical therapy and usual care as detailed in the current guidelines (AHA, ESC) for 15 the care for patients with chronic stable angina. GTN use for the treatment of angina episodes is permitted. In addition, GTN 0.4 mg is administered once daily, preferably before the onset of a voluntary activity of daily life. Conservative CAD therapy. Best medical therapy and usual care as detailed in the current 20 guidelines (AHA, ESC) for the care for patients with chronic stable angina. GTN use for the treatment of angina episodes is permitted. 1.2 Clinical Trial Design 25 1.2.1 Clinical Trial Design - general The study is designed as a * prospective 30 0 randomized * multicenter (German Site, US-Site) - 44 clinical trial, to evaluate glyceryl trinitrate (Nitrolingual*) effects on exercise capacity, the proposed pathophysiological mechanism being an induction of pro-arteriogenic effects. 1.2.2 Study Endpoints 5 Primary Changes in functional exercise capacity, as measured on visit 3 by peak volume of oxygen uptake (V0 2 max) and maximum oxygen uptake at anaerobic threshold (V0 2 max AT) from 10 baseline in a standardized exercise treadmill test (sETT). Secondary Changes in 15 (1) Time to exercise-induced ischemia as measured by time to a>1-Imm ST-segment depression in a standardized exercise treadmill test (sETT), (2) the hemodynamic responses to the sETT, as quantified by the rate-pressure product (RPP)' , which is defined as the systolic blood pressure (mm Hg) multiplied by the heart rate (bpm). Heart rate, blood pressure, and ST segment trends are electronically measured 20 at the J-point + 60 ms, (3) the number of angina episodes per day, (4) exercise duration on sETT, (5) Relative Peak Slope Index (RPSI), (4) Doppler-derived maximal systolic acceleration [ACCmax], 25 (5) CCS and NYHA functional status, (6) Duke Treadmill Score2 The Rate-pressure product (RPP) is a sensitive index of myocardial oxygen consumption (mVO2). Patients are categorized by the rate pressure product (RPP) that existed at the time of maximum ST depression. In the absence of ST depression, the maximum RPP is recorded. 2 The Duke treadmill score calculates risk; it equals the exercise time in minutes minus (5 times the ST-segment deviation, during or after exercise, in millimeters) minus (4 times the angina index, which has a value of "0" if there is no angina, "1" if angina occurs, and "2" if angina is the reason for stopping the test). Among outpatients with suspected CAD, the two thirds of patients with (7) Incidence of cardiovascular events during the treatment phase and (8) same as primary endpoint, but one month after intervention period. 1.2.3 Patients 5 Eligible patients must be clinically stable, receiving before enrolment an antianginal and CAD therapy that is in full accordance with the current ESC/AHA guidelines for the treatment of chronic stable CAD. 10 Prohibited medication * long-acting nitrates e Sildenafil etc. * Anti-inflammatory compounds (other than aspirin) such as steroids or etanercept 15 etc. Inclusion Criteria: Age > 18 yrs Documented evidence of stable coronary artery disease by either positive nuclear exercise stress testing, angiographically documented coronary stenosis or history of documented ST-elevation or myocardial infarction 20 scores indicating low risk had a four-year survival rate of 99% (average annual mortality rate 0.25%), and the 4% who had scores indicating high risk had a four-year survival rate of 79% (average annual mortality rate 5%). The score works well for both inpatients and outpatients, and preliminary data suggest that the score works equally well for men and women [Gibbons et al., 2003 AHA/ACC Guideline] Exclusion Criteria: Nitrate intolerance or intolerance to any component of the study medication. Medication that poses a risk of pharmacologically interacting with GTN. Acute coronary syndrome or unstable angina <6 weeks prior. Left main stenosis of >50%. PCI or CABG < 3 months prior. Coronary angiography <3 weeks prior. Congestive heart failure/ EF of <30%. Valvular heart disease or myocarditis. Uncontrolled hypertension with blood pressure values > 180 / 100 mmHg Severe symptomatic PAD, varicosis, deep vein thrombosis (current or in documented medical history), phlebitis or ulcer. Coagulation disorder or therapeutic anticoagulation. Cardiac arrhythmias that interfere with ECP triggering. ECG characteristics that would invalidate ST segment monitoring: baseline ST segment depression, pacemaker-dependent rhythms, QRS duration >0.12 s, arrhythmias other than sinus arrhythmia. FEV1 < 1.51. Current participation in a cardiac exercise rehabilitation program. Randomization 5 Enrolled patients are randomized in a 1:1:1 ratio to receive/undergo either active training, CardioAccel* therapy or usual care, i.e. a continuation of the baseline treatment in - 4/ accordance with current guidelines. Within these groups, patients are randomized in a 1:1 ration to either a "+ GTN" or a "-GTN" group to receive glycerol trinitrate either in addition to their standard medication, or not. 5 1.2.4 Study Planning, Conduction and Management The trial is planned by Arteriogenesis Network Art.Net. Study management will be covered by Arteriogenesis Network Art.Net. 10 c/o Campus Technologies Freiburg GmbH Technology Transfer of the University of Freiburg CEO: Prof. Dr. Bernhard Arnolds Stefan-Meier StraBe 8, 79104 Freiburg (Germany) Phone: +49 (0)761 203 4990 15 Facsimile: +49 (0)761 203 4992 Sponsor of the trial is CTF. The reporting structures and reporting schemes will be detailed after the participating centers have been assigned. 20 Research Sites participating centers: to be determined contact in case of questions, dissemination of info 25 contact in case of adverse event, dissemination of info 1.2.5 Study Flow Chart and Protocol 30 The Study Flow Chart is given in Figure 27.

- 48 1.2.6 Treatment Assignment Randomization will be done at the conducting centers via envelopes. 5 Stratification will be done according to age-groups, gender and morbidity. Study visits are conducted by an investigator. Study centers in advance assign blinded investigators that are unaware of the randomization, and who carry out the medical examinations and testing at Baseline and 10 First Follow-up. At each study visit, patients are instructed to fill in a short standardized quality of life assessment form (SF-36 3 ). 15 Patients assigned to the C+ / C- groups are contacted on a regular basis by study personnel to help control potential bias effects as these subjects do not have as regular contacts with study personnel as do the CardioAccel* or exercise groups. 1.2.7 Study Visits 20 Visit 1: Eligibility Screening (day 1) * Medical history, including previous interventions, physical exam . Enrolment y/n 25 Visit 2: Baseline Visit (until day 14 (+3 days)) e Detailed medical history and physical exam, including assessment of number of angina episodes per day, CCS and NYHA status and assessment of voluntary physical activity. * Treadmill testing on a standard, calibrated treadmill equipment with 30 cardiopulmonary testing capability (modified Naughton protocol): 3 http://www.rand.org/health/surveys tools/mos/mos core 36item.html - 49 functional exercise capacity (V0 2 max and V0 2 max AT), time to exercise-induced ischemia as measured by time to a >1-mm ST-segment depression, rate-pressure product (RPP), heart rate, blood pressure, and ST segment trends electronically measured at the J-point + 60 ms, exercise duration, DUKE treadmill score, 5 continuous monitoring of vital signs incl. 12-lead ECG and V0 2 , with VO 2 max defined as V0 2 at maximum level of exercise the individual patient is able to achieve (respiratory ratio >1, anaerobic threshold) e Relative Peak Slope Index (RPSI) * Doppler-derived maximal systolic acceleration [ACCmax] 10 e Randomization Interim Visits (non-scheduled) Patients are advised to contact the study center at any time regarding their medical condition. Patients are scheduled to return for their first follow-up visits at 6 weeks after 15 randomization. Visit 3: Short-term follow-up (1-3 days after intervention period) " Medical history and physical exam, including assessment of number of angina episodes per day, CCS and NYHA status and assessment of voluntary physical 20 activity. " Treadmill testing on a standard, calibrated treadmill equipment with cardiopulmonary testing capability (modified Naughton protocol): functional exercise capacity (V0 2 max and V0 2 max AT), time to exercise-induced ischemia as measured by time to a >1-mm ST-segment depression, rate-pressure 25 product (RPP), heart rate, blood pressure, and ST segment trends electronically measured at the J-point + 60 ms, exercise duration, DUKE treadmill score, continuous monitoring of vital signs incl. 12-lead ECG and V0 2 , with VO 2 max defined as V0 2 at maximum level of exercise the individual patient is able to achieve (respiratory ratio >1, anaerobic threshold) 30 e Relative Peak Slope Index (RPSI) e Doppler-derived maximal systolic acceleration [ACCmax] * Incidence of cardiovascular events during the treatment phase Visit 4: Long-term follow-up (1 month after intervention period) (The rational of this study point is to evaluate the long term effect of the study medication after the intervention period). " Medical history and physical exam, including assessment of number of angina 5 episodes per day, CCS and NYHA status and assessment of voluntary physical activity. " Treadmill testing on a standard, calibrated treadmill equipment with cardiopulmonary testing capability (modified Naughton protocol): functional exercise capacity (V0 2 max and V0 2 max AT), time to exercise-induced 10 ischemia as measured by time to a >1-mm ST-segment depression, rate-pressure product (RPP), heart rate, blood pressure, and ST segment trends electronically measured at the J-point + 60 ms, exercise duration, DUKE treadmill score, continuous monitoring of vital signs incl. 12-lead ECG and V0 2 , with VO 2 max defined as V0 2 at maximum level of exercise the individual patient is able to 15 achieve (respiratory ratio >1, anaerobic threshold) * Relative Peak Slope Index (RPSI) * Doppler-derived maximal systolic acceleration [ACCmax] 20 1.2.8 Statistical Considerations The main efficacy parameter is functional exercise capacity, as measured by peak volume of oxygen uptake (V02 max) and maximum oxygen uptake at anaerobic threshold (V02 max AT) in a standardized exercise treadmill test (sETT). We assume no difference at 25 baseline but significantly higher values in the GTN groups at follow-up. Statistical Methods There are two major sources of variance to be considered in this trial: GTN treatment effects and effects of active training/passive training/conservative therapy. Accordingly data will be analysed in a two-way ANOVA. Any therapy effects not related to GTN will 30 be reported in a descriptive way without inference statistic. For secondary parameters parametric or non-parametric tests will be applied as appropriate. Sample Size / Power To establish the necessary sample size for the proposed two-way-ANOVA, we made the following assumptions (based on literature review and internal data): statistical power=80%, standard deviation for outcome measure=15% of mean, effect size (group difference in change between GTN yes/no) = 5% of mean. Power was established in a 5 Monte Carlo simulation based on 10000 repeats per sample size over a range of n per group from 30 to 60 patients. This simulation established a minimum sample size of 48 subjects per group, to allow for potential drop-outs we propose to include 50 subjects per group, resulting in a total sample size of 300 patients. 10 1.3 Ethical and Legal Aspects The investigators plan and conduct any experiments involving humans, including identifiable samples taken from humans and identifiable data, in compliance with 15 (a) the Declaration of Helsinki (Ethical Principles for Medical Research Involving Human Subjects) concluded by the World Medical Association (WMA) in June 1964, as last revised; (b) the ICH Harmonised Tripartite Guideline: Guideline for Good Clinical Practice E6/ 20 International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH E6, 1 May 1996) as well as (c) applicable German regulations (e.g. Arzneimittelgesetz) in their current forms, as well as applicable FDA regulations (e.g. Guidance for Sponsors, Investigators, Informed 25 Consent Elements, 21 CFR § 50.25(c). 5. List of Abbreviations 30 ACCma: Doppler-derived maximal systolic acceleration - b2 Art.Net.: Network Subcontractors of CTF CAD: Coronary Artery Disease CardioAccele: personalized counterpulsation therapy CCS: Canadian Class Society (Angina classification) 5 CTF: Campus Technologies Freiburg FSS: fluid shear stress GTN: glyceryl trinitrate IABP: intra-aortic ballon pump NYHA: New York Heart Association 10 RPSI: Relative Peak Slope Index sETT: a standardized exercise treadmill test SMC: vascular smooth muscle cell V0 2 max: peak volume of oxygen uptake V0 2 max AT: maximum oxygen uptake at anaerobic threshold 15

Claims (33)

1. A method of treating or preventing an arterial insufficiency, wherein an NO donor is administered in an intermitting manner to a subject in an amount effective for the induction of arteriogenesis, wherein the NO donor is a short acting NO donor and wherein the NO donor is administered lingually, sublingually, inhalatively, buccally, transmucosally or oromucosally.

2. The method of claim 1, wherein the arterial insufficiency is due to insufficient oxygen or blood supply of a tissue supplied by the artery or a bypass or shunt during physical rest or exercise.

3. The method of any of claims 1 or 2, wherein the arterial insufficiency is due to an increased demand of oxygen or blood flow of a tissue supplied by the artery or a bypass or shunt.

4. The method of any of claims 1 to 3, wherein the arterial insufficiency is characterized by a partial or complete occlusion of an arterial vessel.

5. The method of any of claims 1 to 4, wherein the arterial insufficiency is due to the deposition of material in the blood vessels.

6. The method of any of claims 1 to 5, wherein the arterial insufficiency is due to an external or internal compression of an artery.

7. The method of any of claims 1 to 6, wherein the arterial insufficiency is a vascular disease.

8. The method of any of claims 1 to 6, wherein the arterial insufficiency is a disease selected from the group consisting of atherosclerosis, an ischemic disease and a further chronic arterial disease.

9. The method of any of claims 1 to 6, wherein the arterial insufficiency is a coronary arterial insufficiency.

10. The method of any of claims 1 to 6, wherein the arterial insufficiency is a cerebral arterial insufficiency.

11. The method of any of claims 1 to 6, wherein the arterial insufficiency is a peripheral arterial insufficiency.

12. The method of any of claims 1 to 6, wherein the arterial insufficiency is an intestinal arterial insufficiency.

13. The method of any of claims 1 to 6, wherein the arterial insufficiency is an urogenital arterial insufficiency.

14. The method of any of claims 1 to 6, wherein the arterial insufficiency is a nerval arterial insufficiency.

15. The method of any of claims 1 to 6, wherein the arterial insufficiency is in the context of scleroderma.

16. The method of any of claims 1 to 6, wherein the arterial insufficiency is a central retinal artery insufficiency.

17. The method of any of claims 1 to 16, wherein the arterial insufficiency is characterized by an absence of an endothelial dysfunction.

18. The method of any of claims 1 to 17, wherein the NO donor is Nitroglycerin.

19. The method of any of claims 1 to 18, wherein the NO donor is administered at least once a day and at least on one day a week for at least two weeks.

20. The method of any of claims 1 to 19, wherein the NO donor is administered for a period of several weeks or months.

21. The method of any of claims 1 to 20, wherein the NO donor is administered in conjunction with an exogenous stimulation of the pulsatile shear forces in the artery.

22. The method of claim 21, wherein the NO donor is administered in the time period of 30 minutes before the onset of the exogenous stimulation until 30 minutes after the termination of the exogenous stimulation.

23. The method of claim 22, wherein the NO donor is administered in the time period of 15 minutes before the exogenous stimulation until 30 minutes after the onset of the exogenous stimulation.

24. The method of any of claims 21 to 23, wherein said stimulation is achieved by physical exercise or the application of an endogenous force to the arterial vessel.

25. The method of any of claim 1 to 24, wherein the method aims at the prevention of said arterial insufficiency.

26. An NO donor when used in a method for the prevention or treatment of an arterial insufficiency, wherein the NO donor is administered in an intermitting manner in an amount effective for the induction of arteriogenesis, wherein the NO donor is a short acting NO donor and wherein the NO donor is administered lingually, sublingually, inhalatively, buccally, transmucosally or oromucosally.

27. The NO donor when used according to claim 26, with the features as defined in any of claims 2 to 25.

28. A method of the suppression of negative effects associated with any treatment of an arterial insufficiency which is anti-anteriogenic or inhibiting arteriogenesis, comprising administering to a subject subjected to said treatment an NO donor in an amount and manner effective for the induction of arteriogenesis, wherein the NO donor is a short acting NO donor and wherein the NO donor is administered lingually, sublingually, inhalatively, buccally, transmucosally or oromucosally.

29. An NO donor when used in a method of the suppression of negative effects associated with any treatment of an arterial insufficiency which is anti-anteriogenic or inhibiting arteriogenesis, wherein the NO donor is administered to a subject subjected to said treatment in an amount and manner effective for the induction of arteriogenesis, wherein the NO donor is a short acting NO donor and wherein the NO donor is administered lingually, sublingually, inhalatively, buccally, transmucosally or oromucosally.

30. The NO donor when used according to claim 29 or the method of claim 28, with the features as defined in any of claims 2 to 25.

31. A method of promoting collateral circulation comprising the step of exposing a subject to a therapeutically effective amount of an NO donor, wherein the therapeutically effective amount of the NO donor promotes arteriogenesis sufficient to augment collateral circulation in a physiological or pathological condition, wherein the NO donor is a short acting NO donor and wherein the NO donor is administered lingually, sublingually, inhalatively, buccally, transmucosally or oromucosally.

32. The method of claim 31, wherein the subject suffers from an arterial insufficiency.

33. The method of claim 32, with the features as defined in any of claims 2 to 25.