Treatment of systolic dysfunction

Abstract

To provide methods for treating systolic dysfunction such as heart failure with reduced ejection fraction.SOLUTION: A method of treating systolic dysfunction in a patient in need thereof comprises orally administering a compound I to the patient at a total daily amount of 25-350 mg, wherein the compound I is (R)-4-(1-((3-(difluoromethyl)-1-methyl-1H-pyrazol-4-yl)sulfonyl)-1-fluoroethyl)-N-(isoxazol-3-yl)piperidine-1-carboxamide or a pharmaceutically acceptable salt thereof, having the structural formula (I).SELECTED DRAWING: None

Description

Technical Field

[0001] (Cross - Reference to Related Applications) This application claims priority from U.S. Provisional Patent Application No. 62 / 849,936, filed on May 19, 2019, and U.S. Provisional Patent Application No. 62 / 852,739, filed on May 24, 2019. The disclosures of these priority applications are hereby incorporated by reference in their entirety into this specification.

Background Art

[0002] Heart failure (HF) is a globally prevalent disease that affects approximately 26 million people worldwide. HF is the most rapidly increasing cardiovascular condition globally, with significant morbidity, mortality, and cost burden on the healthcare system (Ponikowski et al., ESC Heart Fail. (2014) 1(1):4 - 25; Savarese and Lund, Card Fail Rev. (2017) 3(1):7 - 11). HF is the most common cause of hospitalization in patients older than 65 years (Ponikowski, supra; Savarese and Lund, supra; and Shah et al., J Am Coll Cardiol. (2017) 70(20):2476 - 86). The 5 - year mortality rate after HF hospitalization is approximately 42%, comparable to that of many cancers (Benjamin et al., Circulation (2019) 139:e56 - e528).

[0003] Heart failure is a clinical syndrome in which a patient's heart cannot provide sufficient blood flow to the body to meet the body's metabolic demands. In some patients with heart failure, the heart has difficulty pumping enough blood to support the body's other organs. Other patients have sclerosis and stiffness of the myocardium itself, which can block or reduce blood flow to the heart. As a result of these two conditions, blood circulation to the body becomes insufficient and the lungs become congested. Heart failure can occur on the right or left side of the heart, or on both sides simultaneously. Heart failure can be in either an acute (short-term) or chronic (long-term) state. Heart failure may be called congestive heart failure when blood accumulates in various parts of the body. Symptoms of heart failure include, but are not limited to, excessive fatigue, sudden weight gain, loss of appetite, persistent cough, arrhythmia, chest discomfort, angina, heart palpitations, edema (e.g., swelling of the lungs, arms, legs, ankles, face, hands or abdomen), shortness of breath (dyspnea), neck vein distension and decreased exercise tolerance or exercise capacity.

[0004] The volume of blood pumped by the heart is generally determined by (a) myocardial contraction (i.e., how well the heart compresses or its systolic function), and (b) cardiac chamber filling (i.e., how well the heart relaxes and fills with blood or its diastolic function). Ejection fraction is used to evaluate the pumping function of the heart; this represents the percentage of blood pumped from the left ventricle (the main cardiac chamber for pumping) per heartbeat. A normal or maintained ejection fraction is 50 percent or greater. When the systolic function of the heart is impaired and the heart shows a substantial decrease in ejection fraction (i.e., an ejection fraction <50%), this condition is known as heart failure with reduced ejection fraction (HFrEF). HFrEF with an ejection fraction ≤40% is classical HFrEF, while HFrEF with an ejection fraction of 41 - 49% is classified as heart failure with mid-range ejection fraction (HFmrEF) in the 2013 American College of Cardiology Foundation / American Heart Association guidelines (Yancy et al., Circulation (2013) 128:e240-327) and the 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure (Hollenberg et al., J Am Coll Cardiol (2019) 74:1966-2011). Weak myocardium (low ejection fraction) has many causes including ischemia / infarction, hypertension, heart valve defects, genetic mutations, infection, and toxin / drug exposure.

[0005] Diastolic dysfunction can contribute to the prevalence in patients with HFrEF. When the heart pumps normally but is too stiff to fill properly, this condition is known as heart failure with preserved ejection fraction (HFpEF). Historically, HFpEF has been called diastolic heart failure; however, recent studies suggest a more complex and heterogeneous pathophysiology. HFpEF patients show only slight or mild abnormalities in systolic performance, which are more extreme during exercise. Abnormalities in ventricular dilation and systolic reserve, chronotropic response impairment, ventricular tissue stiffness, atrial dysfunction, pulmonary hypertension, vasodilatory impairment, and endothelial dysfunction are all related. These abnormalities are often only recognized when stress is placed on the cardiovascular system.

[0006] In the United States alone, there are approximately 2.6 million patients with HFrEF, which corresponds to about 40% of the HF population in the United States (Bloom et al., Nat Rev Dis Primers. (2017) 3:17058). HFrEF can be caused by ischemic factors (mainly due to coronary artery disease) or non-ischemic factors (due to diseases of the myocardium other than coronary arteries). Coronary artery disease (coronary heart disease) is a disease with stenosis of the coronary artery pathway; in severe cases, stenosis can lead to insufficient blood supply to the myocardium and potentially myocardial cell death (infarction). Non-ischemic HFrEF may be referred to as dilated cardiomyopathy (DCM). Regardless of the terminology, dilated (enlarged) cardiomyopathy can be present in both non-ischemic and ischemic HFrEF patients. In the following specification, DCM refers to non-ischemic HFrEF. DCM can be clinically diagnosed as "idiopathic" DCM when it is genetic DCM or when no specific cause can be found. Mutations in more than 30 genes, including sarcomere genes, destabilize various myocardial proteins, resulting in the DCM phenotype. Some of the genetic associations with DCM are discussed in Hershberger, et al., Nature Reviews (2013) 10(9):531-47 and Rosenbaum et al., Nat Rev Cardiol. (2020) 17(5):286-97.

[0007] Modern medical therapies for HFrEF focus on counteracting the effects of neurohormonal activation with modulators of the renin-angiotensin-aldosterone system, β-adrenergic blockers, diuretics, and modulators of the vasoactive peptide BNP (brain natriuretic peptide). These drugs partially mitigate inappropriate outcomes and improve clinical outcomes, but none address the causal pathways underlying myocardial dysfunction.

[0008] Some inotropic agents are used in medical practice to increase myocardial contractility by increasing intracellular calcium or cyclic adenosine monophosphate, mechanisms that increase myocardial oxygen demand. Long-term trials of these agents have demonstrated an increased mortality rate due to arrhythmia and ischemia, so their use is limited to short-term or end-of-life treatment aimed at palliating symptoms in patients with refractory or end-stage heart failure. However, these agents suggest the clinical benefits of drugs that improve hemodynamics and symptoms and increase contractility without arrhythmia or ischemic impairment. SUMMARY OF THE INVENTION PROBLEMS TO BE SOLVED BY THE INVENTION

[0009] Currently, there is no approved therapy for treating heart failure by directly targeting the contractile apparatus. There remains a strong need for new, safe, and effective treatments for systolic heart failure. MEANS FOR SOLVING THE PROBLEMS

[0010] This specification describes a method for treating systolic insufficiency in a patient in need of treatment, comprising orally administering Compound I to the patient in a total daily dose of 10 to 350 mg, wherein Compound I has the structural formula (I)

Chemical formula

[0011] In some embodiments, the patient has: heart failure (including, but not limited to, heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), congestive heart failure, and dilated heart failure (with reduced systolic reserve)); cardiomyopathy (including, but not limited to, ischemic cardiomyopathy, dilated cardiomyopathy, post-infarct cardiomyopathy, viral cardiomyopathy, toxic cardiomyopathy (including, but not limited to, after anthracycline-based cancer therapy), metabolic cardiomyopathy (including, but not limited to, those associated with enzyme replacement therapy), infiltrative cardiomyopathy (including, but not limited to, amyloidosis), and diabetic cardiomyopathy); cardiogenic shock; a condition that would benefit from inotropic support after cardiac surgery (e.g., ventricular dysfunction resulting from cardiovascular bypass surgery); myocarditis (including, but not limited to, viral myocarditis); atherosclerosis; secondary aldosteronism; myocardial infarction; valvular disease (including, but not limited to, mitral regurgitation and aortic stenosis); systemic hypertension; pulmonary hypertension (i.e., pulmonary arterial hypertension); adverse vascular remodeling; pulmonary edema; and respiratory failure. In certain embodiments, the syndrome or disorder can be chronic and / or stable.

[0012] In some embodiments, the patient has been diagnosed with heart failure and any one of NYHA classes II-IV. In certain embodiments, the patient has symptomatic heart failure. In some embodiments, the patient has acute heart failure.

[0013] This specification also provides a method for treating heart failure with reduced ejection fraction (HFrEF) in patients in need thereof, the method comprising orally administering Compound I to the patient at a total daily dose of 10 to 350 mg. Patients with HFrEF exhibit an ejection fraction of <50%. HFrEF with an ejection fraction ≦40% is classical HFrEF, while HFrEF with an ejection fraction of 41 - 49% is classified as heart failure with mid-range ejection fraction (HFmrEF). In some embodiments, the patient with HFrEF also exhibits mitral regurgitation. In some embodiments, HFrEF is ischemic HFrEF. In some embodiments, HFrEF is dilated cardiomyopathy (DCM); optionally, the patient has a genetic predisposition to DCM or hereditary DCM, which can be caused by pathogenic or pathogenic-like variants of genes related to cardiac function, including but not limited to mutations in MYH7 or titin.

[0014] In some embodiments, the patient has a left ventricular ejection fraction (LVEF) of less than 50%. In certain embodiments, the patient has an LVEF of less than 40%, less than 35%, less than 30%, 15 - 35%, 15 - 40% (e.g., 15 - 39%), 15 - 49%, 20 - 45%, 40 - 49%, or 41 - 49%.

[0015] In some embodiments, the patient has a high NT-proBNP level. In certain embodiments, the patient has an NT-proBNP level of 400 pg / mL or higher.

[0016] In some embodiments, the patient does not have any one, or combination, of the following: a) Currently having angina; b) Diagnosis of recent (<90 days) acute coronary syndrome; c) Coronary revascularization within the past 3 months (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]); and d) Uncorrected severe valvular disease In some embodiments, as a result of the treatment, the following:

[0017] In some embodiments, as a result of the treatment, the following: a) Reduction in the risk of cardiovascular death; b) Reduction in the risk of cardiovascular-related hospitalizations (including, but not limited to, exacerbation of heart failure); c) Improvement in exercise capacity; d) Improvement in the NYHA classification of the patient; e) Delay in clinical deterioration; and f) Reduction in the severity of cardiovascular-related symptoms, indicating any one or combination thereof. In some embodiments, an improvement in exercise capacity is an improvement of >3 mL / kg / min in peak VO2 (pVO2). In some embodiments, the treatment results include an improvement in the NYHA classification (e.g., improvement from class IV to class III, from class III to class II, from class II to class I, or from class I to no heart failure), and an improvement in exercise capacity measured by pVO2 (e.g., the improvement in pVO2 is an improvement of >1.5 mL / kg / min) or an improvement in activity measured by accelerometry. Cardiovascular-related symptoms can include, for example, excessive fatigue, sudden weight gain, loss of appetite, persistent cough, arrhythmia, chest discomfort, angina, palpitations of the heart, edema (e.g., swelling of the lungs, arms, legs, ankles, face, hands or abdomen), shortness of breath (dyspnea), jugular venous distension, decreased exercise tolerance or exercise capacity, and any combination thereof.

[0018] In some embodiments, as a result of the treatment method, the risk of cardiovascular death and hospitalization for heart failure is reduced in patients with chronic heart failure (NYHA classes II-IV) and reduced ejection fraction.

[0019] In some embodiments, the treatment method reduces the risk of hospitalization for exacerbation of heart failure in patients with stable symptomatic chronic HFrEF.

[0020] In some embodiments, the treatment improves survival, prolongs the time to hospitalization for heart failure, and improves the functional status reported by the patient in patients with systolic heart failure.

[0021] In some embodiments, the treatment method increases the left ventricular ejection fraction and improves the symptoms of heart failure, as demonstrated by the improvement in exercise capacity and the reduction in heart failure-related hospitalizations and emergency treatments.

[0022] Any combination of the above treatment results is also intended.

[0023] In some embodiments, the patient is administered Compound I at 10 - 175 mg BID (e.g., 10 - 75 mg or 25 - 75 mg BID, e.g., 10, 25, 50 or 75 mg BID), 25 - 325 mg QD (e.g., 75 - 125 mg QD) or 25 - 350 mg QD. In some embodiments, Compound I is administered to the patient with food or within about 2 hours, 1 hour or 30 minutes of a meal. In some embodiments, Compound I is provided in a solid form with an average particle size of 15 μm or more or 15 - 25 μm. In some embodiments, the QD dose is 200 mg or more.

[0024] In some embodiments, the patient is administered Compound I in a solid form with an average particle size of less than 10 μm. In certain embodiments, the average particle size is 1 - 10 μm or 1 - 5 μm in diameter.

[0025] In some embodiments, the patient a) is administered a loading dose of 50 - 250 mg; b) about 10 - 12 hours after administration, continues with a BID or QD maintenance dose regimen. In certain embodiments, the BID maintenance dose regimen is 10 - 75 mg BID (e.g., 10, 25, 50 or 75 mg BID) and the QD maintenance dose regimen is 75 - 125 mg QD.

[0026] In some embodiments, the dose of Compound I administered to the patient results in a plasma concentration of Compound I of 1000 - 8000 ng / mL, e.g., <2000 ng / mL, 1000 - 4000 ng / mL, >2000 ng / mL, 2000 - 3500 ng / mL, 2000 - 4000 ng / mL, or >3500 ng / mL.

[0027] In some embodiments, the patient has right ventricular heart failure. In certain embodiments, the patient has pulmonary hypertension (i.e., pulmonary arterial hypertension). In some embodiments, the patient has left ventricular heart failure.

[0028] In some embodiments, as a result of administering Compound I to the patient, left ventricular function is improved in the patient. Parameters of the improvement in left ventricular function can be selected from, for example, an increase in ejection fraction, an increase in fractional shortening of the left ventricular internal diameter, an increase in stroke volume, an increase in cardiac output, an improvement in longitudinal or circumferential strain, and / or an improvement in cardiac contractility indicated by a decrease in end-systolic and / or end-diastolic diameter of the left ventricle.

[0029] In some embodiments, as a result of administering Compound I to the patient, there is an improvement in the patient's functionality or exercise capacity, as measured by peak VO2 (e.g., an improvement of > 1.5 or 3 mL / kg / min), a reduction in dyspnea, an improvement in NYHA classification, and / or an improvement in a six-minute walk test or activity (determined by accelerometry). In certain embodiments, as a result of administering Compound I to the patient, there is an improvement in NYHA classification and an improvement in exercise capacity (e.g., > 1.5 mL / kg / min).

[0030] In some embodiments, the patient is further administered an additional agent to improve the patient's cardiovascular condition. The additional agent can be, for example, a beta blocker, a diuretic (e.g., a loop diuretic), an angiotensin-converting enzyme (ACE) inhibitor, an aldosterone antagonist, a calcium channel blocker, an angiotensin II receptor blocker, a mineralocorticoid receptor antagonist (e.g., spironolactone), an ARNI, a RAAS inhibitor, an sGC activator or modulator (e.g., vericiguat), or an antiarrhythmic agent. In certain embodiments, the additional agent is an ARNI such as sacubitril / valsartan or an SGLT2 inhibitor (e.g., dapagliflozin).

[0031] In some embodiments, if the patient experiences headache, the patient is further administered an analgesic.

[0032] In some embodiments, the patient is monitored for NT-proBNP levels, atrial tachycardia, ventricular tachycardia or palpitations.

[0033] This specification also provides a kit comprising Compound I in the form of tablets or capsules for oral administration for treating systolic dysfunction (e.g., HFrEF) in a patient in need of treatment, each tablet or capsule may contain 5, 25, 50, 75 or 100 mg of Compound I, and the kit may include a loading dose of tablets or capsules. In some embodiments, the kit is for treating a patient according to the methods described herein.

[0034] This specification also provides Compound I for use in treating systolic dysfunction (e.g., HFrEF) in a patient in need of treatment, wherein Compound I is orally administered in a total daily dose of 25 - 350 mg. In some embodiments, the treatment is according to the methods described herein.

[0035] This specification also provides the use of Compound I in the manufacture of a medicament for treating systolic dysfunction (e.g., HFrEF) in a patient in need of treatment, wherein the medicament is for orally administering Compound I in a total daily dose of 25 - 350 mg. In some embodiments, the medicament is for treating a patient according to the methods described herein.

[0036] This specification also provides a composition comprising Compound I for treating systolic dysfunction (e.g., HFrEF) in a patient in need of treatment, wherein the composition is for orally administering Compound I in a total daily dose of 25 - 350 mg. In some embodiments, the composition is for treating a patient according to the methods described herein.

[0037] This specification also relates to a pharmaceutical composition in the form of tablets or capsules for oral administration, comprising Compound I for treating systolic insufficiency (e.g., HFrEF) in patients in need of treatment, wherein each tablet or capsule contains 5, 25, 50, 75 or 100 mg of Compound I. In some embodiments, the pharmaceutical composition is for treating a patient according to the methods described herein.

[0038] Other features, objects, and advantages of the invention will be apparent from the detailed description set forth below. It should be understood, however, that the detailed description and the specific examples, while indicating embodiments and aspects of the invention, are given by way of illustration only and not limitation. Various changes and modifications within the scope of the invention will be apparent to those skilled in the art from the detailed description. BRIEF DESCRIPTION OF THE DRAWINGS

[0039]

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[0040] This specification provides methods, uses, and compositions for the treatment of systolic dysfunction (impairment of cardiac systolic function; e.g., systolic heart failure) by Compound I, a small molecule compound. The treatment regimen has been found to be safe and effective, resulting in a significant improvement in the cardiac function of the treated patients.

[0041] **Pharmaceutical Composition** The pharmaceutical composition used in the treatment regimen of the present application contains Compound I as the active pharmaceutical ingredient (API). Compound I has the following chemical structural formula (I): **[Chemical formula]** Refers to the compound (R)-4-(1-((3-(difluoromethyl)-1-methyl-1H-pyrazol-4-yl)sulfonyl)-1-fluoroethyl)-N-(isoxazol-3-yl)piperidine-1-carboxamide or a pharmaceutically acceptable salt thereof. Compound I is a myosin modulator that increases cross-bridge formation (measured as phosphate release) between cardiac actin and myosin. The formation and dissociation of cross-bridges are important steps in each cycle of cardiac contraction. Compound I binds reversibly to myosin and increases the number of myosin / actin cross-bridges that can participate in the strong binding state of the chemomechanical cycle, thereby increasing contraction. However, since Compound I does not inhibit cross-bridge dissociation (measured as ADP release), it has no effect on other states of the contraction cycle and also has no effect on calcium homeostasis.

[0042] The pharmaceutical compositions used herein can be provided in oral dosage forms (e.g., solutions, suspensions, emulsions, capsules or tablets). In some embodiments, the particles of Compound I are compressed into tablets containing 5, 25, 50, 75, 100, 125, 150, 175 or 200 mg of Compound I each. In some embodiments, the particles of Compound I can be suspended in a suitable liquid such as water, a suspension vehicle and / or a flavored syrup for oral administration.

[0043] The API solids of Compound I in tablets or oral suspensions can have an average particle size, for example, of 1 to 100, 1 to 50, or 15 to 50 μm (e.g., 1 to 5, 5 to 10, 1 to 10, 10 to 20, or 15 to 25 μm in diameter). In some embodiments, Compound I has an average particle size of 30 or less, 25, 20, 15, 10, or 5 μm in diameter. In some embodiments, the API solids of Compound I have an average particle size of 15 to 25 μm as the D50 particle size distribution (PSD) (i.e., 50% of the particles have a particle size of 15 to 25 μm in diameter). In certain embodiments, Compound I has an average particle size of 10 μm or less, e.g., a D50 of 10 μm or less (NMT). In certain embodiments, Compound I has an average particle size of 5 μm or less, e.g., a D50 of 5 μm or less. The particle size analysis is typically performed using a PSD method suitable for determining the particle size of primary particles. Ultrasonic waves may be used to reduce aggregation. The primary particle size should not be altered by the PSD technique itself used to measure the particle size. In some of the examples herein, the PSD technique was performed using a Malvern Mastersizer 2000 with or without using ultrasonic waves.

[0044] In addition to Compound I API, the pharmaceutical compositions of the present application may also contain pharmaceutically acceptable excipients. For example, the tablets used in the present application may contain fillers, diluents, binders, fluidizing agents, lubricants, and disintegrants. In some embodiments, the tablets of Compound I contain one or more of microcrystalline cellulose, lactose monohydrate, hypromellose, croscarmellose sodium, and magnesium stearate. The tablets may be coated to make them easier to take.

[0045] Treatment regimen The safe and effective treatment regimen of the present invention was developed based on the results of clinical trials of Compound I in patients with systolic dysfunction. The treatment regimen of Compound I increases myocardial contractility in patients in need thereof, while having no serious side effects on the ventricular dilation function of the patients (i.e., maintaining relaxation). Patients may receive the treatment regimen of the present invention for at least one month, at least six months, at least twelve months, at least one year or longer, or until the patient no longer requires treatment.

[0046] In some embodiments of the treatment regimen of the present invention, Compound I is orally administered at a total daily dose of 10 to 700 mg (e.g., 25 to 700 or 50 to 150 mg). For example, Compound I can be orally administered at a total daily dose of 10, 25, 50, 75, 100, 125, 150, 175, 200, 250, 300, 350, 400, 450, 500, 525, 550, 600 or 700 mg. As another example, Compound I may be orally administered at a total daily dose of 50, 100 or 150 mg. In one embodiment, Compound I is orally administered at 10 to 175 mg (e.g., 25 to 175 mg) BID (twice a day) (e.g., 10, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170 or 175 mg). For example, Compound I can be orally administered at 10 to 75 or 25 to 75 mg (e.g., 10 mg, 25 mg, 50 mg or 75 mg) BID (twice a day). In another embodiment, Compound I is orally administered at 25 to 350 mg QD (once a day) (e.g., 25 to 325, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, 200, 205, 210, 215, 220, 225, 230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345 or 350 mg). The interval between BID administrations is, if possible, for example, about 10 to 12 hours apart (e.g., in the morning and afternoon). As used herein, administration of Compound I or a pharmaceutical composition containing Compound I (the "Compound I pharmaceutical") includes self-administration by the patient himself (e.g., oral ingestion by the patient). The Compound I pharmaceutical can be taken by the patient at a predetermined dose with or without food. The pharmaceutical can optionally be taken with a beverage such as water or milk (e.g., whole milk).

[0047] In some embodiments, the patient is administered a loading dose of Compound I with or without food, and then approximately 10 to 12 hours later, a maintenance dose (e.g., the doses described above) with or without food, and then continues with the recommended once-daily maintenance dose regimen for male / female patients with or without food (e.g., in the case of a BID dosing regimen, in the morning and in the afternoon). In one embodiment, for a target steady-state average concentration of 2000 ng / mL to 4000 ng / mL (e.g., 2000 ng / mL to 3500 ng / mL), the patient is administered, with or without food, (a) a loading dose that is 2 times the maintenance dose as a BID dosing regimen or 1.5 times the maintenance dose as a QD dosing regimen, and (b) approximately 10 to 12 hours later, initiates either the recommended once-daily BID or QD dosing regimen applicable. In another further embodiment, a loading dose of 50 to 250 mg of Compound I is administered in the morning with or without food, and then a BID maintenance dose dosing regimen of 10 to 75 mg (e.g., 25 to 75 mg) BID or a QD maintenance dose dosing regimen of 75 to 125 mg QD is initiated in the evening. A regimen comprising a twice-daily maintenance dose of 10 to 175 mg (e.g., 25 to 175 mg) with or without food may include, for example, (i) the step of administering to the patient a loading dose that is 2 times the maintenance dose with or without food, and (ii) the step of initiating a dosing regimen with a twice-daily maintenance dose with or without food approximately 10 to 12 hours later. A regimen comprising a once-daily maintenance dose of 25 to 350 mg with or without food may include, for example, (i) the step of administering to the patient a loading dose that is 1.5 times the maintenance dose with or without food; and (ii) the step of initiating a dosing regimen with a once-daily maintenance dose with or without food approximately 10 to 12 hours later.

[0048] In some embodiments, the absorption of Compound I by a patient can be promoted by a meal. In some embodiments, the meal is high in fat content; that is, 50% or more of the calories of the meal are derived from fat. In some embodiments, when Compound I is taken with a meal (e.g., a high-fat meal), the average particle size of the Compound I API is 15 μm or more in diameter, and the QD dose is about 200 mg or more. In some embodiments, the total daily dose of Compound I required by a patient can be a lower dose than the total daily dose required by the patient when the pharmaceutical is taken in a postprandial state (e.g., within about 2 hours of a meal, within about 1.5 hours of a meal, or within about 1 hour of a meal) compared to when the pharmaceutical is taken in a non-postprandial state. "Within about X hours of a meal" means about X hours before or after the start of meal intake.

[0049] In certain embodiments, the tablets or capsules of Compound I are orally administered to the patient twice a day, with a meal or within about 2 hours of a meal (e.g., within about 1.5 hours of a meal, or within about 1 hour of a meal); in related embodiments, the pharmaceutical of Compound I contains particles of Compound I having an average particle size with a D50 of 15 - 25 μm in diameter. In some embodiments, the patient takes the pharmaceutical once a day, with a meal (e.g., 400 - 1000 calories, 25 - 50% fat). In some embodiments, the patient takes the pharmaceutical twice a day, with a meal (e.g., 400 - 1000 calories, 25 - 50% fat per meal). For example, the patient may take the pharmaceutical at breakfast and dinner.

[0050] In some embodiments, the API of Compound I in the pharmaceutical is micronized and has an average particle size of 10 μm or less (D50 of 10 μm or less (NMT)) or 5 μm or less (D50 of 5 μm or less). In certain embodiments, the particles of Compound I in the pharmaceutical have a D50 of 5 or 10 μm or less, and the pharmaceutical can be orally administered to the patient twice a day (e.g., every 10 - 12 hours, or in the morning and afternoon), with a meal or without a meal.

[0051] The dosage used for a particular patient can be adjusted based on the patient's condition and / or the patient-specific PK profile. Current studies have shown that the tested drug dosages and exposures were safe and well tolerated. In some embodiments, Compound I can be administered to a patient at a dosage that results in a plasma concentration of 1000 - 8000 ng / mL (e.g., 1000 - 2000 ng / mL, 1500 - 3000 ng / mL, 2000 - 3000 ng / mL, 3000 - 4000 ng / mL, 3000 - 4500 ng / mL, 3500 - 5000 ng / mL, 4000 - 5000 ng / mL, 5000 - 6000 ng / mL, 6000 - 7000 ng / mL, or 7000 - 8000 ng / mL). In some embodiments, Compound I can be administered to a patient at a dosage that results in a plasma concentration of <2000, 2000 - 3500, or > 3500 ng / mL (e.g., 2000 - 3500 ng / mL). In some embodiments, Compound I can be administered to a patient at an amount that results in a plasma concentration of Compound I of 1500, 2000, 2250, 2500, 2750, 3000, 3500, 4000, 5000, 6000, or 7000 ng / mL or more. In some embodiments, the target plasma concentration of Compound I is 1000 - 4000 ng / mL. In certain embodiments, the target plasma concentration of Compound I is 1500 - 3000 ng / mL. In specific embodiments, the target plasma concentration of Compound I is 2000 - 3500 ng / mL. The plasma concentration of Compound I can be determined by any method known in the art, such as, for example, high performance liquid chromatography (HPLC), liquid chromatography-mass spectrometry (LC-MS such as high speed LC-MS), gas chromatography (GC), or any combination thereof.

[0052] Well-known pharmacokinetic (PK) parameters can be used to determine or adjust the dosing of Compound I in a patient. The following are examples of PK parameters.

Table 1

[0053] In some embodiments, the treatment regimens described herein include monitoring the patient for adverse events such as headache, fatigue, chest discomfort, bradycardia, heart block, atrial tachycardia, ventricular tachycardia, palpitations, increased NT-proBNP levels, increased troponin levels, and myocardial ischemia. If a severe adverse event occurs, the patient may be treated for the adverse event and / or the treatment with Compound I may be discontinued.

[0054] Combination therapy This specification provides both Compound I monotherapy and combination therapy. In combination therapy, the regimens of Compound I herein are used in combination with an additional treatment regimen for the patient's cardiac condition, such as guideline-based medical therapy (GDMT), also referred to as standard of care (SOC) treatment, or another treatment useful for treating related diseases or disorders. The additional therapeutic agent may be administered by the routes and amounts generally used for said agent or in lesser amounts, and may be administered simultaneously with, sequentially with, or together with Compound I.

[0055] In certain embodiments, Compound I is administered first in SOC for systolic insufficiency conditions such as systolic heart failure. In some embodiments, the patient, in addition to the pharmaceutical of Compound I, receives another therapeutic agent, such as a beta-blocker (e.g., bisoprolol, carvedilol, carvedilol CR, or metoprolol succinate sustained release (metoprolol CR / XL)), an angiotensin-converting enzyme (ACE) inhibitor (e.g., captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril, and trandolapril), an angiotensin receptor antagonist (e.g., an angiotensin II receptor blocker), an angiotensin receptor neprilysin inhibitor (ARNI) (e.g., sacubitril / valsartan), a mineralocorticoid receptor antagonist (e.g., an aldosterone inhibitor, e.g., a potassium-sparing diuretic, e.g., eplerenone, spironolactone, or canrenone), a cholesterol-lowering drug (e.g., a statin), I fA channel inhibitor (e.g., ivabradine), a neutral endopeptidase inhibitor (NEPi), a positive inotropic agent (e.g., digoxin, pimobendan, a beta-adrenergic receptor agonist, e.g., dobutamine, a phosphodiesterase (PDE)-3 inhibitor, e.g., milrinone or a calcium sensitizer, e.g., levosimendan), potassium or magnesium, a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor, a vasodilator (e.g., a calcium channel blocker, a phosphodiesterase inhibitor, an endothelin receptor antagonist, a renin inhibitor, a smooth muscle myosin modulator, isosorbide dinitrate and / or hydralazine), a diuretic (e.g., a loop diuretic, e.g., furosemide), a RAAS inhibitor, a soluble guanylate cyclase (sGC) activator or modulator (e.g., vericiguat), an SGLT2 inhibitor (e.g., dapagliflozin), an antiarrhythmic agent (e.g., amiodarone, dofetilide and sotalol), an anticoagulant (e.g., warfarin, apixaban, rivaroxaban and dabigatran), an antithrombotic agent, an antiplatelet agent or any combination thereof is administered.

[0056] Suitable ARBs include, for example, A-81988, A-81282, BIBR-363, BIBS39, BIBS-222, BMS-180560, BMS-184698, candesartan, candesartan cilexetil, CGP-38560A, CGP-48369, CGP-49870, CGP-63170, CI-996, CV-11194, DA-2079, DE-3489, DMP-811, DuP-167, DuP-532, E-4177, elsartan, EMD-66397, EMD-73495, eprosartan, EXP-063, EXP-929, EXP-3174, EXP-6155, EXP-6803, EXP-7711, EXP-9270, FK-739, GA-0056, HN-65021, HR-720, ICI-D6888, ICI-D7155, ICI-D8731, irbesartan, isotelin, KRI-1177, KT3-671, KW-3433, losartan, LR-B / 057, L-158809, L-158978, L-159282, L-159874, L-161177, L-162154, L-163017, L-159689, L-162234, L-162441, L-163007, LR-B / 081, LR-B087, LY-285434, LY-302289, LY-315995, LY-235656, LY-301875, ME-3221, olmesartan, PD-150304, PD-123177, PD-123319, RG-13647, RWJ-38970, RWJ-46458, saralasin acetate, S-8307, S-8308, SC-52458, supprasartan, saralasin, sarmesin, SL-91.0102, tasosartan, telmisartan, UP-269-6, U-96849, U-97018, UP-275-22, WAY-126227, WK-1492.2K, YM-31472, WK-1360, X-6803, valsartan, XH-148, XR-510, YM-358, ZD-6888, ZD-7155, ZD-8731 and zolasartan.

[0057] In certain embodiments, the additional therapeutic agent can be an ARNI, such as sacubitril / valsartan (Entresto®), or a sodium-glucose cotransporter 2 inhibitor (SGLT2i), such as empagliflozin (e.g., Jardiance®), dapagliflozin (e.g., Farxiga®), canagliflozin (e.g., Invokana®), or sotagliflozin.

[0058] In some embodiments, a patient being treated for heart failure with Compound I is also being treated with an ARNI, a beta blocker, and / or an MRA.

[0059] In some embodiments, a patient being treated for heart failure with Compound I is also being treated with an ACE inhibitor and / or an ARB and / or an ARNI, in combination with a beta blocker and, optionally, an aldosterone antagonist. In certain embodiments, the ACE inhibitor, ARB, ARNI, beta blocker, and / or aldosterone antagonist is selected from those described herein in any combination.

[0060] If any side effects occur, the patient may be treated for the side effects. For example, a patient experiencing headache due to treatment with Compound I can be treated with analgesics such as ibuprofen and acetaminophen. A patient experiencing arrhythmia due to treatment with Compound I can be treated with antiarrhythmic drugs such as amiodarone, dofetilide, sotalol, flecainide, ibutilide, lidocaine, procainamide, propafenone, quinidine, and tocainide.

[0061] Patient population The treatment regimen of the present invention can be used to treat patients showing systolic dysfunction such as systolic heart failure. Systolic heart failure can be characterized by a decrease in ejection fraction (e.g., about 50%, 45%, 40% or less than 35% including LVEF of 15 - 35%, 15 - 40% (e.g., 15 - 39%), 20 - 45%, 40 - 49% and 41 - 49%) and / or an increase in end-diastolic pressure and volume of the ventricle. In some embodiments, systolic heart failure is HFrEF (<50%, e.g., ≤40% or <40% ejection fraction).

[0062] The treatment regimen herein may include the step of selecting a patient having a type of systolic heart failure as described herein. In some embodiments, the patient is 18 years of age or older. In some embodiments, the patient has not been treated for HF. In some embodiments, the patient has been previously treated for HF, such as systolic heart failure, by, for example, standard care for HF, or is being treated but not showing sufficient improvement. In some embodiments, the patient has been treated with Entresto® and / or omecamtiv but continues to show signs of systolic heart failure. In some embodiments, the patient has been treated with an ACE inhibitor or ARB or ARNI in combination with a beta blocker and optionally an aldosterone antagonist (these drugs can be selected, for example, from those described herein), but continues to show signs of systolic heart failure. The patient may have chronic HF, i.e., have systolic heart failure for more than 4 weeks while receiving standard care for HF; or the patient may have recent HF, i.e., have systolic heart failure for less than 4 weeks while receiving standard care for HF. When a patient experiences sudden-onset symptoms leading to hospitalization (e.g., symptoms of congestion such as shortness of breath) or a rapid worsening of existing symptoms of heart failure, this is often referred to as acute HF.

[0063] The patient may experience systolic heart failure of the left ventricle, right ventricle, or both ventricles. In some embodiments, the patient has right ventricular heart failure. In further related embodiments, the patient has pulmonary hypertension (i.e., pulmonary arterial hypertension).

[0064] In some embodiments, the patient has HFrEF (i.e., <50% ejection fraction). HFrEF with an ejection fraction of ≤40% is classical HFrEF, while HFrEF with an ejection fraction of 41 - 49% is classified as heart failure with mid-range ejection fraction (HFmrEF). The patient may have a reduced left ventricular ejection fraction (LVEF) of less than 50%, such as less than 45%, 40%, 35%, 30%, 25%, 20%, or 15%. In certain embodiments, the patient has an LVEF of ≤45% (e.g., 20 - 45%), ≤40% (e.g., 15 - 40%, 25 - 40%, 15 - 39%, or 25 - 39%), or ≤35% (e.g., 15 - 35%). HFrEF can be of ischemic or non-ischemic origin and can be chronic or acute.

[0065] In certain embodiments, the patient exhibits high-risk HFrEF (or "high-risk HFrEF" as used herein). A high-risk HFrEF patient is a patient having an LVEF of 35% or less. In some embodiments, the patient is further diagnosed as NYHA class III or IV. In some embodiments, the patient has an LVEF of 30% or less. In some embodiments, HFrEF patients are those in which the patient's male / female meets the following criteria: (i) Frequent hospitalization for worsening heart failure (WHF); (ii) Hospitalization for WHF despite taking high-dose diuretics; (iii) <30% or <35% LVEF; (iv) NT-proBNP, a high N-terminal pro-brain natriuretic peptide (e.g., ≥400, 600, 800, 1000, or 1200 pg / mL); (v) Severe symptom burden (NYHA class III - IV, below); (vi) low functional or motor ability (e.g., determined by peak VO2, 6-minute walk test and / or activity (e.g., determined by accelerometry)); (vii) dependence on inotropic agents; and (viii) inability to be treated with HF medications for which an optimal dose is recommended (guideline-based) (e.g., RAAS inhibitors such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), ARNIs (e.g., Entresto®), beta blockers, mineralocorticoid receptor antagonists (MRAs), etc.) If one or more of the above are satisfied, it is further regarded as "high risk".

[0066] In a further embodiment, the HFrEF patient is such that the male / female of the patient meets the following criteria: (a) NYHA class III-IV; (b) LVEF ≤ 35%; and (c) high NT-proBNP of ≥ 400, 600, 800, 1000 or 1200 pg / mL If satisfied, it is regarded as "high risk".

[0067] In some embodiments, the patient has stable HF, e.g., stable HFrEF. As used herein, a patient who is "stable" with respect to a disease refers to a patient who has that disease and has not experienced a worsening of symptoms that could lead to hospitalization or an emergency visit. For example, a patient with stable HF may have systolic dysfunction, but the symptoms of the dysfunction can be controlled or stabilized using available treatments.

[0068] In some embodiments, the patient has stable HFrEF (e.g., moderately severe stable chronic HFrEF) defined by one or both of the following: (i) LVEF < 50%; and (ii) long-term dosing for the treatment of heart failure according to current guidelines, which may include at least one of beta blockers, ACE inhibitors, ARBs, and ARNIs. In certain embodiments, the patient is: (a) Currently, being angina pectoris; (b) Recent (<90 days) acute coronary syndrome; (c) Coronary revascularization within the past three months (percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)); and (d) Uncorrected severe valvular disease None of these or any combination thereof is shown. In some embodiments, the patient further has an LVEF of less than 40% or 35%, 15% - 40% or 15% - 35%. In some embodiments, the patient further has an NT-proBNP level of 400 pg / mL or higher.

[0069] In some embodiments, the treatment regimen of the present invention can be used to treat patients presenting with dilated cardiomyopathy (DCM) (e.g., idiopathic DCM or genetic DCM). In certain embodiments, the patient has an enlarged left or right ventricle, an ejection fraction of less than 50% (e.g., ≤40%), and no known coronary disease. The DCM may be genetic DCM, and the patient has at least one genetic mutation in a sarcomeric contraction or structural protein known to cause DCM, such as myosin heavy chain, titin, or troponin T (see, e.g., Hershberger et al., Nat Rev Cardiol. (2013) 10(9):531-47 and Rosenbaum, supra). In some embodiments, the genetic mutation is present in a gene selected from ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CRYAB, CSRP3, DES, DMD, DSG2, EYA4, GATAD1, LAMA4, LDB3, LMNA, MYBPC3, MYH6, MYH7, MYPN, PLN, PSEN1, PSEN2, RBM20, SCN5A, SGCD, TAZ, TCAP, TMPO, TNNC1, TNNI3, TNNT2, TPM1, TTN, VCL, or any combination thereof. For example, the genetic mutation is present in a gene selected from ACTC1, DES, MYH6, MYH7, TNNC1, TNNI3, TNNT2, TTN, or any combination thereof. In a particular embodiment, the genetic mutation is in the MYH7 gene. In certain embodiments, a patient having DCM (e.g., genetic DCM that can be caused by a mutation in the MYH7 gene) also has HFrEF and can exhibit one or more (e.g., all) of the following: - having an LVEF of -15 to 40%; - having at least mild left ventricular hypertrophy (LVEDD ≥ 3.1 cm / m in males 2 and ≥ 3.2 cm / m in females 2 ); and - For the treatment of heart failure, the patient has been medicated over a long period of time with, for example, a β-blocker, an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), an angiotensin receptor neprilysin inhibitor (ARNI), or any combination thereof. In certain embodiments, the patient does not exhibit one or more (e.g., all) of the following: - QTcF interval > 480 milliseconds; - When the genetic mutation is in the MYH7 gene, a known pathogenic mutation in another gene associated with DCM; - HFrEF that is considered to be mainly caused by ischemic heart disease, chronic valvular disease, or another condition; - Recent (<90 days) acute coronary syndrome or angina; - Coronary revascularization within the last 90 days (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]); - Recent (<90 days) heart failure, use of IV diuretics or chronic IV inotropes, or hospitalization for other cardiovascular events (e.g., cerebrovascular accident); and - Known severe aortic valve stenosis.

[0070] In some embodiments, patients treated with the treatment regimens described herein have New York Heart Association (NYHA) class I, II, III, or IV heart failure as defined in Table 2 below.

Table 2

[0071] Additional or concomitant conditions treatable by the treatment regimen of the present invention include, but are not limited to, HFpEF, chronic congestive heart failure, cardiogenic shock and inotropic support after cardiac surgery, hypertrophic cardiomyopathy, ischemic cardiomyopathy or post-infarct cardiomyopathy, viral cardiomyopathy or myocarditis, toxic cardiomyopathy (e.g., after anthracycline-based cancer treatment), metabolic cardiomyopathy (in relation to enzyme replacement therapy), diabetic cardiomyopathy, dilated heart failure (with reduced systolic reserve), atherosclerosis, secondary aldosteronism, and ventricular dysfunction resulting from cardiovascular bypass surgery. The treatment regimen of the present invention can also promote beneficial ventricular reverse remodeling and / or treat detrimental vascular remodeling of left ventricular dysfunction caused by ischemia or volume or pressure overload, such as myocardial infarction, chronic mitral regurgitation, chronic aortic stenosis or chronic systemic hypertension. By reducing the left ventricular filling pressure, the treatment regimen can improve the symptoms of dyspnea and reduce the risk of pulmonary edema and respiratory failure. The treatment regimen can reduce the severity of chronic ischemic conditions associated with DCM, thereby reducing the risk of sudden cardiac death (SCD) or its equivalent and / or the need for potentially toxic antiarrhythmic drugs in patients with an implantable cardioverter defibrillator (frequent and / or repeated ICD discharges). The treatment regimen can be useful in reducing or eliminating the need for concomitant medications with their attendant potential toxicity, drug interactions and / or side effects. The treatment regimen can reduce interstitial myocardial fibrosis and / or delay, arrest or reverse the progression of left ventricular stiffness and dysfunction.

[0072] In some embodiments, patients having heart failure (e.g., HFrEF) with mitral regurgitation can be treated using the treatment regimen of the present invention. In some embodiments, the mitral regurgitation is chronic. In some embodiments, the mitral regurgitation is acute.

[0073] In some embodiments, patients with systolic dysfunction may exhibit increased blood biomarker levels. Circulating natriuretic peptide (NP) levels are added as an incremental prognostic value to the standard clinical risk stratification algorithm for both ambulatory and hospitalized heart failure patients because NT-proBNP levels rise above 1000 pg / m and the risk of death and recurrent heart failure hospitalization steadily increases. See, e.g., Desai et al., Circulation (2013) 127:509-516. For example, brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP) is present at high levels in the blood of individuals with systolic dysfunction. The normal level of BNP is less than 100 pg / mL. The higher the numerical value, the higher the probability of the presence of heart failure, and the higher the likelihood that the heart failure is more severe. The normal levels of NT-proBNP based on the reference range of the Cleveland Clinic are (1) less than 125 pg / mL for patients aged 0 to 74 years and (2) less than 450 pg / mL for patients aged 75 to 99 years.

[0074] Accordingly, in some embodiments, patients treated with the treatment regimen of the present invention may exhibit elevated serum blood levels of brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP). In some embodiments, the serum blood level of BNP in a patient is considered high when the concentration is at least 35, 45, 55, 65, 75, 85, 95, 100, 105 or 115 pg / mL (e.g., at least 35 or 85 pg / mL). In some embodiments, the serum blood level of NT-proBNP in a patient is considered high when the concentration is at least 95, 105, 115, 125, 135, 145, 155, 165 or 175 pg / mL (e.g., at least 125 or 155 pg / mL).

[0075] In some embodiments, the patient is a patient whose male / female has the following conditions: (i) Acute coronary syndrome (ACS); (ii) Stroke; (iii) Major heart surgery / intervention; (iv) Coronary intervention; (v) Heart valve repair / implantation within 3 months; (vi) Uncorrected valvular or clinically significant congenital heart disease; (vii) Mechanical support for ≤7 days; (viii) LVAD or transplantation scheduled within 60 days; and (ix) IV inotropic dependence If having one or more of the above, patients may not (temporarily or permanently) receive treatment with Compound I or may have treatment discontinued.

[0076] Treatment outcome As used herein, the terms "treat", "treating" and "treatment" refer to disappearance of symptoms; alleviation; reduction; making a pathology, injury, condition or symptom more tolerable to the patient; reducing the frequency or duration of a pathology, injury, condition or symptom; or in some situations, preventing the onset of a pathology, injury, condition or symptom, etc., and indicate an indicator of success of treatment or improvement regarding a pathology, injury, condition or symptom related to systolic dysfunction including any objective or subjective parameters. Treatment or improvement may be based on any objective or subjective parameter including, for example, the results of a physical examination. For example, treatment of systolic heart failure includes, but is not limited to, improvement of the patient's cardiac function and alleviation of symptoms of systolic heart failure (especially during exercise including walking or climbing stairs). Symptoms of systolic heart failure include excessive fatigue, sudden weight gain, loss of appetite, persistent cough, arrhythmia, chest discomfort, angina, palpitations of the heart, edema (e.g., swelling of the lungs, limbs, face or abdomen), dyspnea, elevation of the jugular veins and reduction of exercise tolerance and / or exercise capacity.

[0077] Pharmacodynamic (PD) parameters that can be used for measuring the cardiac function of a patient are shown in Table 3 below. These PD parameters are routinely used by clinicians and can be measured by standard transthoracic echocardiogram as exemplified in the following examples.

Table 3

[0078] The treatment regimen of the present invention can result in one or more improvements in left ventricular function selected from an increase in stroke volume, an increase in cardiac output, an increase in ejection fraction, an increase in left ventricular internal diameter shortening rate, an improvement in longitudinal strain, an improvement in circumferential strain and / or a decrease in left ventricular end-systolic or end-diastolic diameter, and an improvement in myocardial contractility as indicated by a mild to moderate (e.g., moderate) prolongation of systolic ejection time (SET). As a result of the regimen, an improvement in symptoms determined by an improvement in NYHA class and / or a reduction in dyspnea was obtained. As a result of the regimen, the patient's function and / or exercise capacity can be improved as determined by peak VO2, 6-minute walk test and / or activity (determined by accelerometry). In certain embodiments, the treatment regimen of the present invention results in the following in patients with systolic heart failure: (i) One or more improvements in LVEF, LVFS, LVSV, CO, GLS, GCS, E / A and E / e' (e.g., measured by ECHO); (ii) A decrease in the grade of NYHA classification; (iii) A decrease in NT-proBNP levels; (iv) An improvement in exercise capacity determined by peak VO2, 6-minute walk test and / or activity (determined by accelerometry); and (v) An improvement in the results reported by the patient of one or more of these.

[0079] In some embodiments, as a result of the treatment regimen of the present invention, the following: (i) An increase in LVEF and / or LVSV; (ii) A decrease in LVGLS, LVESV and / or LVEDV; and (iii) Minimal effect on diastolic function and relaxation (determined by direct measurement of E, e', E / e', E / A, IVRT, etc.) One or more of these are brought about.

[0080] The treatment regimen of the present invention reduces the risk of cardiovascular death and / or hospitalization / emergency department visits for HF in patients with systolic heart failure, patients with HFrEF (e.g., stable or high-risk HFrEF), patients with chronic heart failure (NYHA class I-IV (e.g., class II-IV) and reduced ejection fraction), or any other patient population as described above. "Reduction in the risk" of an event means that the time to the event increases by at least 10% (e.g., at least 15%, 20%, 30%, 40%, 50%, 60%, 70%, 80% or 90%).

[0081] In some embodiments, the treatment regimen of the present invention improves or prevents one or more symptoms of heart failure, including, for example, dyspnea (e.g., orthopnea, paroxysmal nocturnal dyspnea), cough, cardiac asthma, wheezing, hypotension, dizziness, confusion, cold extremities at rest, pulmonary congestion, chronic venous congestion, ankle swelling, peripheral or generalized edema, nocturia, ascites, hepatomegaly, jaundice, coagulation disorders, fatigue, exercise intolerance, jugular venous distension, pulmonary rales, peripheral edema, pulmonary vascular redistribution, interstitial edema, pleural effusion, fluid retention, or any combination thereof. Other symptoms and signs of HF that may be improved by the treatment regimen of the present invention include, for example, compensatory mechanisms characterized by increased sympathetic tone, peripheral vasoconstriction, activation of various neurohormonal pathways, sodium retention, arterial and venous constriction, neuroendocrine activation, and increased heart rate.

[0082] In some embodiments, as a result of the treatment regimen of the present invention, there is a reduction in the risk of cardiovascular death (e.g., 10, 15, 20, 25, 30, 35, 40, 45 or 50%) and / or a decrease in the frequency and / or duration of hospitalizations for the cardiovascular system.

[0083] In some embodiments, the treatment regimen of the present invention reduces emergency department interventions for heart failure.

[0084] Advantages of the treatment regimen of the present invention include that the treatment is (i) Relaxation (e.g., an increase of up to moderate systolic ejection time and no discernible effect on diastolic function), with minimal impact on calcium homeostasis or troponin levels (e.g., up to mild elevation of troponin); (ii) Does not impair ADP release; (iii) Does not change cardiac phase distribution; (iv) Has up to moderate effect on SET; (v) Does not cause drug-related myocardial ischemia (determined by cardiac biomarkers such as clinical signs, ECG, troponin, creatine kinase - muscle / brain (CK-MB), cardiac imaging, and coronary angiogram); (vi) Does not cause drug-related atrial or ventricular arrhythmias; (vii) Does not cause drug-induced liver injury as measured by alanine aminotransferase or aspartate aminotransferase, bilirubin; and (viii) Also does not result in abnormalities in the patient's urine, serum, blood, systolic blood pressure, diastolic blood pressure, pulse, body temperature, blood oxygen saturation, or electrocardiogram (ECG) measurements are features.

[0085] Diastolic dysfunction is also associated with systolic heart failure and can contribute to morbidity. By maintaining relaxation, the treatment regimen of the present invention can provide enhanced clinical benefits superior to treatment with myocardial myosin activators that do not maintain relaxation.

[0086] Products and kits The present invention also provides a kit comprising a product, e.g., one or more dosages of a pharmaceutical of Compound I and instructions for a patient (e.g., for treatment according to the methods described herein). The product may also contain additional therapeutic agents in the case of combination therapy. Tablets or capsules of Compound I may be thermoformed from a resin and then packaged with backing paper, e.g., manufactured at 5 to 20 tablets per blister card; each tablet or capsule can contain 5, 25, 50, 75 or 100 mg of Compound I, and such blister cards may or may not further include loading dose tablets or capsules. This specification also includes a method for manufacturing the said product.

[0087] Unless otherwise defined herein, scientific and technical terms used in connection with this specification shall have the meanings commonly understood by those of ordinary skill in the art. Exemplary methods and materials are described below, but methods and materials similar or equivalent to those described herein can also be used in the practice or testing of the present invention. In case of conflict, the specification, including definitions, will control. In general, the specialized terms and techniques used in connection with cardiology, medicine, pharmaceuticals and pharmaceutical chemistry, and cell biology described herein are well known and commonly used in the art. Enzyme reactions and purification techniques are performed as commonly practiced in the art or as described herein, according to the manufacturer's specifications. Further, unless the context requires otherwise, singular terms shall include the plural and plural terms shall include the singular. Throughout this specification and the embodiments, the words "have" and "comprise," or variations such as "has," "having," "comprises," or "comprising," are intended to indicate the inclusion of the recited integer or group of integers, but not the exclusion of any integer or group of integers. It should also be noted that the term "or" is generally used in the sense of "and / or" unless the context clearly states otherwise. As used herein, the term "about" refers to a numerical range of plus or minus 10%, 5%, or 1% from the numerical value stated within the context of a particular use. Further, the headings presented herein are for convenience only and do not define or explain the scope or meaning of the claimed embodiments.

[0088] All publications and other references mentioned in this specification are incorporated by reference in their entirety. Although some of these publications are cited herein, this citation does not admit that any of these publications form part of the common general knowledge in the art.

[0089] To better understand the present invention, the following examples are provided. These examples are for illustrative purposes only and should not be construed as limiting the scope of the present invention in any way.

Example

[0090] Example 1: Randomized, placebo-controlled trial of the safety, tolerability, preliminary pharmacokinetics, and pharmacodynamics of single escalating oral doses of Compound I in healthy adult volunteers This example describes the first-in-human administration trial of Compound I. Based on its mechanism of action, Compound I may provide a targeted treatment for patients with DCM caused by genetic or non-genetic mechanisms. The study was a randomized, double-blind, placebo-controlled, sequential group, single escalating (oral) dose study in healthy subjects aged 18 - 55 years. Eight dosing cohorts, each containing 8 healthy subjects, were enrolled. Within each cohort, subjects were randomized to Compound I:placebo in a 6:2 ratio.

[0091] Materials and Methods Study Design Subjects stayed at the clinical site for up to 4 nights and 5 days from Day - 1 (the day before dosing) to Day 4 and took a single dose of Compound I or placebo on Day 1. ECG telemetry was initiated 1 hour before dosing and continued until 48 hours (Day 3) after dosing. Subjects with a pre-dose resting heart rate HR ≥ 80 beats per minute were considered ineligible and not treated. If the half-life of Compound I was significantly longer than the predicted 12 hours, the SRC could modify the study schedule to house the subjects at a PK sampling or PD measurement facility for a period corresponding to approximately 5 times the mean terminal half-life, but within 5 days after dosing. Subjects returned for safety follow-up 7 (±1) days after dosing.

[0092] Since this was a first-in-human trial, a sentinel dosing plan was used at each dose level. The first two subjects in each cohort were dosed as sentinels. One of the sentinel subjects was randomized to receive Compound I and the other was randomized to receive placebo. After reviewing the safety data of the sentinel subjects over 24 hours, one or two subjects per day might be enrolled. On each study day, until the principal investigator or sub-investigator reviewed the safety data, vital signs, and ECG obtained from the first subject through the interval encompassing the predicted peak plasma concentration of Compound I (predicted t max ) hours after dosing, the second subject was not dosed. Prior to dosing each day, the principal investigator or sub-investigator reviewed the safety data of previous subjects, including vital signs, safety test values, hs-troponin I concentration, and ECG.

[0093] To assess the pharmacodynamic effect, serial echocardiograms were performed. The sonographers used in the study completed echo protocol training and submitted study cases for evaluation to the evaluation laboratory (core lab) for assessment. The TTE core lab certified that the sonographers could perform TTE at a satisfactory level to obtain the required protocol data.

[0094] The dose escalation stopping criteria included subjects in whom the mean of the maximum SET within the cohort increased by >50 milliseconds at any point in time, or in whom the SET was prolonged by ≥75 milliseconds in any two consecutive TTE evaluations. These criteria were selected to prevent an increase in SET that could lead to myocardial ischemia in the subject. The dose escalation stopping criteria also included findings of a >20% baseline-corrected group mean relative increase in at least two of the measurements of LV contractility: LVOT-VTI, LVFS, LVEF, or LVSV in any two consecutive TTE evaluations in subjects receiving Compound I. A placebo control evaluation may be considered. For this comparison, subjects receiving placebo may be pooled across cohorts.

[0095] After each dose administration, SRC conducted a blinded review of the data, but the data may not be blinded if there are safety concerns or if it is considered that a change in PD is observable. The dosing information for two subjects is not blinded as described below.

[0096] Dosing procedure All randomized study subjects received either Compound I or the corresponding placebo as a single oral dose after at least a 6-hour fasting period. The free base form of Compound I is a crystalline synthetic molecule with a molecular weight of 435.4 g / mol. Compound I is non-hygroscopic and substantially insoluble in aqueous media.

[0097] Compound I is provided as a powder for oral suspension. The placebo is provided as calcium carbonate powder. Both treatments were orally dosed as suspensions. The suspensions were prepared by mixing Ora-Plus® Suspending Vehicle (Perrigo) and cherry syrup flavored vehicle (Humco) 50% to 50%. Approximately 100 mL of water was then added to the suspension. The suspensions were prepared within 14 days of dosing and dosed in accordance with the stability data of the suspension. The suspensions were prepared to have a volume of 20 mL, the same volume as that administered to subjects taking Compound I.

[0098] Dose escalation The starting dose was set at 3 mg using the FDA guidelines for a 60 kg human. After the first dose, the dose escalation was C maxIt was approximately three-fold until the dose predicted to show 300 ng / mL or the dose at which initial PD activity was observed was reached. Subsequently, the dose escalation was two-fold. If the PK data did not match the predicted PK profile, the dose escalation step was set to two-fold or less. The dose escalation was terminated using the stopping criteria defined by prediction at the time of acquisition and was terminated based on two observations. The first was that the exposure did not increase dose-dependently. It was revealed that the exposure at doses exceeding 350 mg was almost the same as the exposure after administration of 350 mg. Also, since the dose escalation was determined to stop at the time when initial PD activity was observed after administration of 350 mg and 525 mg (both with almost the same exposure), an initial evaluation of the dose-response effect was possible based on PD parameters that could distinguish from the placebo group.

[0099] Each subject was administered the dose of the cohort in which they were enrolled. The cohorts were enrolled sequentially and each cohort was administered escalating doses of Compound I. The doses administered were 3 mg, 10 mg, 25 mg, 50 mg, 100 mg, 175 mg, 350 mg, and 525 mg, respectively.

[0100] PK, PD, and Safety Assessments PK and PD data were collected as described herein (the exposures (C max and both AUCs) after administration of single doses of 350 mg and 525 mg were very similar, so data from both groups were combined for some PD analyses). Safety was evaluated throughout the study. Safety evaluations included medical history, physical examination, SET by TTE, 12-lead ECG and ECG telemetry, vital signs, serum hs-troponin I concentration, AEs, and safety study results. The SET determined by photoelectric plethysmography was an exploratory safety parameter. Safety study data including hematology, chemistry, and vital signs were evaluated over time for the safety analysis population using descriptive statistics. The change from baseline at each time point after baseline was evaluated.

[0101] Medical History and Physical Examination The full medical history was recorded at the screening visit, and the record included an assessment (past or current) of the following: general, head and neck, eyes, ears, nose, throat, chest / respiratory, heart / cardiovascular, gastrointestinal / liver, gynecological / urological, musculoskeletal / limbs, skin, neurological / psychiatric, endocrine / metabolic, blood / lymph, allergy / drug sensitivity, past surgeries, substance abuse or any other disease or disorder, as well as participation in clinical trials (investigational drug and / or device or other treatment). The medical history was updated on day -1 if necessary.

[0102] On screening and day -1, a full physical examination including neurological examination (gross motor function and deep tendon reflexes) and an assessment of the following: general appearance, skin, head and neck, mouth, lymph nodes, thyroid, abdomen, musculoskeletal, cardiovascular, neurological and respiratory systems was performed. At all other time points, a simplified physical examination (lungs, heart, abdomen and other systems relevant to the symptoms) was performed.

[0103] Systolic ejection time The SET determined by TTE was evaluated using summary statistics. Findings and changes from baseline were summarized by treatment at each time point, and the maximum change from baseline was determined for each subject. Additionally, categorical analysis was performed on the number of subjects with a change >50 milliseconds from baseline and the number of subjects with a change >75 milliseconds from baseline in 1 or any 2 consecutive TTE evaluations. The relationship between the plasma concentration of Compound I and SET was investigated. An analysis of the change in SET corrected for placebo from baseline was also performed.

[0104] During each TTE procedure, for several minutes, an experimental non-invasive optical biosensor similar to FitBit was fixed to the subject's wrist to collect data on the arterial waveform morphology by photoplethysmography.

[0105] Electrocardiogram After allowing the subject to rest in the supine position for at least 10 minutes, a 12-lead electrocardiogram (ECG) was obtained. If the subject showed any symptoms or signs suggesting troponin I abnormality or myocardial ischemia, additional ECGs were obtained. Digital 12-lead ECG evaluations were performed at screening, before dosing on Day 1 (within 2 hours of dosing), and at various predetermined time points, after 10 minutes of rest. Each time an ECG was completed, a 10-second ECG rhythm strip was also taken and retained in the subject's source documentation.

[0106] The principal investigator of the clinical trial judged all ECG interpretations as either (a) normal, (b) clinically insignificant abnormalities, or (c) clinically significant abnormalities. If clinically significant, the abnormalities were recorded. Additionally, before each treatment period, the principal investigator of the clinical trial or a sub-investigator reviewed the available ECGs from the previous treatment period and looked for symptoms of ischemia. If there were symptoms of ischemia, dosing was withheld until the possible ischemic changes were fully understood.

[0107] The ECGs were sent to the ECG core laboratory and the recordings were read in a blinded manner. An automated methodology was used together with a manual review by a cardiologist. The following intervals were measured: RR, PR, QRS, and QT. The heart rate (HR) was calculated as 60 / (RR × 1000) (where RR is expressed in milliseconds), rounded, and taken as the nearest integer. Correction of Heart Rate

[0108] The corrected QT interval (QTc) was calculated using the manually reviewed QT value based on the standard procedure of the core ECG laboratory. Each individual ECG QT value was corrected for HR. The measured QT data were corrected for HR using the following formula / method (where QT, RR, and QTc are expressed in milliseconds):

Number

[0109] ECG numerical variable HR, PR, QRS, and QTcF were summarized using descriptive statistics. The changes from baseline of these ECG parameters at each time point were tabulated for each subject. For each measurement at each time point, the change from baseline was summarized using descriptive statistics. The relationship between the HR / ECG interval and time was plotted.

[0110] Categorical analysis The number and percentage of subjects with post-dose QTcF values > 450 milliseconds, > 480 milliseconds, and > 500 milliseconds were tabulated for all subjects. Subjects with a QTc value > 500 milliseconds were listed along with the corresponding baseline value, ΔQTcF, and baseline and treatment HR. The number and percentage of subjects showing a ΔQTcF increase > 30 milliseconds and > 60 milliseconds were tabulated.

[0111] Morphological findings The new ECG morphology for each subject with no ECG at baseline was summarized across all observation time points. The number and percentage of subjects with T-wave morphological changes and / or the occurrence or worsening of morphological abnormalities from baseline or the occurrence of abnormal U waves indicating such were reported.

[0112] Concentration-QTc analysis Concentration-QTc regression analysis based on data collected from the ECG recordings after administration of the investigational drug and the drug plasma concentration values for each subject at each corresponding time point was performed.

[0113] Adverse events Abnormal findings clinically determined to be important by the principal investigator of the clinical trial were recorded as adverse events (AE). AEs were mapped to System Organ Class (SOC) and Preferred Term (PT) by organ using the Medical Dictionary for Regulatory Activities (MedDRA). AEs were monitored during the trial, and data were analyzed regarding overall incidence, severity, and potential relationship with the investigational drug. Blind AEs were presented to the SRC for consideration after each cohort to assist the SRC in determining subsequent cohort dosing or whether to end the trial. The review committee unblinded the data for one subject who showed arrhythmic TEAE and for a second subject who had a mildly elevated hs-troponin I level (16 ng / mL, normal range 0 - 15 ng / mL) 6 hours after dosing and intermittent premature ventricular contractions (PVC) on remote monitoring >48 hours after dosing. No ECG changes or signs were noted.

[0114] For the final analysis, all subjects who received placebo were pooled into one group, and AEs were grouped by treatment group. AEs that developed at or after the first dose of the investigational drug, or that developed before the first dose of the investigational drug and had increased severity at or after the first dose of the investigational drug, or AEs after treatment initiation (defined as AEs starting from informed consent by the duration of the trial) were summarized for the safety analysis population by MedDRA SOC and PT, as well as by severity and relationship to treatment. Severe and life-threatening AEs, SAEs, and AEs leading to trial discontinuation, if any, were presented in the data listings.

[0115] Serum hs-troponin I concentration Serum samples were taken for hs-troponin I. Analysis was performed using the Abbott Architect STAT high-sensitivity troponin I assay. When a subject showed symptoms or signs suggestive of myocardial ischemia, additional serial hs-troponin I samples were obtained as appropriate to evaluate the possibility of ischemia.

[0116] Drug concentration measurement The concentrations of Compound I in human plasma and urine were quantified by high performance liquid chromatography with tandem mass spectrometric detection (LC MS / MS) (Biological Sample Analysis Test Report Alturas AD17-726). Plasma samples were extracted by protein precipitation with acetonitrile containing internal standard MYK-5654. The calibration curve was linear in the concentration range of 0.500 - 1000 ng / mL, and the lower limit of quantitation (LLOQ) was 0.500 ng / mL.

[0117] The PK population included all subjects who received Compound I. Blood samples were collected for PK evaluation. The actual timing of the samples could be changed and / or up to two additional samples were sometimes requested by the SRC after reviewing data from previous cohorts. It was important that PK sampling was performed as close as possible (±10%) to the scheduled time. Both blood and urine samples were used for PK evaluation.

[0118] Furthermore, for subjects given placebo, a single plasma sample around the predicted t max was evaluated to confirm the absence of circulating Compound I. Plasma concentration data for Compound I were summarized using descriptive statistics including mean, standard deviation (SD), median, minimum and maximum values, and percent coefficient of variation. Other PK parameters included, but were not limited to, C max , t max , AUC, t 1 / 2 and MRT. Furthermore, the apparent terminal half-life was calculated. The dose proportionality of AUC and C max was explored.

[0119] Test Results Plasma Concentration of Compound I The plasma concentration of Compound I over time is summarized in Table 4 and Figure 1.

Table 4

[0120] From the results, it was demonstrated that eight cohorts (48 subjects) were safely administered single doses up to 525 mg. Compound I was detectable at 48 hours post - administration in all subjects, and at 72 hours and 7 days post - administration in selected doses and subjects. On day 7, Compound I was detectable in 24 subjects. Plasma samples from placebo subjects were analyzed at all time points; none of the plasma samples from 16 placebo subjects had detectable levels of Compound I.

[0121] The 525 mg group showed slightly lower mean plasma concentrations compared to the 350 mg group up to the 24 - hour time point; however, the 525 mg group had the highest plasma concentrations at 48 hours and 72 hours. On day 7, no detectable Compound I was present in the plasma from the 3 mg Compound I group, while in all other groups, the drug was still detectable. On day 7, the mean (SD) plasma concentration (ng / mL) of Compound I was extremely low compared to C max and was consistent with the concentration predicted based on an approximately 15 - hour terminal t 1 / 2 .

[0122] Plasma pharmacokinetic parameters of Compound I The plasma PK parameters of Compound I are summarized in Table 5. After oral administration of a single - dose escalating suspension of Compound I, peak plasma concentrations occurred at approximately 4.5 - 5 hours across eight dosing groups. C max , AUC 0-t and AUC 0-∞ increased as the dose of Compound I increased up to 350 mg. The mean (SD) C max was 2820 (478) ng / mL for the 350 mg dose group. The exposure after oral administration of the 525 mg dose was similar to the exposure after 350 mg.

Table 5 - 1

Table 5 - 2

[0123] The dose proportionality was evaluated using a power model. The plots of C max and AUC inf against dose are shown in Figures 2 and 3, respectively. There appeared to be a generally direct relationship, although the doses up to the 350 mg dose group slightly missed dose proportionality (slope = 0.8888, 95% CI interval = 0.8358 - 0.9417), and the 525 mg dose did not meet dose proportional response. Therefore, an additional sensitivity analysis was performed to evaluate the dose proportionality with the AUC data excluding the 525 mg group; this analysis showed that the dose response was approximately proportional to the dose up to 350 mg of Compound I, and the slope was less than 1.0 (slope = 0.9347; 95% CI interval = 0.8813 - 0.9882).

[0124] The disappearance of Compound I appeared to be monoexponential (Figure 1). The terminal t 1 / 2 was about 11 - 16 hours across the dose groups (Table 5). The apparent oral clearance (CL / F) and volume of distribution (Vz / F) were estimated to be about 3.1 - 8.1 L / h and 58 - 166 L, respectively, for doses in the range of 3 mg to 525 mg. CL / F and Vz / F at higher doses both increased as the dose increased, suggesting a decrease in the absorption rate at the highest dose; this could be the result of, for example, limited solubility, slow dissolution rate, and / or excretion of undissolved Compound I molecules into the feces. Here, Compound I was determined to be a compound of Biopharmaceutics Classification System (BCS) class II. The decrease in exposure in the 525 mg cohort is thought to be the result of slow dissolution due to insufficient solubility of Compound I and incomplete absorption of undissolved drug molecules in the gastrointestinal tract. The mean apparent clearance and volume of distribution were about 4.2 L / h and 78 L, respectively, for doses up to 175 mg.

[0125] The collection period (Ae) 48 hours after administration 0-48h) The cumulative urinary excretion of unchanged Compound I over [time period] increased as the dose increased from 3 to 525 mg. Approximately 12% (range 3.9% - 23.9%) of the dose of Compound I was recovered as unchanged Compound I in urine collections from 0 to 48 hours after oral administration at doses of 3 - 175 mg. At doses of 350 and 525 mg, the percentages of the dose recovered in urine collections from 0 to 48 hours were approximately 6.0% and 8.6%, respectively. The decrease in urinary excretion of Compound I in urine from 0 to 48 hours at higher doses is thought to be caused by (1) lower absorption rates at higher doses due to limited solubility; and (2) incomplete urinary excretion within 48 hours after dosing.

[0126] Renal clearance appeared to be dose-dependent, with an average value of approximately 0.570 L / hour (or 9.5 mL / min) (range individually 0.177 - 1.400 L / hour). The variability in renal clearance (CL r ) among subjects was moderate, with a coefficient of variation percentage (%CV) in the range of 32% - 80% across the 8 cohorts. Renal clearance was lowest, with a mean (SD) value of 0.333 (0.135) L / hour in the 350 mg dose group and highest, with a mean (SD) value of 0.800 (0.319) L / hour in the 525 mg dose group. The variability in CL r was relatively greater than that of total plasma clearance (CL / F). Renal clearance can be affected by multiple factors, including physiological parameters such as renal blood flow, urine flow, renal function, urine volume, and urine pH. The renal excretion and renal clearance of Compound I are thought to be affected by the variability of these parameters among individuals.

[0127] Renal clearance varies depending on glomerular filtration rate, tubular active secretion, and tubular reabsorption. The extent to which a drug is filtered depends on molecular size, protein binding, ionization, polarity, and renal function. When CL r depends only on filtration, CL r = GFR * f u (where f u is the unbound fraction of the drug and GFR is the glomerular filtration rate). The renal clearance observed in this study was GFR * f u(For example, for a subject with normal renal function, GFR = 100 mL / min, and for the free fraction of Compound I in plasma, f u was close to 14 - 18%), suggesting that glomerular filtration was the major mechanism for renal elimination of Compound I.

[0128] PK Conclusion The above data indicate that the exposure (C max and AUC 0-∞ ) of Compound I increased almost linearly and was close to a dose - proportional pattern up to the 350 mg dose. At the 525 mg dose, no further increase in exposure relative to the 350 mg dose was observed; this was thought to be due to a decrease in absorption rate (lower oral bioavailability). Since the exposures in the 350 and 525 mg cohorts were similar, the data from the two groups were combined to obtain a mean C max of 2585 ng / mL and an AUC 0-∞ of 74359 ng×h / mL, a mean t max of 5 hours, and an approximate mean terminal t 1 / 2 of 15 hours. The ranges for the combined 350 and 525 mg groups were 3 - 6 hours for t max and 11 - 22 hours for t 1 / 2 . The data also show T max and t 1 / 2This indicates that it was dose-independent. At doses up to 175 mg, the apparent total oral clearance (CL / F) was on average 4.2 L / h, suggesting that Compound I is a low-clearance drug, and the apparent volume of distribution (Vz / F) was 78 L, indicating extensive tissue distribution. All values were higher in the 525 mg dose group, supporting the hypothesis of decreased oral bioavailability at doses > 350 mg. The data also show that approximately 12% of the administered dose was excreted in the urine as unchanged Compound I at doses < 350 mg. This value was lower in the two highest dose groups, which is likely due to incomplete recovery of all the drug excreted in the 48-hour urine collection and decreased oral bioavailability at the highest doses. Renal clearance was mainly dose-independent (average 0.57 L / h). The renal clearance of Compound I was close to the product of the glomerular filtration rate and the unbound fraction of Compound I in plasma, indicating that glomerular filtration is the main mechanism of renal excretion.

[0129] Pharmacodynamic analysis As a result of the predicted pharmacological effect of Compound I, an increase in contractility was observed, which could lead to an increase in LVFS, LVEF, LVSV, LVOT-VTI and a decrease in left ventricular end-systolic diameter (LVESD) and left ventricular end-systolic volume (LVESV). Variability within and between subjects as predicted was demonstrated by echocardiographic parameters, as reflected in the serial measurements obtained in the placebo group; thus, the changes in TTE measurements were thought to reflect mainly the within- and between-subject variability of TTE measurements rather than being in agreement with the pharmacology of Compound I and were in the opposite direction. Some variability was also reflected in the recordings of subjects taking placebo.

[0130] Ejection time in systole When healthy volunteers were administered high doses of omecamtiv mecarbil, a myosin modulator, it resulted in ischemia that was considered to be correlated with a significant increase in SET. Therefore, SET was determined as a safety parameter. After administration at higher dose levels (175 mg to 525 mg) using Compound I, the increase in SET reached its peak at approximately 1.5 to 2 hours. This was before the maximum plasma concentration of Compound I was observed. The maximum mean (SD) increase in SET that was observed was recorded at 19.2 (20.5) milliseconds for the 350 mg Compound I group at 1.5 to 2 hours after administration. The observed mean (SD) increase in SET for the combined dose group of 350 mg and 525 mg of Compound I was 18.0 (19.5) milliseconds at 1.5 to 2 hours after administration. In all groups except for the 3 mg and 10 mg groups, the mean SET change from baseline reached its peak at approximately 1.5 to 2 hours after administration. SET was trending upward at the last measurement (24 hours after administration), and the plasma concentration was significantly lower at C max A transient decrease in SET was mainly observed in the placebo and lower dose groups, and this decrease was probably a reflection of the diurnal variation in the measured values.

[0131] Left ventricular outflow tract - velocity time integral The resting LVOT-VTI showed peak mean absolute changes from baseline at approximately 6 and 12 hours after administration. The maximum LVOT-VTI that was observed was 2.54 (1.78) cm at 6 hours after administration in the 350 mg group. The observed mean (SD) increase in LVOT-VTI for the combined dose group of 350 mg and 525 mg of Compound I was 2.28 (1.43) cm at 6 hours after administration. Most of the values were below baseline 24 hours after administration.

[0132] Left ventricular ejection fraction The mean resting LVEF was measured. There was a time-dependent change in the resting LVEF, and t maxThere was an early peak increase at approximately 6 hours after dosing, which was almost identical. The value returned to near baseline by 24-hour TTE. The maximum mean (SD) increase was 4.65 (1.45)% at 6 hours after dosing in the 525 mg Compound I group and 4.83 (2.65)% at 12 hours after dosing in the 100 mg Compound I group.

[0133] Left ventricular stroke volume Mean resting LVSV was measured. At 6 and 12 hours after dosing, all dose groups demonstrated an increase in stroke volume compared to the measurement at baseline. The maximum mean (SD) increase was 10.848 (9.893) mL at 12 hours after dosing in the 350 mg Compound I group. The mean (SD) increase in LVSV for the combined dose groups of 350 mg and 525 mg of Compound I was 7.623 (7.842) mL at 12 hours after dosing. Most of the groups were at or below baseline at 24 hours after dosing. The mean of the 350 mg group tended towards baseline at 24 hours after dosing.

[0134] Fractional shortening of the left ventricle An increase in LVFS was observed in the higher-dose cohorts, with the maximum increase occurring at 6-hour TTE, which was approximately the time of maximum plasma concentration. At lower doses, there was little change in LVFS over time, and the change from baseline was within the range of measurement variability.

[0135] Left ventricular end-systolic diameter Resting LVESD decreased generally in a dose- and time-dependent manner, except for the 3 mg Compound I group. The maximum mean (SD) decrease observed was -0.455 (0.357) cm at 12 hours after dosing in the 525 mg group. For most of the dose groups, the change remained below baseline until 24 hours after dosing, but the change tended towards the baseline value.

[0136] Left ventricular end-systolic volume At rest, LVESV generally decreased overall in a dose-dependent manner. Since the maximum mean (SD) decrease observed was -9.21 (3.18) mL at 6 hours after dosing in the 525 mg group, it was found that the minimum LVESV (at approximately 6 hours after dosing) was dose-dependent. The observed mean (SD) decrease in LVESV for the combined dose group of 350 mg and 525 mg of Compound I was -6.82 (5.99) mL at 6 hours after dosing. Most of the values remained below baseline at 24 hours after dosing.

[0137] Left ventricular end-diastolic diameter At rest, left ventricular end-diastolic diameter (LVEDD) did not show a dose- or time-dependent trend, but there was a slight decrease in LVEDD from 1.5 - 2 to 12 hours after dosing at doses of 100 mg to 525 mg. The maximum mean (SD) decrease observed was -0.213 (0.221) cm at 12 hours after dosing in the 525 mg Compound I group. The mean (SD) decrease in LVEDD for the combined dose group of 350 mg and 525 mg of Compound I was -0.171 (0.177) cm at 12 hours after dosing. The maximum change from baseline observed at 24 hours after dosing was 0.103 (0.217) cm in the 50 mg group.

[0138] Left ventricular end-diastolic volume At rest, left ventricular end-diastolic volume (LVEDV) generally decreased overall in a dose-dependent trend. Since the maximum mean (SD) decrease observed was -12.5 (6.96) mL at 6 hours after dosing in the 525 mg group, the decrease (at approximately 6 hours after dosing) was considered to be dose-dependent. The mean (SD) decrease in LVEDV for the combined dose group of 350 mg and 525 mg of Compound I was -9.98 (7.83) mL at 6 hours after dosing. Most of the values remained below baseline 24 hours after dosing.

[0139] Left ventricular pre-ejection period The pre-ejection period (PEP) at rest showed the peak average absolute change from baseline at approximately 1.5 - 2 and 8 - 9 hours after administration, with the minimum at about 6 hours after administration. The maximum observed left ventricular pre-ejection period had a positive (above baseline) trend at 24 hours after administration in most dose groups.

[0140] Isovolumetric contraction time The isovolumetric contraction time (IVCT) at rest showed a decrease in the average absolute change from baseline at approximately 6 and 12 hours after administration. The maximum observed IVCT had a positive (towards baseline) trend at 24 hours after administration in most dose groups.

[0141] Isovolumetric relaxation time The isovolumetric relaxation time (IVRT) at rest showed an increase in the average absolute change from baseline at approximately 1.5 - 2 and 8 - 9 hours after administration. The average IVRT had a positive trend at 24 hours after administration.

[0142] Relationship between drug dose, drug concentration and response In most subjects, C max occurred at 4 - 6 hours, so the TTE obtained at 6 hours after administration was considered the best time point to explore the relationship between concentration and pharmacological effect. The TTE obtained at 1.5 and 3 hours after dosing was before C max , and at 9 hours it was after the peak C max . Based on preclinical data, it was considered unlikely that there was a long delay between C max and the peak pharmacological effect. The exposures after administration of the 350 mg and 525 mg doses were similar, so it was decided not only to present the results from these groups separately, but also to combine the data from these groups. By combining the data from the two groups, the number of subjects administered increased from 6 to 12, thus increasing the power to observe a statistically significant change from baseline in the target TTE parameters.

[0143] In the 525 mg dose group, at 6 hours after administration, there were statistically significant differences in SET, LVESD, LVFS (uncorrected p < 0.001), and IVCT (uncorrected p < 0.05) at an average (SD) plasma level of 2215 (543) ng / mL. In the 350 mg dose group, at 6 hours after administration, there were statistically significant differences (uncorrected p < 0.05) in SET, LVESD, LVFS, IVRT, and HR at an average (SD) plasma level of 2660 (515) ng / mL. In the combined 350 mg and 525 mg dose group, at 6 hours after administration, there were statistically significant differences in SET, LVESD, LVFS (uncorrected p < 0.001), LVEF, and IVRT (uncorrected p < 0.05) at an average (SD) plasma level of 2438 (556) ng / mL. Statistically significant differences were seen in several parameters at lower plasma concentrations of Compound I.

[0144] Analysis of the placebo-corrected change from baseline at 6 hours after administration by bin of plasma concentration of Compound I is presented in Table 6 below. [Table 6-1] [Table 6-2]

[0145] As shown in Table 6, there was a significant (uncorrected p < 0.05) effect of Compound I in the range of 1001 - 2000 ng / mL on SET, LVESD, LVFS, and LVESV. At plasma concentrations of Compound I > 2000 ng / mL (median 2425 ng / mL), there were significant effects (LS mean difference ± SE) on SET (25.6 ± 7.71 milliseconds), stroke volume (8.20 ± 3.99 mL), LVESD (-0.306 ± 0.077 cm), LVFS (6.29 ± 1.55%), LVESV (-6.03 ± 1.87 mL), LVEDV (-9.68 ± 2.95 mL), LVEF (3.22 ± 1.48%), left ventricular global longitudinal strain (LVGLS) (-1.78 ± 0.76 milliseconds), left ventricular global circumferential strain (LVGCS) (-2.85 ± 0.99 milliseconds), and IVRT (evaluated by mitral inflow Doppler) (12.0 ± 3.92 milliseconds). Based on the lack of change in E / A ratio and E / e’, there was no significant effect on diastolic function / relaxation; however, IVRT was significantly increased.

[0146] Further analysis of the relationship between plasma concentration of Compound I and PD parameter response was performed using Loess regression (Cleveland and Devlin, Journal of the American Statistical Association 84(403):596 - 610 (1988)). There was an overall increase in SET, LVSV, LVOT - VTI, and LVFS associated with increasing plasma concentration of Compound I.

[0147] PD Conclusion The above PD data indicate that there were apparent dose - and concentration - dependent reversible increases in forward - going blood flow associated with reduced LV volume and in systolic cardiac echo measurements. The PD effect was mainly distinguishable at concentrations ≥ 1000 ng / mL; the peak effect was at t maxObserved at the TTE time point closest to (6 hours), except for the highest dose group where some effect on contractility was maintained, it returned to approximately baseline at 24 hours. These changes were accompanied by only a moderate increase in SET and limited side effects on diastolic function, as evidenced by the lack of consistent changes in E / A and E / e'. For subjects with concentrations exceeding 2000 ng / mL (median concentration 2592 ng / mL), there were statistically significant changes from baseline in the following parameters: a mean absolute increase of 6.3% in LVFS, a mean absolute increase of 3.2% in LVEF, a mean increase of 8.2% in LVSV, a mean increase of 25.7 milliseconds in SET, a mean decrease of 0.31 cm in LVESD, a mean decrease of 0.12 cm in LVEDD, a mean decrease of 6.03 mL in LVESV, a mean decrease of 9.68 mL in LVEDV, a mean absolute decrease of 1.78% in LVGLS, and a mean absolute decrease of 2.85% in LVGCS.

[0148] Safety evaluation A total of 50 AEs were reported in 34 subjects. Except that arrhythmias occurred more frequently in subjects administered Compound I, there was no tendency for the frequency of AEs due to dosing with Compound I to increase, and there was no significant difference from pooled placebo. Since all the observed arrhythmias are known to occur spontaneously in healthy volunteers, this difference was probably due to chance. All AEs were of mild or moderate severity. One subject had a serious AE of transient complete AV block (100 mg Compound I dose group). At 16 - 22 hours after dosing, this subject had bradycardia (heart rate < 50 [bpm] per minute) and three short episodes of complete heart block (each 4 - 8 seconds). Other possible AEs considered to be drug-related included three subjects who were administered Compound I and showed short episodes of arrhythmia (one subject with frequent ventricular rhythm observed by telemetry, one subject with ventricular premature contractions, and one subject with isolated non-sustained ventricular tachycardia (NSVT, 3 beats)). It should be noted that such AEs can occur in healthy subjects. There were no subjects who discontinued due to AEs. AEs considered to be treatment-related by the principal investigator of the clinical trial were reported in three subjects (50.0%) in the 350 mg and 50 mg Compound I dose groups and one subject each for each of the remaining dose groups (excluding 25 mg Compound I in which no related TEAEs were reported).

[0149] In conclusion, the trial indicates that overall, compound I was well tolerated at a maximum dose of 525 mg, and no safety signals worthy of note were identified during the trial. Most AEs were of mild or moderate severity, and most were not related to the investigational drug. There was no tendency for the frequency or severity of AEs to increase with increasing doses of compound I. The most common AEs (occurring in ≥ 3 subjects) were headache, fatigue, reactions related to the catheter site, back pain, dizziness, upper respiratory tract infection, and chest discomfort. Chest discomfort or non - cardiac chest pain occurred in 4 subjects: 1 subject on placebo (2 hours after dosing) and 3 subjects on the active ingredient (occurring 4 - 5 days after dosing at 10, 25, and 350 mg, respectively). The only AEs considered drug - related and occurring in more than 2 subjects were headache and chest discomfort. Headache episodes were rated as mild to moderate in severity. All episodes of chest discomfort were rated as mild. One of the two episodes of chest discomfort occurred after dosing with 350 mg. The other episode of chest discomfort and the headache episodes occurred after dosing with lower doses of compound I below 50 mg.

[0150] One subject (001 - 136), a 31 - year - old male who received compound I (100 mg), experienced three short (4 - 8 seconds each) asymptomatic episodes of third - degree AV block by telemetry during sleep 16 - 22 hours after dosing. The patient had no history of syncope or heart disease, but it should be noted that this subject had first - degree AV block and bradycardia on screening and pre - dosing ECG. This event was rated as mild in severity by the trial responsible physician and was considered possibly related to the investigational drug, while the trial sponsor rated this event as not related to the investigational drug (possibility of increased vagal tone during sleep).

[0151] Three other subjects who received compound I experienced arrhythmias 8.5 - 48 hours after dosing with compound I. Each arrhythmia was of a type that could be observed in healthy volunteers, had a short duration (a few seconds), and was asymptomatic.

[0152] One subject experienced a slight increase in hs-troponin I (16 ng / L, upper limit of normal range is 15 ng / L). No increase in troponin was observed in other subjects.

[0153] There were no significant changes in the ECG or ECG intervals including the PR interval. One case of QTcF > 450 milliseconds was recorded in a subject administered the low dose (10 mg). A dose-dependent trend involving high QTcF was not observed.

[0154] There were no clinically significant changes in vital signs or safety test parameters.

[0155] Troponin I Troponin was measured using a high-sensitivity human troponin assay (Abbott Architect STAT high-sensitivity troponin I), and the upper limit of the normal range was 15 ng / mL. A slight increase in hs-troponin I concentration was seen in one subject (525 mg compound I treatment group), with the value being 16 ng / mL at 6 hours after administration and within the normal range 2 hours later. The subject experienced PVC at around 48 hours but had no chest pain.

[0156] Example 2: Open-label pilot randomized phase 2 crossover trial to evaluate the effect of food on 25 mg tablets of compound I at a dose of 200 mg in healthy adult volunteers This example describes a clinical trial to demonstrate the effect of a high-fat, high-calorie meal on the PK profile of compound I compared to drug administration in the fasting state in healthy volunteers. The trial also aimed to determine the safety and tolerability of a single oral dose of compound I in healthy volunteers in the fed and fasting states. Measurements of PK, PD, and other clinical parameters were performed as described in Example 1 above.

[0157] Materials and methods Study design This was an open-label, randomized, phase 2 crossover trial in healthy volunteers aged 18 - 55 years. Subjects were screened up to 28 days prior to the maximum of the first treatment period. Subjects were admitted to the clinical site on day - 1 (the day before dosing) of period 1. On day 1 of the first treatment period, approximately half of the subjects were randomly administered a single dose of Compound I after ingestion of a high-fat, high-calorie breakfast, and the remaining subjects were administered in a fasting state. Subjects with a pre-dose resting heart rate HR ≥ 95 (bpm) were considered ineligible and not treated. Subjects with acute gastrointestinal disorders (e.g., vomiting, diarrhea) that could affect drug / food absorption had their schedules reorganized. Subjects were housed in the medical facility until day 4 and discharged after PK, test samples, and vital signs were obtained 72 hours after dosing. After a washout period during the 7 - 10 days of dosing (or, if the subject could not attend the hospital within 7 - 10 days, after examination by the principal investigator of the clinical trial, up to 21 days after the first dosing), the subject advanced to period 2. The order of fed / fasted vs. fasted / fed periods was randomized. Subjects returned for a safety follow-up on day 7 (±1 day) after the second treatment period.

[0158] In both treatment periods, Compound I was administered with 240 mL of water. In the fasting state, subjects were fasted for 10 hours before and 4 hours after administration of Compound I. Water could be ingested up to 1 hour before dosing and from 1 hour after dosing. In the fed state, subjects were fasted for 10 hours before and 4 hours after food intake, but water could be ingested up to 1 hour before dosing and from 1 hour after dosing. In the fed state, subjects ingested a high-fat, high-calorie meal within 30 minutes before administration of Compound I and finished the meal within 30 minutes. The meal contained approximately 800 - 1000 calories, with approximately 50% of the calories being from fat. The meal had approximately 150 calories from protein, 250 calories from carbohydrates, and 500 - 600 calories from fat. An example of the meal was a breakfast consisting of 2 eggs fried in butter, 2 slices of bacon, 2 slices of buttered toast, 4 ounces of hash brown potatoes, and 8 ounces of whole milk.

[0159] Treatment Administration Each subject received two oral doses of 200 mg of Compound I formulated as 25 mg tablets (8 tablets) in a randomized crossover fashion, once in the fasting state and once after ingestion of a high-fat, high-calorie breakfast. There was a washout period of 7 to 21 days between the two doses. The Compound I drug substance was a crystalline free base synthetic molecule with a molecular weight of 435.4. Compound I is non-hygroscopic and substantially insoluble in aqueous media.

[0160] Pharmacokinetic Evaluation Plasma drug concentrations were measured as described in Example 1 above. Blood samples for measuring the plasma concentration of Compound I were taken before dosing (1 hour before dosing) on Day 1 of both treatment periods, and at various time points including 1 (±5 minutes), 2 (±5 minutes), 3 (±5 minutes), 4 (±10 minutes), 5 (±10 minutes), 6 (±10 minutes), 9 (±20 minutes), 12 (±20 minutes), 18 (±30 minutes), 24 (±30 minutes), 36 (±30 minutes), 48 (±30 minutes), and 72 (±30 minutes) hours after dosing.

[0161] Electrocardiogram (12-Lead ECG) ECGs were performed as described in Example 1. The following intervals were measured: RR, PR, QRS, and QT. Heart rate (HR) was calculated as 60 / (RR×1000) (where RR is expressed in milliseconds), rounded, and taken as the nearest integer. Each individual ECG QT value was corrected for HR. Measured QT data were corrected for HR using the Fridericia method (QTcF) based on the following formula / method (where QT, RR, and QTc are expressed in milliseconds):

Equation

[0162] Electrocardiogram Remote Monitoring The real-time remote measurement method for ECG was shown at various predetermined time points. The real-time remote measurement method for ECG was started at least 1 hour before administration and continued until 48 hours after administration. The principal investigator or the study implementer of the clinical trial monitored the continuous ECG remote measurement data, and correlated the findings with any other clinical findings, the medical history of the trial participants, the clinical status of the trial participants and the trial data, and determined the clinical significance of the findings.

[0163] Serum troponin I concentration The serum troponin I concentration was determined as described in Example 1. In the case of abnormal troponin values and / or high troponin values (taking into account the potential baseline troponin increase based on the judgment of the principal investigator of the clinical trial), the subjects were clinically evaluated for the possibility of myocardial ischemia. If the subjects had symptoms or signs suggesting the possibility of myocardial ischemia, additional serial troponin (and other safety indicators such as creatine kinase MB isoenzyme [CK-MB]) levels were obtained and the continuation of the medication was withheld until the possible ischemic event was fully understood. All clinical findings were evaluated (e.g., symptoms, signs, new ECG changes, new troponin and CK-MB abnormalities), and correlated with any other relevant clinical findings, the medical history of the subjects and the laboratory data, and the clinical significance of the findings was determined.

[0164] Test results Plasma concentration of Compound I The plasma concentration of Compound I over time according to fed / fasted state is summarized in Table 7 and Figure 4. A single dose was administered to all randomized subjects (11 subjects) by oral administration of 200 mg of Compound I after an overnight fast or after a high-fat meal. These 11 randomized subjects included 9 subjects who received treatment during both periods, 1 subject who received the investigational drug in the fed state, and 1 subject who received the investigational drug in the fasted state.

Table 7-1

Table 7-2

[0165] The plasma concentration of Compound I was detectable in all subjects for 1 - 72 hours after administration, both in the fed and fasted states. The average plasma concentration was higher in the fed state than in the fasted state at the time points from 2 - 72 hours after administration, and the C max in the fasted state was 2310 (405.8) ng / mL, and the t max was 5 hours after administration, and the C max in the fed state was 3204 (638.0) ng / mL, and the t max was 6 hours after administration.

[0166] Plasma pharmacokinetic parameters of Compound I The plasma PK parameters of Compound I are summarized for each treatment group in Table 8 below.

Table 8

[0167] As shown in Table 8, after oral administration of a single 200 mg dose of Compound I, the exposure was approximately 50% higher in the fed state than in the fasted state (AUC last , AUC inf ), and also 60% higher (C max ). The mean (SD) maximum plasma concentration (C max ) was 2347 (366.9) ng / mL in the fasted state and 3677 (500.7) ng / mL in the fed state. The median (range) T max occurred at 5 (3.0 - 6.0) hours in the fasted state and at 5.5 (2.0 - 12.0) hours in the fed state.

[0168] To evaluate the effect of food on the PK of Compound I, a two - one - sided t - test was used to compare plasma AUC inf , AUC last and C maxA 90% CI around the geometric mean ratio (fed / fasted) was constructed. A mixed effects model with order, period, and treatment condition as fixed effects and subject as a random effect was used. The bioequivalence data for all subjects administered a single dose of 200 mg of Compound I are shown in Table 9 below. [Table 9]

[0169] As shown above, the geometric mean ratios (fed / fasted) were 154.28%, 154.02%, and 158.11%, respectively. In the fed state, there was an approximately 50% increase in AUC inf and AUC last (i.e., AUC 0-t ), and a 60% increase in C max . The 90% CI for the ratio of geometric means based on log-transformed data was not within the 80 - 125% equivalence limits for AUC inf , AUC last and C max , demonstrating a diet effect.

[0170] The bioequivalence data for all subjects who completed both the fasted and fed periods of Compound I are shown in Table 10 below. [Table 10]

[0171] As shown above, the geometric mean ratios (fed / fasted) were 153.63%, 153.20%, and 156.43%. In the fed state, there was an approximately 50% increase in AUC inf , AUC 0-t and C max for each. The 90% CI for the ratio of geometric means based on log-transformed data was not within the 80 - 125% equivalence limits for AUC inf , AUC last and C max , demonstrating a diet effect.

[0172] Conclusions Regarding PK After a single 200 mg dose, plasma Compound I was detectable between 1 and 72 hours post-dose in both fed and fasted states. Concentrations peaked at 5 hours in the fasted state and 5.5 hours in the fed state (Table 8). Exposure was 50% (based on AUC last AUC inf ), to 60% (based on C max ) higher in the fed state compared to the fasted state (Tables 9 and 10). In all subjects, the 90% CI of the geometric mean ratio based on log-transformed data was not within the 80 to 125% equivalence limits for AUC inf AUC last and C max , demonstrating a dietary effect on the PK of Compound I. The same results were obtained when subjects who completed both the fasted and fed periods were analyzed.

[0173] Safety Evaluation This study demonstrated that Compound I was generally well tolerated at a single 200 mg dose, and no safety signals of concern were identified during the study. All AEs were mild or moderate in severity, and overall, most AEs were not related to the investigational drug. There was no tendency for the frequency or severity of AEs to increase in the fed state compared to the fasted state. The most common AE (occurring in ≥ 2 subjects) was headache, which occurred in 4 subjects in the fasted state and 1 subject in the fed state. Cardiac dysfunction occurred in 2 subjects in the fasted state (1 case of sinus tachycardia and 1 case of ventricular tachycardia) and 1 subject in the fed state (palpitations); both AEs resolved and no treatment was required for the study treatment. The only drug-related AE occurring in ≥ 2 subjects was headache (3 subjects in the fasted state and 1 subject in the fed state).

[0174] Increases in troponin I were not observed in any subjects in either the fasted or fed states. No clinically significant changes in safety test parameters or vital signs, or ECG intervals, were present in this study. Abnormal ECG results were recorded 3 times (30.0%) in the fasted state and 2 times (20.0%) in the fed state.

[0175] Example 3: A randomized, double-blind, placebo-controlled, two-stage adaptive design trial regarding the safety, tolerability, preliminary pharmacokinetics and pharmacodynamics of single and multiple escalating oral doses of Compound I in patients with stable HFrEF In this example, a study is described to preliminarily establish the safety and tolerability of single and multiple escalating oral doses of Compound I in ambulatory patients with heart failure with reduced ejection fraction (HFrEF). Important eligibility criteria included stable HFrEF of ischemic or non-ischemic origin treated with guideline-based medical therapy (initial requirement for EF during screening was 20 - 45% and was later changed to 15 - 35% by correction). Subjects with active ischemia or severe or valvular heart disease were excluded. The study aimed to (1) establish the preliminary human PK of Compound I after single and multiple escalating oral doses of Compound I in patients with HFrEF; (2) determine the changes in left ventricular stroke volume (LVSV), left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) obtained from left ventricular outflow tract - velocity time integral (LVOT - VTI) by Compound I after single and multiple dose escalations compared to baseline and placebo, measured by transthoracic echocardiogram (TTE); (3) determine the changes in systolic ejection time (SET) by Compound I after single and multiple dose escalations compared to baseline and placebo, measured by TTE; and (4) determine the changes in pharmacodynamics (PD) dose / concentration effects [changes in LVSV (obtained from LVOT - VTI), LVEF, LVFS] by Compound I after single and multiple dose escalations compared to baseline and placebo, measured by TTE.

[0176] The effects of Compound I on (1) LV strain, LV dimensions, LV diastolic function, (2) potential electrocardiogram (ECG) QT / heart rate - corrected QT interval (QTc) effects upon administration of Compound I, (3) the relationship between the pharmacogenetic profile and the PK - PD properties of Compound I, (4) the potential impact of the genetic etiology of dilated cardiomyopathy (DCM) on any PD or safety - related parameters, (5) the effect of Compound I on right ventricular (RV) contractility, (6) changes in SET by Compound I during the first part of the study using photoplethysmography (single - ascending dose [SAD]), and (7) plasma and / or urine concentrations of metabolites of Compound I, as well as pharmacokinetics were also investigated.

[0177] Materials and Methods Study Design In the first part of the two - stage study, the single - ascending dose (SAD) of Compound I was evaluated, and in the second part, the multiple - ascending dose (MAD) of Compound I was evaluated (Figures 5A and 5B).

[0178] First Part (SAD Cohort) The first part was a randomized crossover double - blind placebo - controlled two - cohort sequential ascending (oral) single - dose study in outpatients with heart failure. All patients received 2 or 3 active doses of placebo and Compound I. Each patient received sequential single - dose treatments separately over 5 days or more and within 14 days. Patients in Cohort 1 may return for a fourth dosing period (open - label) after SRC reviewed the available data and recommended a dose. Patients enrolled before the implementation of Amendment 1 may be provided the opportunity to return for the open - label period. Patients in Cohort 2 participated in 2 - 4 dosing periods based on the SRC's decision. Patients were randomized to one of the different dosing sequences outlined in Figure 5A. Multiple patients may be dosed simultaneously or in the same week depending on administrative convenience, i.e., capacity and schedule.

[0179] For each dosing period, the patient was admitted to the clinical site on Day - 1. The patient was evaluated for the absence of exclusion criteria (e.g., new test abnormalities and / or conditions indicating that the patient is clinically unstable). The patient was administered Compound I or placebo on the morning of Day 1, after which serial PK and PD evaluations, as well as serial safety evaluations, were performed. The patient was discharged on Day 3 (i.e., approximately 48 hours after dosing on Day 1). Additional plasma PK samples were collected at the outpatient clinic on Day 4, at the 72 - hour time point after dosing.

[0180] Before administering the dose, all available safety data, including vital signs, troponin concentrations assayed on - site, TTE, ECG, and safety test values including ECG telemetry, were reviewed. Dosing using the DB procedure was performed simultaneously on each dosing day. Where applicable, background concomitant medications, including diuretics, were also administered simultaneously on each dosing day. Before dosing, patients with a pre - dose resting HR ≥ 95 bpm (average of three measurements) were considered ineligible and not treated. All PK profiles and multiple TTEs and ECGs were obtained at baseline and after dosing of each dose. The patient returned for the final safety follow - up 7 (±1) days after the last dose was administered. During the study, the patient continued to take their own therapeutic medications for the treatment of congestive heart failure and other medical conditions at the same dose and at approximately the same time as usual.

[0181] Part 2 (MAD Cohort) This was a randomized parallel - group, DB placebo - controlled, adaptive - design, sequential - escalating (oral), multiple - dose study in stable patients with heart failure. Four MAD cohorts (A, B, C, D) were enrolled (Figure 5B). The SRC reviewed the results from each cohort, determined the dose, and confirmed the initial sample size for the next cohort. Additionally, the first 3 patients in each cohort had an LVEF ≥ 25%; the SRC reviewed the preliminary safety data from these patients and determined whether to allow enrollment of patients with an LVEF < 25% into the cohort.

[0182] After screening and eligibility confirmation, patients were housed in a clinical trial facility from day 1 (check-in) to day 11. Each patient was first administered placebo BID for 2 days (days 1 and 2) in a single-blind manner (as a "break-in" while getting used to being housed in the clinical trial facility), and then received treatment with the randomized DB investigational drug on day 3. Thereafter, all patients were administered either placebo or active compound I for 7 days (from day 3 to day 9), and after the follow-up period, the patients were discharged from the facility on day 11. The visit to the medical facility for the last follow-up was conducted on day 16. Up to two or more patients in the cohort could be dosed simultaneously or in the same week depending on administrative convenience, i.e., capacity and schedule.

[0183] Patients were administered twice a day (every 12 hours). Dosing could be conducted within ±2 hours from the scheduled dosing time as long as the time was at least 10 hours and no more than 14 hours apart. Day 9 was an exception to the twice-daily dosing (the last dose of the randomized DB investigational drug treatment). On day 9, a single dose was administered in the morning.

[0184] Prior to each dosing event, all available safety data from the previous day were reviewed (for non-housed patients, when using a home healthcare provider, the healthcare provider and the site communicated daily to ensure safety). Dosing for the DB treatment was conducted at approximately the same time each day.

[0185] During the study period, multiple evaluations were performed, including: serial TTE evaluations (11 - 14 TTEs per patient on days 1, 2, 3, 4, 7, 9, 10, and 11); PK sample collection (PK samples collected concomitantly with each echocardiogram after randomization); ECG (on days 2, 3, 4, 7, 9, 10, 11, and 16); troponin (collected concomitantly with each ECG after randomization); and safety study evaluations. Housed patients received continuous remote monitoring. Holter electrocardiograms were performed in all patients at baseline (days 1 - 2) and at the end of the double-blind treatment (days 7 - 9). Vital signs were collected daily.

[0186] Selection Criteria This trial was conducted in patients with HFrEF due to any etiology. Each patient met at least the following criteria to be included in this trial: 1. Men or women aged 18 - 80 years at the time of screening visit 2. At the screening visit, body mass index (BMI) of 18 - 40 kg / m 2 (including the endpoints), and be able to reliably perform all necessary evaluations 3. Sinus rhythm or stable atrial pacing with a heart rate (HR) of 50 - 95 beats per minute (bpm) (including the endpoints) at rest on average. (If the HR measurement before dosing on day 1 is ≥ 95 bpm, the patient is ineligible for dosing. The heart rate is the average of three measurements taken 1 minute apart. A single measurement value does not render the patient ineligible.) 4. Have moderately severe stable chronic HFrEF as defined by all of the following: (i) For the first 3 patients in each MAD cohort tested at a new (higher) daily dose: Recorded LVEF of 25% - 35% (confirmed by the ECHO Central Laboratory) at screening (ii) For other patients in the MAD cohort (and all patients in the SAD cohort): Recorded LVEF of 15% - 35% (confirmed by the ECHO Central Laboratory) at screening iii) The LVEF must be confirmed by a second screening ECHO performed at least 7 days after the first screening ECHO. Since both results must meet the inclusion criteria, the results should be received from the central laboratory before dosing. If the screening window is extended by the review of the SRC, efforts should be made to have the second ECHO performed near the randomization scheduled time. (iv) The chronic drug therapy for the treatment of heart failure is in line with the current guidelines, administered at a stable dose for more than two weeks and should not be changed during the trial. This treatment includes the use of at least one of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors / angiotensin receptor blockers (ARBs) / angiotensin receptor neprilysin inhibitors (ARNIs), unless intolerant or contraindicated.

[0187] Exclusion Criteria Patients meeting any of the following criteria were excluded from the trial: 1. Inadequate echocardiogram ultrasound window 2. Having any of the following ECG abnormalities: (a) QTcF > 480 milliseconds (mean of three screening ECGs, not due to pacing or prolonged QRS duration, Fridericia correction) or (b) Second-degree atrioventricular block type II or higher in patients without a pacemaker 3. Hypersensitivity to any component of Compound I or the formulation of Compound I 4. Clinically significant active infections as determined by the principal investigator of the clinical trial 5. History of any type of malignancy within 5 years prior to screening, except for the following cancers that occurred more than 2 years prior to screening and were resected surgically: non-invasive cervical cancer, non-melanoma skin cancer, non-invasive ductal breast cancer, and non-metastatic prostate cancer 6. Positive serological tests for infection with human immunodeficiency virus (HIV), hepatitis C virus (HCV), or hepatitis B virus (HBV) at the time of screening 7. Liver dysfunction (defined as alanine aminotransferase (ALT) / aspartate aminotransferase (AST) > 3 times the ULN, and / or total bilirubin (TBL) > 2 times the ULN) 8. Severe renal insufficiency (defined as current estimated glomerular filtration rate [eGFR] < 30 mL / min / 1.73 m2 by the simplified Modification of Diet in Renal Disease [sMDRD] equation) 9. Serum potassium < 3.5 or serum potassium > 5.5 mEq / L 10. Continuation of any out-of-range safety laboratory parameters (chemistry, hematology, urinalysis) clinically determined by the principal investigator and the clinical research associate to be critical 11. History or evidence of any other clinically critical disorder, condition or disease (including substance abuse) that threatens patient safety, or is considered to interfere with the evaluation, conduct or completion of the trial, or lead to early withdrawal from the trial 12. Participation in a clinical trial in which the patient has received any investigational drug (or is currently using an investigational medical device) within 30 days prior to screening, or at least five times (whichever is longer) the respective elimination half-life 13. At screening, symptomatic hypotension or systolic BP > 170 mmHg or < 90 mmHg, or diastolic BP > 95 mmHg or HR < 50 bpm; HR and BP are the mean of three measurements taken at least one minute apart 14. Currently having angina pectoris 15. Recent (< 90 days) acute coronary syndrome 16. Coronary revascularization procedure (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) within the past three months 17. Recent (< 90 days) hospitalization for heart failure, use of chronic IV inotropes, or other cardiovascular event (e.g., cerebrovascular accident) 18. Uncorrected severe valvular disease 19. High troponin I at screening (> 0.15 ng / mL) based on the core laboratory evaluation; note: the ULN for the central laboratory troponin I assay is 0.03 ng / mL 20. Presence of an inappropriate heart rate that interferes with the evaluation of the trial by electrocardiogram or echocardiogram: evaluation of the trial includes (a) current atrial fibrillation, (b) recent (< 2 weeks) persistent atrial fibrillation or (c) frequent ventricular ectopy; patients using cardiac resynchronization therapy (CRT) or a pacemaker (PM) are eligible if initiated at least two months prior and there are no planned changes to CRT or PM settings during the trial 21. Life expectancy is <6 months

[0188] Test treatment In the first part (SAD), test subjects were administered separate escalating doses of Compound I (2 - 3 doses) and a single dose of the corresponding placebo. In the second part (MAD), test subjects were administered single - blind placebo BID on Days 1 and 2, and then received DB treatment (either placebo or Compound I) for 7 days (from Day 3 to Day 9). In cohorts A, B, C, and D, on Day 9, patients were administered a single morning dose of placebo or Compound I for continuous PK / PD evaluation, but from Day 3 to Day 8, patients in these cohorts were administered placebo or Compound I BID.

[0189] The raw drug of Compound I was as described in Example 1 above and was provided as 5, 25, or 100 mg tablets. Placebo tablets were provided as corresponding tablets. The tablets were blister - processed and then made into card form. Each blister card contained only 5 mg, only 25 mg, only 100 mg, or only placebo. The blister cards were packaged in a "kit box".

[0190] Investigational drug, administration, and schedule The investigational drug consisted of 5 mg tablets, 25 mg tablets, 100 mg tablets of Compound I, or corresponding placebo tablets. In the first part (SAD), Compound I or placebo was administered after an overnight fast (at least 6 hours), and in the second part (MAD), Compound I was administered after a 2 - hour fast (cohort A) or with food (cohorts B, C, and D). The administered dose was taken with at least 240 mL of water, and more water was ingested as needed. The total dose was administered over a maximum of 15 minutes. The time of administration used to determine future evaluations was the time when the last tablet was taken. In the cohorts of the second part (MAD), a BID regimen was used.

[0191] In the first part (SAD), the patients fasted from overnight (about 6 hours) until 4 hours after dosing. Except for the water ingested with the medication, water could be ingested about 1 hour before dosing and up to 1 hour after dosing. When splitting the dosing dose, the subjects fasted 6 hours before administration of the first half dose. Two hours after administration of the first half dose, a low-fat light meal could be taken, and fasting was continued until 2 hours after the second half dose.

[0192] In the second part (MAD), the patients in cohort A fasted 2 hours before dosing and 2 hours after dosing. For example, if the morning dose was administered at 8:00 am, the patient could have a light meal at 6:00 am and a complete breakfast at 10:00 am. If the afternoon dose was administered at 8:00 pm, the patient could have dinner at 6:00 pm and a light meal at 10:00 pm. These times may be changed based on the local schedule setting, but the dosing was performed at intervals of at least 10.5 hours. The patients in cohorts B, C, and D had meals at each dosing time.

[0193] Pharmacological effects in overdose and management of overdose Based on non-clinical pharmacological properties, the effects of Compound I in overdose may cause myocardial ischemia. The duration of the effect follows the PK profile of Compound I, which has a T of 4 - 6 hours and a half-life of about 15 hours in healthy volunteers, but the half-life was slightly longer (20 - 25 hours) in patients who received Compound I as part of cohort 1. Clinical signs and symptoms that may include chest pain, dizziness, sweating, and ECG changes will begin to weaken within a short time. Patients with signs and / or symptoms suggestive of myocardial ischemia were immediately evaluated by a physician for the possibility of myocardial ischemia, and additional ECGs and serial troponins were obtained as part of the evaluation if necessary. max

[0194] ​When there was evidence of qi deficiency and blood stasis, patients received standard treatment for ischemia as needed, including oxygen and nitrate supplementation. Compound I had the potential to prolong the SET, and as a result, the diastolic duration decreased and diastolic ventricular filling decreased. Therefore, caution was required when administering drugs that increased HR. Additionally, since the pharmacological effects in overdose could increase myocardial oxygen demand, the administration of drugs that could further increase myocardial oxygen demand needed to be carried out carefully.

[0195] Patients who were administered higher doses than planned received appropriate support as described above if there were pharmacological effects in overdose.

[0196] Combination therapy Throughout the trial, in order to maintain the pre- and post-load states as similar as possible throughout the trial and to minimize confounding factors for evaluating the effect of Compound I, patients continued to take drugs for treating congestive heart failure and other medical conditions at the same dose and around the same time as usual during the trial. In particular, when patients were being treated with diuretics, the administration time of the diuretics for the DB treatment was maintained similarly throughout the trial. The administration time of the diuretics was recorded when applicable. When patients were not hospitalized, patients were instructed to keep the timing of their daily drug administration, including diuretics, constant and record the time of administration.

[0197] All prescription and over-the-counter drugs were reviewed by the responsible investigator of the clinical trial. Questions regarding registration or dosing should be consulted with the medical monitor. Over-the-counter drugs could be taken during the trial period at a stable dose (at the discretion of the responsible investigator of the clinical trial) and in an amount not exceeding the specified amount stated on the label. All combination treatments (prescription or over-the-counter) were recorded. Other investigational therapies were discontinued at least 30 days before screening or 5 half-lives (whichever was longer).

[0198] When there was an AE that required treatment (including taking acetaminophen or ibuprofen) in the patient, the dosing details were recorded: for example, including administration time (start / stop), date, dose, and indication.

[0199] PD evaluation The PD evaluation was performed by transthoracic echocardiogram as described in Example 1 above. The TTE evaluations of LVSV (derived from LVOT-VTI), LVEF, LVFS, SET, and other parameters were PD evaluations at a predetermined time point. The patients were kept at rest in bed for 10 minutes before obtaining the TTE. In Part 2 (MAD), TTE was usually obtained in the morning before dosing and / or 7 hours after dosing (i.e., near the peak of the predicted effect based on the PK profile from the healthy volunteer study).

[0200] Safety and efficacy evaluation The safety and efficacy evaluation was conducted by measuring the patients' vital signs and test parameters: for example, performing TTE to measure the systolic ejection time; performing electrocardiogram (e.g., 12-lead ECG), real-time ECG telemetry (e.g., at least 3 leads), and Holter ECG; and measuring the levels of troponin (e.g., troponin I and / or troponin T) and 4β-hydroxy cholesterol.

[0201] The following safety test parameters were measured: (1) hematological parameters (CBC including differential count and platelet count); (2) serum chemistry parameters (e.g., sodium, potassium, chloride, bicarbonate, calcium, magnesium, urea, creatinine, ALP, ALT, AST, total bilirubin, glucose, and CPK); and (3) urine test parameters (e.g., pH, protein, glucose, leukocyte esterase, and blood).

[0202] In cases of abnormal and / or elevated troponin values (taking into account the possibility of baseline troponin increase frequently observed in heart failure, based on the judgment of the principal investigator of the clinical trial), the patients were clinically evaluated for the possibility of myocardial ischemia. Also, when there were any symptoms or signs suggesting the possibility of myocardial ischemia in the patients, additional serial troponin (and other safety test items including creatine kinase-MB [CK-MB] samples) were obtained, and continuation of dosing was withheld until the possibility of an ischemic event was fully understood. All clinical items (such as symptoms, signs, new ECG changes, new troponin and CK-MB abnormalities) were evaluated and correlated with any other relevant clinical findings, the patient's medical history and test data to determine the clinical significance of the findings. The results of troponin measured at the local laboratory on Day 2 of Part 1 (SAD) and Day 10 of Part 2 (MAD) were reviewed the next day before the patient was discharged.

[0203] Endpoints of the trial The primary evaluation items (primary endpoints) (safety indicators) of this trial included AEs and SAEs caused by the treatment; ECG recording, interpretation and intervals; vital signs; serum troponin I concentration; abnormal test values; and abnormal physical examination values.

[0204] The secondary endpoints were as follows: 1. The human PK profile of Compound I. The analysis included at least the following PK parameters: Cmax at each dose level, Tmax at each dose, AUC at each dose, apparent first-order elimination half-life (t 1 / 2 ), mean residence time (MRT) at each dose level, and the determined accumulation ratio (with appropriate confidence intervals) for C max and AUC 0-t (for Part 2 only). 2. SET determined using TTE. The primary parameters were the amount of change from baseline and the maximum change from baseline at each time point according to the treatment level. 3. Items evaluated by TTE: Changes from baseline in LVSV (derived from LVOT-VTI), changes from baseline in LVEF, changes from baseline in LVFS, and changes from baseline in SET.

[0205] The exploratory endpoints were as follows: 1. Pharmacokinetic dose proportionality of AUC and Cmax after administration of both single (Part 1) and multiple (Part 2) doses 2. QT interval corrected using Fridericia's formula (QTcF), change from baseline (absolute value or relative change %), and, if effective, exploring the potential effect of Compound I on the concentration-effect relationship of the change in QTcF from baseline 3. Relationship between plasma concentration / PK parameters of Compound I and PD parameters (LVEF, SET, LVFS, LVSV) 4. The following items evaluated by TTE: Changes from baseline in LV strain, changes from baseline in LV dimensions, changes from baseline in LV diastolic function, changes from RV systolic baseline, and changes from baseline in PEP (Part 1) 5. SET evaluated by photoplethysmography (Part 1 only).

[0206] Additional possible endpoints were as follows: 1. Exploring the effect of genetic biomarkers on the PK or PD profile of Compound I 2. Determination of Compound I metabolites in plasma samples 3. Amount of Compound I excreted in urine at each urine collection interval, as well as total amount and amount of administered dose excreted in urine

[0207] Test results PK / PD and safety data for Part 1 (SAD) - Cohorts 1 and 2 Cohort 1 Eight patients with stable heart failure were enrolled and randomized to receive compound I or placebo at doses of 175, 350, 525, 450 (divided dose) or 550 mg (divided dose) in a crossover study design over four periods (A - D). All patients had non - ischemic heart failure and showed an average baseline ejection fraction of 43%. During periods A - C, all eight subjects received placebo, 175 mg, and 350 mg (in random order). Six subjects were selected to proceed to the fourth open - label period D, and the following doses were administered: 350 mg (n = 1), 525 mg (n = 2), 450 mg (2 divided; n = 1), and 550 mg (2 divided, n = 2). Single - dose administrations were given to patients under fasting conditions. Divided doses were administered every 4 hours, but patients were fasted for 6 hours before the first - half dose administration and 2 hours after the second - half dose administration, and allowed a light meal 2 hours after the first - half dose administration. Subsequently, patients were observed for a long time and then given a wash - out period. This process was repeated until each patient had received at least three doses (compound I or placebo).

[0208] Cohort 2 Four subjects with stable heart failure were enrolled and randomized to receive compound I or placebo at doses of 400 mg (divided dose) or 500 mg (divided dose) over three periods (A - C). Divided doses were administered at 4 - hour intervals, but patients were fasted for 6 hours before the first - half dose administration and 2 hours after the second - half dose administration, and allowed a light meal 2 hours after the first - half dose administration. During periods A - C, all four subjects received placebo, 400 mg, and 500 mg (in random order).

[0209] The results of the PK evaluation were summarized in Table 11 below.

Table 11

[0210] The mean plasma concentration-time profile of Compound I for SAD Cohort 1 is illustrated in Figure 6. In this cohort, Compound I was detectable at 72 hours post-dose in all subjects to whom Compound I was administered. Compound I was observed in the plasma of 4 subjects who received placebo during Period B or C, indicating that Compound I was not completely excreted during the washout period. The peak in plasma concentration occurred at approximately 5-6 hours, in the range of 2.0 - 9.1 hours, after oral administration of a single dose of 175, 350, or 525 mg of Compound I. Plasma exposure (C max , AUC 0-24 and AUC 0-∞ ) increased approximately dose-dependently with increasing Compound I dose for single doses of 175 mg to 350 mg, but reached a plateau for C max at the 525 mg dose and had a lower increase than dose-dependent increase for AUC. Mean (SD) C max was 1510 (350) ng / mL for a single dose of 175 mg, 2760 (856) ng / mL for a single dose of 350 mg, and 2720 (127) ng / mL for a single dose of 525 mg. Mean (SD) AUC 0-∞ was 53800 (13800) ng*h / mL for a single dose of 175 mg, 103000 (27200) ng*h / mL for a single dose of 350 mg, and 127000 (20100) ng*h / mL for a single dose of 525 mg.

[0211] These results were equivalent to those observed in healthy subjects as already described in Example 1. The decrease in exposure following administration of the 525 mg dose was thought to be due to a decrease in bioavailability caused by insufficient solubility, slow dissolution, and incomplete absorption of undissolved drug molecules in the gastrointestinal tract. To overcome saturated absorption at high doses, a placebo, 175 mg or 350 mg single dose was administered during Period A, Period B or Period C, and a divided dose was administered to patients who had completed treatment, at 4-hour intervals. During Period D, a 450 mg dose was administered to one patient and a 550 mg dose (administered as two divided doses, 4 hours apart) was administered to two patients. As shown in Table 11, the exposure of Compound I following oral administration of 450 and 550 mg as divided doses increased more than dose-dependently, compared to single administration of 175 mg and 350 mg doses. The increase beyond the dose-dependent increase in exposure is probably due to food intake between the two administrations.

[0212] For both Cohorts 1 and 2, the pharmacodynamic effects of Compound I on cardiac echo markers of cardiac structure and function were analyzed by plasma concentration group of Compound I: <2000 ng / mL (low concentration group) and ≧2000 ng / mL (high concentration group) (Table 12).

[0213] In the high plasma concentration group (≧2000 ng / mL), Compound I showed a statistically significant increase from baseline in mean (SE) stroke volume (9.0 [3.0] ml; p<0.001) and mean (SE) LV ejection fraction (4.4% [1.9]; p<0.05), as well as a correlation with a significant decrease in mean (SE) LV longitudinal strain (-2.1% [0.7]; p<0.001).

[0214] As a result of the administration of Compound I, a relative increase of about 10% from the baseline of cardiac contractility was brought about over a plurality of echocardiographic measurements including one - stroke volume (SV), left ventricular ejection fraction (LVEF) and fractional shortening (FS) of the left ventricle. Compound I increased the contractility of the heart, but there did not seem to be a significant change in the ability to fill with oxygen - containing blood due to the duration of contraction or the relaxation of the heart. A slight increase in SET was seen (<50 milliseconds), and the effect of Compound I on left ventricular filling was slight over multiple measurements of diastolic relaxation. As summarized in Table 12, these data were consistent with the results provided in Example 1 in healthy volunteers.

Table 12

[0215] The single - ascending dose of Compound I administered to HFrEF patients in the range of 175 - 550 mg (across both SAD cohorts 1 and 2) was safe and well - tolerated. There were no serious AEs, severe TEAEs or TEAEs leading to discontinuation of the trial. A list of reported TEAE findings is shown in Table 13. There were no TEAEs occurring in more than two subjects, and all TEAE findings were considered to be mild or not related to the investigational drug (with the exception of the TEAE observed in one subject at the highest dose of 550 mg, which is detailed below).

Table 13 - 1

Table 13 - 2

[0216] One patient reached the stopping criterion for individual dose increase regarding the PD protocol during Cycle 3. The stopping criterion at that time was an increase in SET of at least 50 milliseconds in two consecutive echocardiograms (subsequently changed to 75 milliseconds in two consecutive echocardiograms or 110 milliseconds in any one echocardiogram). After administration of 350 mg of Compound I, the SET of one patient was prolonged by approximately 63 milliseconds at 1.5 and 3 hours after administration, and then by <35 milliseconds at 6 and 9 hours after administration. There were no clinical or ECG findings, and troponin levels did not increase. There was no additional dosing for this patient. The mean SET prolongation for all patients between 3 and 9 hours after dosing at 350 mg was 16.2 milliseconds.

[0217] One 67-year-old male subject with HFrEF and a long history of ischemic heart disease (20 years) received a 4-cycle treatment period: the first 3 cycles were dosed with 175 mg, 350 mg, and placebo in this order, with a 14-day interval between periods. Mild dyspnea and fatigue were noted during the periods of 175 mg and placebo administration. 28 days after Cycle 3, the subject started Cycle 4 and 550 mg was administered. Approximately 12 - 24 hours after dosing, the subject complained of moderate dyspnea and a feeling of cardiac discomfort. There were no new ECG changes suggestive of ischemia. The subject's plasma concentration of Compound I during the episode ranged from 3400 - 4900 ng / mL. The subject also experienced an AE related to an increase in troponin from a pre-dose normal value to a maximum level of 0.12 ng / mL (4×ULN of the assay) of troponin I at 24 hours after dosing. The troponin I level began to decline by 36 hours after dosing and was normal at the follow-up visit 7 days after the last dose. Since these TEAEs resolved without intervention, they were judged to possibly be related to the investigational drug. The SRC reviewed this event and considered the possibility of myocardial injury.

[0218] In two SAD cohorts of HFrEF patients, a total of 12 subjects were placed in a 12-week placebo period and a 30-week active drug treatment period. Transient troponin increases were observed in 0 subjects (0 / 8) during the placebo period and in 3 subjects (3 / 12 = 25%) during a total of 3 active drug treatment periods (out of a total of 30 active treatment periods) at doses in the range of 175 - 550 mg (3 / 30 = 10%). All other troponin increases, except those noted above, were asymptomatic. No troponin increases were associated with ECG changes suggestive of ischemia. All cases of troponin increase were transient and resolved without sequelae.

[0219] In the analysis of ECG tests for all patients, no signal of QTcF increase was noted. In the evaluation of Holter monitoring for all patients, no signal of increased total atrial ectopy, atrial fibrillation, ventricular ectopy or NSVT runs with compound I was revealed compared to placebo.

[0220] PK and PD data from patients treated with compound I in this study showed preliminary evidence of the expected positive inotropic effect of compound I in HFrEF patients and were associated with a moderate increase in SET and a clear effect on relaxation. These changes in PD parameters were within a range understandable as clinical effects during a long-term treatment period.

[0221] PK / PD and safety data from Part 2 (MAD) A total of 40 subjects across 4 cohorts received 7-day treatment with placebo or compound I BID at doses of 50 mg (with food), 75 mg (1 cohort with food, 1 cohort with 4-hour fasting) or 100 mg (with food) (see Figure 5B and Table 14).

Table 14

[0222] Analysis of PK, PD, clinical safety and tolerability data is shown below.

[0223] In view of the fact that HFrEF subjects may show an increase in troponin values associated with the subject's background HFrEF condition (i.e., not related to ischemia or infarction), and that troponin values may fluctuate near the upper limit of normal (ULN), "troponin increase" in the test was defined as follows: - If troponin was within the normal range before administration (≤0.03 ng / mL for troponin I and <0.014 ng / mL for hs-troponin T), and the subject experienced at least one value >2×ULN (>0.06 for troponin I or ≥0.028 for hs-troponin T) during or after treatment, the subject was identified as showing "troponin increase". - If troponin exceeded the ULN before administration, and the subject experienced at least one value that increased by 0.03 ng / mL or more compared to the baseline during or after treatment, the subject was identified as showing "troponin increase" (in the case of troponin I or hs-troponin T).

[0224] Cohort A Eight patients with stable heart failure were enrolled. Compound I (6 patients) or placebo (2 patients) was fasted 2 hours before and 2 hours after administration and orally administered at a dose of 75 mg twice a day for 6 days and then as a single dose on day 7, randomly divided. The results of the pharmacokinetic parameters are summarized in Table 15 below. As shown in Panel A of Figure 7, the plasma concentration reached a steady state approximately 3 days or 72 hours after the first dose.

[0225] Cohort B Twelve patients with stable heart failure were enrolled. Compound I (9 patients) or placebo (3 patients) was orally administered at a dose of 50 mg twice a day with food for 6 days and then as a single dose on day 7, randomly divided. The results of the pharmacokinetic parameters are summarized in Table 15 below. As shown in Panel A of Figure 8, the plasma concentration of these patients reached a steady state approximately 4 days or 96 hours after the first dose.

[0226] Cohort C Twelve patients with stable heart failure were enrolled and randomly divided to receive Compound I (9 patients) or placebo (3 patients) orally twice daily at a dose of 75 mg with food for 6 days and then as a single dose on Day 7. The results of the pharmacokinetic parameters are summarized in Table 15 below. Plasma concentrations over time are shown in Panel B of Figure 7.

[0227] Cohort D Eight patients with stable heart failure were enrolled, fasted for 2 hours before dosing and 2 hours before the second dosing, and randomly divided to receive Compound I (6 patients) or placebo (2 patients) orally twice daily at a dose of 100 mg for 6 days and then as a single dose on Day 7. The results of the pharmacokinetic parameters are summarized in Table 15 below. Plasma concentrations over time are shown in Panel B of Figure 8.

[0228] Table 15 summarizes the PK parameters calculated from data obtained from MAD cohorts A - D. Overall, t 1 / 2 was consistent with the data obtained in the SAD cohort. C max , T max and AUC tau were consistent with the modeled parameters.

Table 15

[0229] The pharmacodynamic effects of Compound I on cardiac structural and functional cardiac echocardiographic markers were analyzed by Compound I plasma concentration groups: <2000 ng / mL (low concentration group), 2000 - 3500 ng / mL (medium concentration group) and ≥3500 ng / mL (high concentration group) (Table 16) and PK - PD scatter plots (Figures 9A - 9C). The medium concentration group corresponds to the steady - state plasma concentration achieved at 50 mg BID (Table 17). A total of 526 echocardiograms were performed to derive the PK - PD analysis.

Table 16 - 1

Table 16-2

Table 17

[0230] Treatment with Compound I led to a concentration-dependent increase in stroke volume (mean increases after placebo correction of 7.8 [p<0.01] and 5.7 mL [p<0.05] in the medium- and high-concentration groups, respectively). Compound I also improved LV longitudinal and circumferential strain (mean decreases after placebo correction of -2.1 and -3.3% in the medium- and high-concentration groups, respectively) and reduced LV dimensions (mean decreases after placebo correction of LVESD of -1.3 [p<0.01] and -1.8 mm [p<0.01] in the medium- and high-concentration groups, respectively). A non-significant increase in LVEF was noted. A dose-dependent increase in SET was observed, with mean increases after placebo correction of 36 (p<0.01) and 48 milliseconds (p<0.01) observed in the medium- and high-concentration groups, respectively (Figure 9B). A correlation was seen between the change in LVSV from baseline and the change in SET from baseline (Figure 9C). No significant changes in relaxation (e’, peak E wave) were observed in the medium-concentration group. E / A decreased due to an increase in the A peak wave velocity. In the high-concentration group, decreases in e’, peak E wave (-10 cm / sec, p<0.01) and E / A were observed. Changes in filling pressure (E / e’) were not seen in the medium- or high-concentration groups. No significant changes in vital signs were observed in the low- and medium-concentration groups. In the high-concentration group, a decrease in systolic blood pressure was seen, but no changes in diastolic blood pressure or heart rate were noted. No increase in QTc was observed. Holter monitoring revealed no increase in ventricular arrhythmias with Compound I compared to placebo.

[0231] Adverse events (TEAEs) after treatment initiation were reported in 17 (57%) Compound I patients and 4 (40%) placebo patients, with no organ specificity and no clear relationship with dose (Table 18). All TEAEs observed with Compound I (except one) were mild and / or considered unrelated to the test treatment, and all TEAEs resolved without sequelae. One patient had two episodes of non-sustained ventricular tachycardia (NSVT), which was considered to be of moderate intensity and related to Compound I. The patient showed NSVT on baseline Holter. There were no TEAEs that led to permanent treatment discontinuation or death. In this trial, hyperkalemia was reported as one severe AE in patients administered Compound I. This event resolved and was considered unrelated to the test treatment. The most common TEAEs in patients administered Compound I (reported in two patients each) were as follows: increased ALT (in both cases, the event was mild, unrelated to the test treatment, and self-resolved), contact dermatitis (in both cases, the event was mild and not related to the test treatment), fatigue, increased troponin, and non-sustained ventricular tachycardia (NSVT episodes were observed in two patients, and NSVT was also observed in these patients on baseline Holter). A transient and asymptomatic increase in either troponin I or hs-troponin T was noted in 7 (23%) patients treated with Compound I (2 / 9 patients at 50 mg, 2 / 15 patients at 75 mg, 3 / 6 patients at 100 mg; all 7 patients experienced an increase in troponin I, and one of the patients treated at 100 mg also had an increase in hs-troponin T), whereas none was noted with placebo (Table 19). The increased troponin observed in the MAD cohort was not associated with symptoms suggestive of ischemia or ECG changes.

Table 18

Table 19

[0232] SAD and MAD Cohorts: Pharmacokinetic-Pharmacodynamic Relationships Changes in the main cardiac echo PD parameters by concentration groups from the SAD cohort and the MAD cohort are shown in Tables 12 and 16, respectively. Increases related to exposure to the antegrade diastolic flow (an increase of about 8 - 9 mL of SV) and LV contractility (LV strain) were observed. The myocardial performance (or Tei index, an index of the combined function in systole and diastole (Bruch et al., Eur Heart J. (2000) 21:1888 - 95)) was improved by about 10% at concentrations ≥ 2000 ng / mL. The SET increased moderately (< 50 milliseconds).

[0233] Safety / Tolerability Conclusions from Single and Repeated Dose Escalation Cohorts Single - dose (up to 550 mg) and repeated - dose (50 - 100 mg BID for 7 days) administrations of Compound I in HFrEF subjects were safe and generally well - tolerated. Ischemic changes by ECG were not observed, and no clinically significant worsening of arrhythmias was noted. Mild transient increases in troponin were occasionally observed with Compound I. In one subject in SAD cohort 1 who received a high dose (550 mg), the troponin increase was considered potentially associated with myocardial injury (in the absence of related symptoms and ECG changes). In the MAD cohort, mild increases in troponin were observed, but no association with symptoms or ECG changes was noted. Mild troponin increases have also been observed with omecamtiv mecarbil, another agent in this class of myocardial myosin activators, which is currently being investigated in large - scale phase 3 cardiovascular outcome trials in HFrEF (Teerlink et al., Lancet (2016) 388(10062):2895 - 903); Teerlink et al., JACC Heart Fail. (2020) doi: 10.1016 / j.jchf.2019.12.001).

[0234] Example 4: Investigation of the Non - linear Pharmacokinetics of Compound I by Physiology - Based Pharmacokinetic Modeling The pharmacokinetics of Compound I have been evaluated in multiple canine studies. As shown in Figure 13, after oral administration of a single dose of Compound I to beagle dogs, the systemic exposure of Compound I increased with increasing dose at doses higher than 3 mg / kg, but less than dose-proportionally, with an increase less than dose-dependent. At a single dose of <3 mg / kg, the observed oral bioavailability was approximately 100%. This non-linear pharmacokinetics of Compound I was also observed in humans. As described in Example 1, after oral administration of a single escalating dose of 3 - 525 mg to healthy volunteers, the systemic exposure (C max and AUC) increased slightly less than dose-proportionally up to a dose of 350 mg, but the exposure profile after oral administration of the 525 mg dose was the same as that of the 350 mg dose. To clarify the underlying mechanism causing non-linear pharmacokinetics, a physiologically based absorption model of Compound I in beagle dogs and healthy volunteers was developed and used to evaluate the effect of particle size on in vivo dissolution, absorption, bioavailability, and systemic exposure of Compound I.

[0235] Materials and Methods Data Collection The data used for the development and validation of the physiologically based pharmacokinetic (PBPK) model of Compound I were obtained from in vivo non-clinical studies in dogs (Figure 13), clinical studies in healthy volunteers (Example 1), and in vitro experiments (Table 20).

[0236] Development of the PBPK Model Absorption models based on PBPK mechanisms include: (1) physicochemical and pharmacobiological properties obtained from in vitro experimental measurements or in silico estimates based on chemical structure using GastroPlus (version 9.6)'s ADMET Predictor (version 7.2); (2) formulation properties of the drug such as the raw drug particle size distribution, formulation type, and release or dissolution rate; (3) compartment model kinetic parameters such as systemic clearance, volume of distribution, and intercompartmental rate constants; and (4) gastrointestinal (GI) physiological parameters such as GI transit time, pH, absorption surface area, compartment dimensions, and water content. Existing physiological parameters of GastroPlus (version 9.6) for healthy US volunteers and beagle dogs under fasting conditions were used without modification.

[0237] The particle size distribution data of the tested batches are shown in Figure 13. The parameters input into the model are summarized in Table 20.

[0238] The Johnson dissolution model was selected to predict the in vivo dissolution rate and is described by the following Equation 1, which includes the change in particle radius during dissolution and the time-dependent diffusion layer thickness and shape factor to account for the dissolution of cylindrical particles.

Equation

[0239] Evaluation of the particle size effect Using a PBPK model for humans, the in vivo dissolution, absorption, and plasma concentration-time profiles after oral administration were predicted. The simulations were performed using the IR: suspension formulation option of GastroPlus and the particle size distribution data measured in vitro. Parameter sensitivity analysis was used to evaluate the effects of particle size distribution and dose on the in vivo dissolution, absorption, bioavailability, and systemic exposure of Compound I.

[0240] Results As shown in Figure 13, the bioavailability of Compound I in beagle dogs was approximately 100% after a single oral administration of 25 mg (3 mg / kg) or less of Compound I, regardless of the particle size distribution of the drug substance. The bioavailability was approximately 40% after oral administration of 100 mg of Compound I with Dv50 = 46 μm, and more than 100% after oral administration of 10 mg / kg of micronized Compound I (Dv50 = 3.2 μm). The predicted plasma concentration-time profiles, bioavailability, and systemic exposure parameters (F, C max , AUC last and AUC inf ) were equivalent to those observed in various canine studies (Figure 13) after intravenous or oral administration of a single dose of Compound I in solution or suspension formulation under fasting conditions. In humans, the predicted plasma concentration-time profiles (Figure 10) and systemic exposure parameters (C max , AUC last and AUC inf ) were equivalent to those observed in the clinical trial described in Example 1 (Figure 14). The prediction errors for all variables were within -26.3% to 16.1%, which were verified in both canine and human PBPK models.

Table 20

[0241] From this model, it was predicted that the bioavailability (F) and absorption fraction (Fa) in dogs and humans would decrease with increasing dose, which is consistent with the results observed in dogs. The decrease in the normalized systemic exposure after oral administration of a batch suspension of Compound I with Dv50 = 46 μm was suggested to be caused by the decrease in Fa. The decrease in bioavailability at higher doses was due to incomplete absorption, which is due to poor solubility, slow dissolution, and as a result, undissolved drug molecules are excreted in the feces.

[0242] By incorporating the particle size distribution information measured in vitro into the GastroPlus model, the in vivo dissolution, absorption, and plasma concentration-time profiles for Compound I with Dv50 = 46, 26, and 3.2 μm were simulated. The simulated in vivo absorption, in vivo dissolution, and plasma concentration-time profiles are shown in Figure 11. As shown in Figure 11, it was shown that the in vivo dissolution rate of Compound I with Dv50 = 3.2 μm was the fastest, and as a result, the absorption was the fastest and the peak plasma concentration was the highest. The local absorption profiles were also different. The percentage of the dose absorbed in different segments of the GI tract also differed among the three batches. The percentage of the absorbed dose was 97.4% in the small intestine and 2.4% in the colon for Compound I with Dv50 = 3.2 μm, while for Compound I with Dv50 = 46 μm, only 68% of the dose was absorbed in the small intestine and 23.8% of the dose was absorbed in the colon.

[0243] Parameter sensitivity analysis (PSA, Figure 12) revealed that the particle size distribution and dose had a significant impact on in vivo dissolution, absorption, and systemic exposure. At a 500 mg dose, even for micronized drug substance, the absorption fraction and systemic exposure were significantly decreased.

[0244] The results of PSA suggested that when the average particle diameter is 10 μm or less, the therapeutic dose can achieve optimal absorption at 50 - 100 mg twice a day.

[0245] Conclusion An absorption model based on the physiological mechanism of Compound I in dogs and healthy volunteers was developed and demonstrated to reproduce the plasma concentration-time profiles observed in various in vivo tests.

[0246] By PBPK modeling and simulation, it was demonstrated that the absorption of Compound I in both dogs and humans depends on the dose and particle size of the drug substance. Micronization of the drug substance of Compound I can increase the in vivo dissolution rate at doses higher than 3 mg / kg, resulting in increased absorption, bioavailability, and systemic exposure.

[0247] Alternative dosing Plasma concentration profiles for nine different dosing regimens (with food intake) were simulated for a target steady-state mean concentration of 2000 ng / mL to 4000 ng / mL (about 1000 ng / mL, excluding the 25 mg BID group as a special population). The steady state could be achieved with a maintenance dose twice as high in the BID dosing regimen and a loading dose 1.5 times as high in the QD dosing. See also Table 21 below. [Table 21]

[0248] Example 5: Open-label exploratory study of oral administration of Compound I in stable outpatients with primary dilated cardiomyopathy caused by MYH7 mutation This example describes a study aimed at establishing the safety and tolerability in advance regarding treatment with Compound I in patients with dilated cardiomyopathy caused by MYH7 mutation (MYH7-DCM subjects) that results in harmful changes in actin-myosin binding. The study also aims to (1) pre-confirm the effect of treatment with Compound I on cardiac pharmacodynamics (PD) determined by transthoracic echocardiogram (TTE) in MYH7-DCM subjects as compared to the baseline effect; and (2) pre-confirm the effect of Compound I on the daily activity level in MYH7-DCM subjects.

[0249] Materials and Methods Study Design This is a single-cohort, baseline-controlled, two-period open-label study (Figure 15) to investigate the safety and efficacy of Compound I in stable outpatients with primary DCM associated with MYH7 mutations. Up to a total of approximately 12 subjects are planned to be enrolled; additional cohorts may be enrolled. The predicted study duration is approximately 4 to 11 weeks, including approximately 1 to 8 weeks for screening, 9 to 15 days for IMP dosing, and approximately 1 week (7 ± 1 days) for follow-up visits.

[0250] Screening If permitted by local regulations, subjects may consent remotely in advance by confirming their genetic test results to pre-evaluate eligibility. Otherwise, at the first screening visit, subjects will be provided with anonymized genetic information after submitting their informed consent.

[0251] Subjects will undergo screening and eligibility assessment for up to 8 weeks (-8 weeks to -1 week) at one or several study visits as needed. Screening will be completed in 1 to 3 visits (V0, V1A, V1B), and screening will include, but not be limited to, for example, medical history, physical examination, safety tests, 12-lead ECG (3 times), and 1 to 2 TTEs.

[0252] Abnormal findings (e.g., sample hemolysis, abnormal potassium levels) from laboratory evaluations performed at V1 may be repeated once during screening after corrective measures.

[0253] If a backward-facing test is used for eligibility assessment, the heart rate monitoring patch is applied during the first TTE. If a second TTE is required, the patch is applied at the end of the second TTE / screening visit. The duration of the heart rate monitoring patch may be 5 to 14 days. If the patch is removed within 5 days, another patch should be applied.

[0254] Open-label treatment period All eligible patients then receive two open-label treatment periods with the active drug. Both treatment periods 1 and 2 last for 5 to 8 days each (i.e., period 1 from D1 to D5–D8, period 2 from D5–8 to D9–15), but they do not have to be the same duration.

[0255] Treatment period 1 (5–8 days): Visit 2 (day 1 of treatment period 1) should be conducted in the morning. The baseline assessment including TTE (see the assessment schedule, Appendix 1) is completed before the subject goes home and before the first dose of IMP to be taken by the subject is administered. The heart rate monitoring patch is applied at the end of visit 2. The subject is provided with IMP for administration at 25 mg twice a day for up to 8 days.

[0256] At the end of the visit, the subject is given clear instructions on how to take the open-label IMP treatment until the next visit (i.e., daily, twice a day, with food at each administration).

[0257] Contact with the patient 1: Three days before the end of treatment period 1 (V3), contact the subject to confirm compliance with the study treatment, confirm the scheduled time of the next visit (visit 3) with the subject, and have the subject take the medication (with food) approximately 7 hours before the scheduled time of visit 3 in the morning.

[0258] Visit 3 - end of treatment period 1 (days 5–8, scheduled in the afternoon): The subject returns for re-evaluation of safety, tolerability, PK, and PD responses.

[0259] The schedule window for Visit 3 is adjusted on weekends and holidays. The final dose of 25 mg IMP is taken in the morning, approximately 7 hours before arrival at the medical facility. Complete TTE and other test evaluations (including, but not limited to, test samples and PK blood samples, 12-lead ECG (3 times)). For example, there are no criteria for permanent discontinuation, although evaluation is performed, including the absence of excessive prolongation of QTcF (>500 milliseconds). Thereafter, the echocardiographer at each local facility carefully measures the SET. The change in SET from the baseline value (i.e., the change from the SET determined at V2) determines the dose for Treatment Period 2, which starts either on the night of that day with 50 mg BID or in the next morning with 10 mg BID.

[0260] Inspect the heartbeat monitoring patch. If the adhesive appears to be intact, the existing patch should be left as it is. If the adhesiveness has decreased or the patch has peeled off, a new patch is applied at that time.

[0261] Treatment Period 2 (5 - 8 days): From Visit 3 to Visit 4: Administer BID of Compound I with meals starting on the night of the last day of Treatment Period 1 or the next morning, depending on the SET result in the TTE performed at Visit 3.

[0262] Contact with the patient 2: Three days before the end of Treatment Period 2 (V4), contact the subject to confirm compliance with the test treatment, confirm the scheduled time for the next visit (Visit 4), and have the subject take the medication (with meals) approximately 7 hours before the scheduled arrival time at Visit 4 in the morning.

[0263] Visit 4 (scheduled 5 - 9 days after V3, i.e., on the 9th day (up to the 15th day)): The subject returns to the medical facility in the afternoon for evaluation of safety, tolerability, PK, and PD responses. The final dose of IMP for Treatment Period 2 is taken in the morning, approximately 7 hours before this medical facility visit. Complete additional test evaluations, including, but not limited to, clinical tests and PK blood samples and 12-lead ECG (3 times).

[0264] Follow-up Contact with patients 3: To evaluate safety, contact the subject 1 to 3 days after the final dose of the IMP.

[0265] Visit 5 - The final visit to the medical facility to evaluate the safety of the subject is conducted 7 (±1) days after the final dose of the IMP.

[0266] Selection criteria This study is conducted for patients who meet the following criteria: 1. Males or females aged 18 to 80 years at the time of screening visit 2. Clinically stable and diagnosed with primary dilated cardiomyopathy (DCM) associated with MYH7 mutation defined by all of the following: a. Subjects with primary DCM diagnosed with reduced ejection fraction heart failure without identified etiologies other than MYH7 mutation (e.g., coronary artery disease or severe valvular disease; acceptable if the presence of coronary artery disease, functional mitral regurgitation, or mild to moderate valvular disease is not considered a major factor in heart failure); b. Pathogenic or likely pathogenic mutations in the MYH7 gene; c. DCM is not secondary to long - standing MYH7 - related hypertrophic cardiomyopathy (HCM) or LV non - compressing cardiomyopathy; d. LVEF is 15 - 40% (occurring 2 times including at least once during the screening period): - If the result of the subject's most recent TTE (within the past 12 months) was LVEF ≤ 40%, it is necessary to undergo only 1 screening test to confirm that LVEF ≤ 40%; - If there is no previous result record of LVEF ≤ 40% by TTE within the past 12 months, 2 screening TTEs with an interval of at least 1 week (7 days) are required; - Furthermore, for the subject to be eligible, the absolute difference between the two LVEF values must be < 12%; e. At least mild left ventricular dilation according to the ASE criteria (LVEDD ≥ 3.1 cm / m for males2 For females, ≥ 3.2 cm / m 2 ); f. Receiving chronic medication for the treatment of heart failure reflecting current guidelines, including, unless intolerant or contraindicated, at least one of the following: β-blockers, ACE inhibitors, ARBs or ARNIs. Such treatment has been administered at a stable dose for at least 2 weeks without a change in the plan and is not scheduled to be changed during the trial. 3. Adequately rate-controlled sinus rhythm or stable atrial or ventricular pacing, or persistent atrial fibrillation, such that PD assessment by TTE is possible.

[0267] Exclusion Criteria Patients meeting any of the following criteria are excluded from the trial: 1. Inadequate echocardiographic windows for cardiac echo. 2. Patients having a QTcF interval > 480 milliseconds (mean of 3 ECGs not involving ventricular pacing or an extended QRS duration ≥ 120 milliseconds, Fridericia correction). 3. Subjects having a known pathogenic variant in another gene associated with DCM in addition to the MYH7 variant. 4. HFrEF mainly due to ischemic heart disease, chronic valvular disease or other conditions. 5. Recent (< 90 days) acute coronary syndrome or angina pectoris. 6. Those who have undergone coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) within the last 90 days. 7. Recent (< 90 days) hospitalization due to heart failure, use of IV diuretics or chronic IV inotropes, or other cardiovascular events (e.g., cerebrovascular disorders). 8. Moderate to severe known aortic valve stenosis. 9. Presence of the following ineligible cardiac rhythms that make cardiac echo evaluation impossible as determined by the principal investigator of the clinical trial: (a) rapid atrial fibrillation with an inadequately controlled heart rate, or (b) frequent ventricular premature contractions that may interfere with reliable echocardiographic measurement of LV function. 10. Hypersensitivity to Compound I or any component of the formulation of Compound I. 11. Clinically demonstrated active infectious diseases. 12. History of any malignant tumor within 5 years before screening. However, the following cancers that occurred more than 2 years before screening and were resected by surgery are excluded: non-invasive cervical cancer, non-melanoma skin cancer, non-invasive ductal breast cancer, and non-metastatic prostate cancer. 13. Severe renal insufficiency (defined as the current estimated glomerular filtration rate [eGFR] < 30 mL / min / 1.73 m2 by the simplified MDRD equation for diet therapy of kidney disease). 14. Serum potassium < 3.5 or > 5.5 mEq / L. 15. Persistent (more than 2 times) out-of-range safety test parameters (chemical, hematological) considered clinically significant. 16. History or evidence of other clinically significant disorders, conditions or diseases (including drug abuse) that threaten the safety of the subject, or interfere with the evaluation, procedure, completion of the trial, or lead to early withdrawal from the trial. 17. Life expectancy < 6 months. 18. Participants in clinical trials who received investigational drugs within 30 days before screening (or those currently using investigational medical devices), or each half-life is at least 5 times (whichever is longer).

[0268] Study treatment Subjects with stable MYH7-DCM who visit the hospital will participate in two consecutive open-label treatment periods of 5 to 8 days each.

[0269] Compound I is administered as 5 mg tablets (for 10 mg and 25 mg dosages) and 25 mg tablets (for 50 mg dosages). The tablets are blister-processed and then card-shaped; each blister card contains only 5 mg or only 25 mg.

[0270] Treatment period 1 The subject takes 25 mg of Compound I twice a day (every 12 hours). Administration may be carried out within ±2 hours from the scheduled dosing time, as long as the administrations are at least 10 hours apart and up to 14 hours or more, for at least 5 days to a maximum of 8 days. The first dose is taken in the morning on Day 1, and the last dose is taken as early as on the morning of Day 5 and as late as on the morning of Day 8 (corresponding to a total of 9 to 15 administrations for Period 1). An echocardiogram is performed in the afternoon on the last dosing day of Treatment Period 1, approximately 7 hours after the morning dose. The dose to be administered in Treatment Period 2 is determined by the change in systolic ejection time (SET) from the baseline measured by TTE by a sonographer at each local facility.

[0271] Treatment Period 2 At the end of Period 1, if the change in SET from the baseline (D1, before dosing) is >60 milliseconds, the subject is instructed to reduce the dose to 10 mg BID without taking a single dose.

[0272] At the end of Period 1, if the change in SET from the baseline (D1, before dosing) is ≤60 milliseconds, the subject is increased to 50 mg BID.

[0273] The first administration in Treatment Period 2 starts in the evening on the last day of Treatment Period 1 if the subject has the dose increased, and starts the next morning if the subject has the dose reduced. The administration in Period 2 is continued for 5 to 8 days, and the last dose in Period 2 is taken as early as on the morning of Day 9 and as late as on the morning of Day 15 (corresponding to a total of 7 to 14 administrations for Period 2).

[0274] For both treatment periods: · The subject is administered twice a day (every 12 hours). Administration may be carried out within ±2 hours from the scheduled dosing time, as long as the administrations are at least 10 hours apart and up to 14 hours apart. · Each administration is taken with food. The two treatment periods do not have to be the same duration.

[0275] Management of Pharmacological Effects in Overdose Based on non-clinical pharmacological properties, the effects of Compound I in overdose may cause myocardial ischemia. The duration of effect follows the PK profile of Compound I with a Tmax of 4 - 6 hours and a half-life of approximately 15 hours in healthy volunteers, although the half-life was slightly longer (20 - 25 hours) in HFrEF subjects taking Compound I. Clinical signs and symptoms that may include chest pain, dizziness, sweating, and ECG changes will begin to wane within a short time. Patients with symptoms and / or signs suggestive of myocardial ischemia should be immediately evaluated by a physician for the possibility of myocardial ischemia. In making this determination, all items including clinical signs, ECG, and serial cardiac biomarkers (e.g., troponin, CK-MB) as well as cardiac imaging (including coronary angiography if applicable) should be considered as the patients enrolled in the trial had baseline ECG abnormalities related to their heart failure symptoms and may possibly show an increase or fluctuation in troponin levels. If evidence of myocardial ischemia is present, subjects should receive standard treatment for ischemia as appropriate, including oxygen and nitrate supplementation. Since Compound I may prolong the SET, as a result, the diastolic duration may decrease and diastolic ventricular filling may decrease, caution is required when administering drugs that increase HR. Furthermore, since the pharmacological effects in overdose may increase myocardial oxygen demand, drugs that may further increase myocardial oxygen demand should be administered with caution.

[0276] Combination therapy Throughout the trial, to maintain the pre- and post-dose states as similar as possible and to minimize confounding factors for the assessment of the effects of Compound I, subjects should continue to take medications for the treatment of congestive heart failure and other medical conditions at the same doses and at the same times as much as possible during the trial.

[0277] All prescription and over-the-counter drugs should be reviewed. Over-the-counter drugs may be taken at a stable dose throughout the trial and not in an amount exceeding that indicated on the label. Consult a medical monitor for registration or dosing problems. Co-administration with Compound I and fluconazole (a potent CYP2C19 inhibitor and a moderate inhibitor of CYP2C9 and CYP3A4) and rifampin (a potent inducer of CYP3A4, CYP2C19 and CYP2C9) should be avoided. Other investigational drugs must be discontinued at least 30 days before screening or 5 half-lives (whichever is longer).

[0278] If the subject has an AE that requires treatment (including taking acetaminophen or ibuprofen), the dosing details including the administration time (start / stop), date, dose and indication should be recorded.

[0279] Evaluation and Procedures of the Trial I. Pharmacodynamic Evaluation Throughout this trial, the PD effect of Compound I is evaluated by serial TTE examinations according to a standardized imaging protocol and compared to baseline. The major TTE measurements include, but are not limited to: - Change in left ventricular systolic ejection time (SET) - Change in left ventricular systolic function parameters - Stroke volume (LVSV) - Ejection fraction (LVEF) - Longitudinal strain (LVGLS) and circumferential strain (LVGCS) - Left ventricular end-systolic dimension (LVEDVi, LVESVi) indexed to body surface area - Change in left ventricular diastolic parameters - Tissue Doppler imaging (TDI): mitral annulus velocity (e’) - E / A ratio - E / e’ ratio.

[0280] Changes in diurnal activity are investigated by tracking with a wearable device.

[0281] II. Pharmacokinetic Evaluation Blood samples are taken at peak time to measure the plasma concentration of Compound I (and potential metabolites).

[0282] III. Gene / Genotype / Pharmacogenetic / Biomarker Evaluation All subjects are requested to consent to blood sampling for the analysis of the future potential of genetic markers related to efficacy, safety, PD or PK parameters to be determined by future studies using clinically significant endpoints by DNA genotyping, direct sequencing or other genetic testing methods, provided that there are no local regulations prohibiting these analyses. If genetic or pharmacogenetic studies are conducted, genetic information will not be returned to the subjects.

[0283] IV. Pharmacodynamic Analysis TTE data for all measured parameters are analyzed using descriptive statistics. Changes from baseline are summarized at each time point. The measured values at each time point and the changes from baseline at each time point (either absolute or relative change rates) are summarized for each treatment period. Changes from baseline are analyzed taking into account the relationship with time after dosing and dose levels.

[0284] The relationship between the TTE endpoint and the plasma concentration of Compound I is evaluated using linear or non-linear correlation.

[0285] V. Pharmacokinetic Analysis Plasma concentration data for Compound I at different doses are appropriately summarized using descriptive statistics such as mean or geometric mean, standard deviation (SD), median, minimum and maximum values, and coefficient of variation percentage (CV%).

[0286] VI. Pharmacokinetic / Pharmacodynamic Analysis The correlation between the TTE parameter and the plasma concentration of Compound I is evaluated. Each subject is expected to provide PK and PD data at two drug exposure levels from the last dosing day of both treatment periods 1 and 2.

[0287] VII. Troponin Analysis Determine the number of subjects having an abnormal and / or increased troponin value (taking into account potential troponin increases at baseline). In the case of an abnormal and / or increased troponin value (taking into account the potential for baseline troponin increases frequently observed in heart failure), the subject shall be clinically evaluated for the possibility of myocardial ischemia. Also, if the subject has any symptoms or signs suggesting the possibility of myocardial ischemia, serial troponin (and other safety test items including CK-MB samples) should be obtained and subsequent dosing withheld until the likelihood of an ischemic event is fully understood. It is desirable to evaluate all clinical items (e.g., signs, symptoms, new troponin and CK-MB abnormalities) and correlate them with other relevant clinical findings, the subject's medical history, and test data to determine the clinical significance of the findings.

[0288] VIII. Safety Analysis AE, ECG, vital signs, and laboratory values are analyzed using descriptive statistics.

[0289] IX. Exploratory Analysis Changes in daily activity levels can be measured by a wearable device and summarized using descriptive statistics.

[0290] X. Restrictions on Subjects During the Trial Starting at screening and throughout the trial period, subjects should be instructed to maintain stable lifestyle habits. This includes, but is not limited to, the following: - Concomitant medications: Efforts should be made to maintain a stable dose of concomitant medications and to take such medications at a fixed time of day; for cardiovascular medications, this can minimize fluctuations in cardiac load conditions. - Activity level: Subjects should not engage in unfamiliar strenuous exercise from 72 hours before the first dose until the final follow-up visit. - Diet: Consume at a fixed time of day whenever possible (take Compound I twice a day with meals). - Avoid grapefruit or grapefruit juice, Seville oranges, and quinine (e.g., tonic water). - Fluid intake: Avoid excessive fluid intake and excessive alcohol intake.

[0291] Furthermore, the subject is required to refrain from donating blood or plasma from the time of screening until three months after the last visit for the final test.

[0292] Endpoints of the test The primary evaluation items are - AEs and SAEs after the start of treatment, and - Clinically significant abnormal values obtained from vital signs, physical examinations, ECG recordings, and safety laboratories Clinical safety and tolerance evaluated by

[0293] The secondary endpoints include the following PD parameters evaluated by TTE: - Systolic ejection time - Parameters of left ventricular systolic function including, but not limited to, LVSV, LVEF, LVESV, and LV strain are evaluated, - Parameters of left ventricular diastolic function including TDI (e’), E / A, and E / e’ are evaluated.

[0294] The exploratory endpoints are as follows: - The daily activity level measured by an accelerometer, and - Additional exploratory endpoints including PK can be included.

Claims

1. A pharmaceutical composition for treating systolic dysfunction in a patient, comprising Compound I, wherein Compound I has the structural formula (I): 【Chemistry 1】 or a pharmaceutically acceptable salt thereof, wherein Compound I is orally administered in a total daily dose of 10 to 350 mg.

2. the patient suffers from a syndrome or disorder selected from the group consisting of heart failure, cardiomyopathy, cardiogenic shock, conditions that would benefit from inotropic support after cardiac surgery, myocarditis, atherosclerosis, secondary aldosteronism, myocardial infarction, valvular disease, systemic hypertension, pulmonary hypertension or pulmonary arterial hypertension, adverse vascular remodeling, pulmonary edema, and respiratory failure; and, optionally, the heart failure is selected from heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), congestive heart failure, and diastolic heart failure (reduced contractile reserve); the cardiomyopathy is selected from ischemic cardiomyopathy, dilated cardiomyopathy, post-infarction cardiomyopathy, viral cardiomyopathy, toxic cardiomyopathy (optionally after anthracycline anti-cancer treatment), metabolic cardiomyopathy (optionally cardiomyopathy associated with enzyme replacement therapy), infiltrative cardiomyopathy (optionally amyloidosis), and diabetic cardiomyopathy; the condition that would benefit from post-cardiac surgery inotropic support is ventricular dysfunction resulting from vascular bypass surgery; the myocarditis is viral myocarditis, and / or 2. The pharmaceutical composition of claim 1, wherein the valvular disease is mitral valve regurgitation or aortic valve stenosis.

3. The pharmaceutical composition of claim 2, wherein the syndrome or disorder is chronic and / or stable.

4. The pharmaceutical composition according to any one of claims 1 to 3, wherein the patient has heart failure and has been diagnosed as any one of NYHA classes II to IV.

5. The pharmaceutical composition according to any one of claims 1 to 4, wherein the patient has symptomatic heart failure.

6. The pharmaceutical composition according to any one of claims 1 to 5, wherein the patient has acute heart failure.

7. A pharmaceutical composition for treating heart failure with reduced ejection fraction (HFrEF) in a patient, comprising Compound I, wherein Compound I has the structural formula (I): 【Chemistry 2】 or a pharmaceutically acceptable salt thereof, wherein Compound I is orally administered in a total daily dose of 10 to 350 mg.

8. The pharmaceutical composition according to claim 7, wherein the HFrEF is ischemic HFrEF.

9. The pharmaceutical composition of claim 7, wherein the HFrEF is dilated cardiomyopathy (DCM).

10. 10. The pharmaceutical composition of claim 9, wherein the patient has a genetic predisposition to DCM or inherited DCM.

11. The pharmaceutical composition of claim 10, wherein the hereditary DCM is associated with a MYH7 mutation.

12. The pharmaceutical composition according to any one of claims 1 to 11, wherein the patient exhibits mitral regurgitation.

13. The pharmaceutical composition according to any one of claims 1 to 12, wherein the patient has a left ventricular ejection fraction (LVEF) of less than 50%.

14. 14. The pharmaceutical composition of claim 13, wherein the patient has a LVEF of less than 40%, less than 35%, less than 30%, 15-35%, 15-40%, 15-50%, 20-45%, 40-49%, or 41-49%.

15. If the patient: a) Current angina pectoris; b) recent (<90 days) diagnosis of acute coronary syndrome; c) coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) within the past 3 months; and d) Uncorrected severe valvular disease 15. The pharmaceutical composition of any one of claims 1 to 14, wherein the composition does not comprise any one or combination of:

16. As a result of the treatment: a) reduced risk of cardiovascular mortality; b) reduced risk of cardiovascular-related hospitalization (including, but not limited to, worsening heart failure); c) improved athletic performance; d) improvement in the patient's NYHA classification; e) delay in clinical deterioration; and f) Reduction in the severity of cardiovascular-related symptoms The pharmaceutical composition according to any one of claims 1 to 15, wherein any one or combination of

17. Treatment results in improvement of NYHA classification and pVO2. ２ 17. The pharmaceutical composition of claim 16, wherein the composition results in improved athletic performance as measured by:

18. Improved athletic ability leads to peak VO ２ (pVO ２ 18. The pharmaceutical composition of claim 16 or 17, wherein the improvement in blood pressure is > 3 mL / kg / min.

19. Improved athletic ability leads to peak VO ２ (pVO ２ 18. The pharmaceutical composition of claim 16 or 17, wherein the improvement in blood pressure is > 1.5 mL / kg / min.

20. The pharmaceutical composition according to any one of claims 1 to 19, wherein the patient has a high NT-proBNP level.

21. 21. The pharmaceutical composition of claim 20, wherein the NT-proBNP level is 400 pg / mL or more.

22. 22. The pharmaceutical composition of any one of claims 1 to 21, wherein the patient is administered Compound I at 10 to 175 mg BID, 25 to 325 mg QD, or 25 to 350 mg QD.

23. 23. The pharmaceutical composition of claim 22, wherein Compound I is administered to a patient with a meal or within about 2 hours, about 1 hour, or about 30 minutes of a meal.

24. 24. The pharmaceutical composition according to any one of claims 1 to 23, wherein compound I is provided in solid form with an average particle size of greater than or equal to 15 μm in diameter or between 15 μm and 25 μm in diameter.

25. 25. The pharmaceutical composition of claim 24, wherein the patient is administered a QD dose of 200 mg or more.

26. 24. The pharmaceutical composition according to any one of claims 1 to 23, wherein compound I is provided in solid form with an average particle size of less than or equal to 10 μm in diameter.

27. 27. The pharmaceutical composition of claim 26, wherein the average particle size of Compound I is 1 μm to 10 μm in diameter or 1 μm to 5 μm in diameter.

28. The patient, a) administered a loading dose of Compound I of 50-250 mg; 28. The pharmaceutical composition of any one of claims 1-27, wherein b) thereafter a BID or QD maintenance dose regimen is continued for about 10-12 hours, optionally wherein the maintenance dose regimen is 10-75 mg BID (optionally 10, 25, 50 or 75 mg BID) or 75-125 mg QD.

29. 28. The pharmaceutical composition of any one of claims 1 to 27, wherein the patient is administered Compound I at 10 to 75 mg BID, optionally 10, 25, 50 or 75 mg BID.

30. 30. The pharmaceutical composition of any one of claims 1 to 29, wherein administration results in a plasma concentration of Compound I in a patient of 1000 to 8000 ng / mL.

31. 31. The pharmaceutical composition of claim 30, wherein administration results in a plasma concentration of Compound I of <2000 ng / mL, 1000-4000 ng / mL, 2000-3500 ng / mL, 2000-4000 ng / mL, or >3500 ng / mL.

32. The pharmaceutical composition according to any one of claims 1 to 31, wherein the patient has right ventricular heart failure.

33. 33. The pharmaceutical composition of claim 32, wherein the patient has pulmonary hypertension (i.e., pulmonary arterial hypertension).

34. The pharmaceutical composition according to any one of claims 1 to 33, wherein the patient has left ventricular heart failure.

35. The pharmaceutical composition of any one of claims 1 to 34, wherein treatment results in improved left ventricular function in the patient.

36. The pharmaceutical composition of claim 35, wherein the improvement in left ventricular function is an increase in ejection fraction; an increase in left ventricular fractional shortening; an increase in stroke volume; an increase in cardiac output; an improvement in longitudinal strain or circumferential strain; and / or an improvement in cardiac contractility as indicated by a decrease in the end-systolic and / or end-diastolic diameter of the left ventricle.

37. As a result of treatment, peak VO ２ 37. The pharmaceutical composition of any one of claims 1 to 36, which results in an improvement in a patient's function or exercise capacity as measured by reduced dyspnea, improvement in NYHA class, improvement in 6-minute walk test, or improvement in activity as determined by accelerometry.

38. The pharmaceutical composition according to any one of claims 1 to 37, further comprising administering an additional drug to improve the cardiovascular condition of the patient.

39. 39. The pharmaceutical composition of claim 38, wherein the additional agent is a beta-blocker, a diuretic, an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin II receptor blocker (ARB), a mineralocorticoid receptor antagonist, an angiotensin receptor-neprilysin inhibitor (ARNI), an sGC activator or modulator, or an antiarrhythmic agent.

40. 40. The pharmaceutical composition of claim 39, wherein the additional agent is an ARNI or SGLT2 inhibitor such as sacubitril / valsartan.

41. The pharmaceutical composition according to any one of claims 1 to 40, further comprising administering an analgesic if the patient experiences a headache.

42. 42. The pharmaceutical composition according to any one of claims 1 to 41, further characterized in that the patient is monitored for NT-proBNP levels, sinus tachycardia, ventricular tachycardia or palpitations.

43. 11. The pharmaceutical composition of claim 10, wherein the hereditary DCM is associated with a genetic mutation in a gene selected from ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CRYAB, CSRP3, DES, DMD, DSG2, EYA4, GATAD1, LAMA4, LDB3, LMNA, MYBPC3, MYH6, MYH7, MYPN, PLN, PSEN1, PSEN2, RBM20, SCN5A, SGCD, TAZ, TCAP, TMPO, TNNC1, TNNI3, TNNT2, TPM1, TTN, VCL, or any combination thereof.

44. 11. The pharmaceutical composition of claim 10, wherein the hereditary DCM is associated with a genetic mutation in a gene selected from ACTC1, DES, MYH6, MYH7, TNNC1, TNNI3, TNNT2, TTN, or any combination thereof.

45. The pharmaceutical composition of claim 10, wherein the hereditary DCM is associated with a TTN mutation.

46. ​​A pharmaceutical composition for treating contractile dysfunction in a subject, comprising Compound I, comprising: (a) administering to the subject an initial dose of Compound I in a first treatment period; (b) assessing the subject's prolongation of systolic ejection time (SET) after the first treatment period; (c) selecting a second dose of Compound I that is different from the first dose based on the assessment of SET prolongation; and (d) administering to the subject a second dose of Compound I during a second treatment period. wherein compound I is represented by the structural formula (I): 【Transformation 3】 or a pharmaceutically acceptable salt thereof.

47. The pharmaceutical composition of claim 46, wherein the subject is suffering from a syndrome or disorder selected from the group consisting of heart failure, cardiomyopathy, cardiogenic shock, conditions that benefit from inotropic support after cardiac surgery, myocarditis, atherosclerosis, secondary aldosteronism, myocardial infarction, valvular disease, systemic hypertension, pulmonary hypertension or pulmonary arterial hypertension, adverse vascular remodeling, pulmonary edema, and respiratory failure.

48. The pharmaceutical composition of claim 47, wherein the subject is suffering from a syndrome or disorder selected from the group consisting of heart failure, cardiomyopathy, and conditions that would benefit from inotropic support after cardiac surgery.

49. The heart failure is selected from heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), congestive heart failure, and diastolic heart failure; the cardiomyopathy is selected from ischemic cardiomyopathy, dilated cardiomyopathy, post-infarction cardiomyopathy, viral cardiomyopathy, toxic cardiomyopathy, metabolic cardiomyopathy, infiltrative cardiomyopathy, and diabetic cardiomyopathy; and 49. The pharmaceutical composition of claim 48, wherein the condition that would benefit from post-cardiac surgery inotropic support is ventricular dysfunction resulting from vascular bypass surgery.

50. A pharmaceutical composition described in claim 48 or 49, wherein the heart failure or cardiomyopathy is chronic and / or stable.

51. A pharmaceutical composition described in any one of claims 46 to 50, wherein the subject shows signs of heart failure of NYHA Class II to IV.

52. A pharmaceutical composition for treating cardiomyopathy in a subject, comprising Compound I, comprising: (a) administering to the subject an initial dose of Compound I in a first treatment period; (b) assessing the subject's prolongation of systolic ejection time (SET) after the first treatment period; (c) selecting a second dose of Compound I that is different from the first dose based on the assessment of SET prolongation; and (d) administering to the subject a second dose of Compound I during a second treatment period. wherein compound I is represented by the structural formula (I): 【Chemistry 4】 or a pharmaceutically acceptable salt thereof.

53. The pharmaceutical composition described in claim 52, wherein the cardiomyopathy is dilated cardiomyopathy (DCM).

54. The pharmaceutical composition described in claim 53, wherein the dilated cardiomyopathy is ischemic dilated cardiomyopathy.

55. A pharmaceutical composition described in any one of claims 52 to 54, wherein the subject has a genetic predisposition to DCM or hereditary DCM.

56. The pharmaceutical composition of claim 55, wherein the hereditary DCM is associated with a genetic mutation in a gene selected from ABCC9, ACTC1, ACTN2, ANKRD1, BAG3, CRYAB, CSRP3, DES, DMD, DSG2, EYA4, GATAD1, LAMA4, LDB3, LMNA, MYBPC3, MYH6, MYH7, MYPN, PLN, PSEN1, PSEN2, RBM20, SCN5A, SGCD, TAZ, TCAP, TMPO, TNNC1, TNNI3, TNNT2, TPM1, TTN, VCL, or any combination thereof.

57. The pharmaceutical composition of claim 55, wherein the hereditary DCM is associated with a genetic mutation in a gene selected from ACTC1, DES, MYH6, MYH7, TNNC1, TNNI3, TNNT2, TTN, or any combination thereof.

58. The pharmaceutical composition described in claim 57, wherein the hereditary DCM is associated with a genetic mutation in a gene selected from TTN or MYH7.

59. A pharmaceutical composition described in any one of claims 52 to 58, wherein the subject has heart failure.

60. The pharmaceutical composition described in claim 59, wherein the heart failure is heart failure with reduced ejection fraction (HFrEF).

61. A pharmaceutical composition for treating heart failure in a subject, comprising Compound I, comprising: (a) administering to the subject an initial dose of Compound I in a first treatment period; (b) assessing the subject's prolongation of systolic ejection time (SET) after the first treatment period; (c) selecting a second dose of Compound I that is different from the first dose based on the assessment of SET prolongation; and (d) administering to the subject a second dose of Compound I during a second treatment period. wherein compound I is represented by the structural formula (I): 【Transformation 5】 or a pharmaceutically acceptable salt thereof.

62. The pharmaceutical composition described in claim 61, wherein the heart failure is heart failure with reduced ejection fraction (HFrEF).

63. The pharmaceutical composition described in claim 62, wherein the HFrEF is ischemic HFrEF.

64. A pharmaceutical composition described in any one of claims 46 to 63, wherein assessing the subject's SET prolongation includes comparing the subject's SET prolongation to a threshold value and determining whether the SET prolongation is above or below the threshold value.

65. The pharmaceutical composition described in claim 64, wherein the subject's SET prolongation after the first treatment period exceeds a threshold value and the second dose is less than the initial dose.

66. The pharmaceutical composition of claim 65, wherein the initial dose is 25 mg BID and the second dose is 10 mg BID.

67. The pharmaceutical composition of claim 64, wherein the subject's SET prolongation after the first treatment period is below a threshold and the second dose is greater than the initial dose.

68. The pharmaceutical composition described in claim 67, wherein the initial dose is 25 mg BID and the second dose is 50 mg BID.

69. A pharmaceutical composition described in any one of claims 64 to 68, wherein the threshold is 60 milliseconds.

70. A pharmaceutical composition described in any one of claims 64 to 68, wherein the threshold is 75 milliseconds.

71. A pharmaceutical composition described in any one of claims 64 to 68, wherein the threshold is 50 milliseconds.

72. A pharmaceutical composition described in any one of claims 64 to 68, wherein the subject's SET prolongation includes a SET prolongation measurement in a single echocardiogram or two SET prolongation measurements in two consecutive echocardiograms.

73. A pharmaceutical composition described in any one of claims 46 to 63, wherein the initial dose is administered twice daily.

74. The pharmaceutical composition of claim 73, wherein the second dose is administered twice daily.

75. A pharmaceutical composition described in any one of claims 46 to 63, wherein the initial dose is 10 to 75 mg BID.

76. The pharmaceutical composition described in claim 75, wherein the second dose is 10 to 75 mg BID and is an amount different from the first dose.

77. A pharmaceutical composition described in any one of claims 46 to 63, wherein the initial dose is 25 mg BID.

78. The pharmaceutical composition of claim 77, wherein the second dose is 10 mg or 50 mg BID.

79. A pharmaceutical composition described in any one of claims 46 to 78, wherein the first treatment period is 5 to 8 days.

80. A pharmaceutical composition described in any one of claims 46 to 79, wherein the second treatment period is 5 to 8 days.

81. A pharmaceutical composition described in any one of claims 46 to 80, wherein the assessment of SET prolongation is determined by transthoracic echocardiography (TTE).

82. The pharmaceutical composition described in any one of claims 46 to 81, further characterized in that if SET prolongation exceeds a threshold, administration of a dose of compound I or a pharmaceutically acceptable salt thereof after the first treatment period is omitted.

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