METHODS OF TREATING CANCER USING TRIMETAZIDINE-BASED COMPOUNDS

[0001] This application claims the benefit of, and priority to, U.S. Provisional Patent Application No. 62/819,798, filed Mar. 18, 2019, the contents of which are incorporated by reference.

[0002] The application is related to compositions and methods for treating a subject having cancer.

[0003] Each year over 8 million people die worldwide from cancer or cancer-related illnesses. Cancer results from unchecked cell growth, and the unregulated cells invade other parts of the body, hijack nutritional resources, and impair the function of other tissues. Cancer is an indiscriminate killer: although lifestyle factors, such as smoking and diet, can increase one's risk of getting cancer, many cancers are attributable to a person's genetic makeup or to unknown causes. Nearly two in five people will be diagnosed with cancer at some point in their lives.

[0004] The invention provides methods for treatment of subjects having cancer by providing compounds that shift cellular metabolism from fatty acid oxidation to glucose oxidation. The invention recognizes that fatty acid oxidation promotes survival of many types of cancer cells by increasing ATP production, preventing apoptosis, and combating oxidative stress. By providing compounds that decrease fatty acid oxidation, the methods of the invention combat such survival mechanisms and inhibit the growth and proliferation of cancer cells.

[0005] The compounds that shift metabolism from fatty acid oxidation to glucose oxidation may be derivatives of trimetazidine. Where trimetazidine itself can cause Parkinsonian symptoms for a portion of the population, the methods of the invention overcome this issue by delivering the molecule in a modified form. Without being limited by any particular theory or mechanism of action, it is also believed that delivery of trimetazidine as a component of a larger molecule may improve its efficacy and mitigate its side effects.

[0006] The methods may include providing compounds that include a molecule that shifts cellular metabolism from fatty acid oxidation to glucose oxidation linked to a molecule, such as nicotinic acid, that serves as a precursor for synthesis of nicotinamide adenine dinucleotide (NAD⁺). Such compounds can be metabolized in the body to allow the individual components to exert distinct biochemical effects to increase glucose oxidation relative to fatty acid oxidation and improve overall mitochondrial respiration.

[0007] In an aspect, the invention provides methods of treating cancer in a subject. The methods include providing to the subject a composition comprising a compound represented by formula (VII):

A-C  (VII),

in which:

[0008] A includes a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation; and

[0009] C is a NAD⁺ precursor molecule.

[0010] The cancer may be any type of cancer, such as bladder cancer, brain cancer, breast cancer, carcinoma, cervical cancer, colon cancer, colorectal cancer, gastric cancer, glioblastoma, glioma, head and neck cancer, kidney cancer, leukemia, liposarcoma, liver cancer, lung cancer, lymphoma, medullablastoma, melanoma, muscle cancer, neuroblastoma, oligoastrocytoma, oligodendroglioma, osteosarcoma, ovarian cancer, pancreatic cancer, paraganglioma, prostate cancer, sarcoma, or thyroid cancer.

[0011] The composition may be administered in a single unit dose. The composition may be administered in a dose including multiple units.

[0012] The composition may be formulated for any route of administration. For example, the composition may be formulated for oral or intravenous administration.

[0013] A may be PEGylated with an ethylene glycol moiety. For example, the ethylene glycol moiety may have the formula (CH₂CH₂O)_x, in which x=1-15.

[0014] C may be covalently linked to A. The covalent linkage may be via the ethylene glycol moiety, or it may not be via the ethylene glycol moiety.

[0015] A may be trimetazidine, etomoxir, perhexiline, a PPAR agonist, a malonyl CoA decarboxylase inhibitor, or dichloroacetate.

[0016] C may be nicotinic acid, nicotinamide, or nicotinamide riboside.

[0017] The compound may be represented by formula (X):

[0018] The method may include providing a second cancer therapy. The second cancer therapy may be or include surgery, radiation therapy, chemotherapy, or immunotherapy.

[0019] In another aspect, the invention provides methods of treating cancer in a subject by providing to the subject a composition comprising a compound represented by formula (VIII):

A-L-C  (VIII),

in which:

[0020] A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation;

[0021] L is a linker; and

[0022] C is a NAD⁺ precursor molecule.

[0023] The cancer may any type of cancer, such as any of those described above.

[0024] The composition may be administered as a single unit dose or in a dose comprising multiple units, as described above.

[0025] The composition may be formulated for any route of administration, as described above.

[0026] A may include any of the elements described above.

[0027] C may include any of the elements described above.

[0028] L may have the formula (CH₂CH₂O)_x, in which x=1-15.

[0029] The compound may be represented by formula (X), as show

[0030] The compound may be represented by formula (X):

[0031] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0032] In another aspect, the invention provides methods of treating cancer in a subject by providing to the subject a composition comprising a compound represented by formula (VI):

in which:

[0033] at least one of positions A, B, C, D, E, and F is substituted with —(CH₂CH₂O)_nH and n=1-15.

[0034] The cancer may any type of cancer, such as any of those described above.

[0035] The composition may be administered as a single unit dose or in a dose comprising multiple units, as described above.

[0036] The composition may be formulated for any route of administration, as described above.

[0037] The compound may have a substitution at position F. For example, the compound may be represented by formula (IX):

[0038] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0039] In another aspect, the invention includes methods of treating cancer in a subject by providing to the subject a composition comprising a compound represented by formula (I):

A-L-B  (I),

in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, L is a linker, and B is a compound that promotes mitochondrial respiration.

[0040] The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may be trimetazidine, etomoxir, perhexiline, a PPAR agonist, a malonyl CoA decarboxylase inhibitor, or dichloroacetate.

[0041] The compound that promotes mitochondrial respiration may be an intermediate of the citric acid cycle or a molecule that can be metabolized to enter the citric acid cycle. For example, the compound may be succinate, fumarate, malate, oxaloacetate, citrate, isocitrate, α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyric acid, β-ketopentanoate, or β-hydroxypentanoate.

[0042] The linker may be any suitable linker that can be cleaved in vivo. The linker may be an alkoxy group. The linker may be polyethylene glycol of any length. Preferably, the linker is represented by (CH₂CH₂O)_x, in which x=1-15.

[0043] The compound may include a NAD⁺ precursor molecule covalently linked to another component of the compound. The NAD⁺ precursor molecule may be nicotinic acid, nicotinamide, or nicotinamide riboside. The NAD⁺ precursor molecule may be attached to the compound that shifts cellular metabolism, the compound that promotes mitochondrial respiration, or the linker. The NAD⁺ precursor molecule may be attached to another component via an additional linker. Preferably, the NAD⁺ precursor molecule is attached to the compound that promotes mitochondrial respiration via a 1,3-propanediol linkage.

[0044] The compound of formula (I) may be represented by formula (II):

in which y=1-3.

[0045] The compound of formula (I) may be represented by formula (III):

in which y=1-3.

[0046] The cancer may any type of cancer, such as any of those described above.

[0047] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0048] In another aspect, the invention includes methods of treating cancer in a subject by providing to the subject a composition comprising a compound represented by formula (IV):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴ and R⁵ together are ═O, —O(CH₂)_mO—, or —(CH₂)_m—, in which m=2-4, or R⁴ is H and R⁵ is OR¹⁴, SR¹⁴, or (CH₂CH₂O)_nH, in which R¹⁴ is H or a (C₁-C₄)alkyl group and n=1-15; and R⁶ is a single or multi-ring structure optionally substituted at one or more ring positions by a heteroatom, in which each ring position optionally comprises one or more substituents.

[0049] One or more ring position of R⁶ may include a substituent that includes a compound that promotes mitochondrial respiration, such as succinate, fumarate, malate, oxaloacetate, citrate, isocitrate, α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyric acid, β-ketopentanoate, or β-hydroxypentanoate. The substituent may include a linker, such as (CH₂CH₂O)_x, in which x=1-15. The substituent may include a NAD⁺ precursor molecule, such as nicotinic acid, nicotinamide, and nicotinamide riboside.

[0050] The substituent on a ring position of R⁶ may be

in which y=1-3.

[0051] The substituent on a ring position of R⁶ may be

in which y=1-3.

[0052] R⁶ may be

[0053] The compound of formula (IV) may have a structure represented formula (IX) or formula (X):

[0054] The cancer may any type of cancer, such as any of those described above.

[0055] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0056] In another aspect, the invention includes methods of treating cancer in a subject by providing to the subject a composition comprising a compound represented by formula (V):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴ and R⁵ together are ═O, —O(CH₂)_mO—, or —(CH₂)_m—, in which m=2-4, or R⁴ is H and R⁸ is H, OR¹⁴, SR¹⁴, or (CH₂CH₂O)_nH, in which R¹⁴ is H or a (C₁-C₄)alkyl group and n=1-15; R⁹, R¹⁰, R¹², and R¹³ are independently H or (CH₂CH₂O)_zH, in which z=1-6; and R¹¹ comprises a compound that promotes mitochondrial respiration.

[0057] The compound that promotes mitochondrial respiration may be an intermediate of the citric acid cycle or a molecule that can be metabolized to enter the citric acid cycle. For example, the compound may be succinate, fumarate, malate, oxaloacetate, citrate, isocitrate, α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyric acid, β-ketopentanoate, or β-hydroxypentanoate.

[0058] R¹¹ may include a linker, such as polyethylene glycol. For example, R¹¹ may include (CH₂CH₂O)_x, in which x=1-15.

[0059] R¹¹ may be

in which y=1-3.

[0060] R¹¹ may include a NAD⁺ precursor molecule. For example, R¹¹ may include nicotinic acid, nicotinamide, or nicotinamide riboside.

[0061] R¹¹ may be

in which y=1-3.

[0062] The cancer may any type of cancer, such as any of those described above.

[0063] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0064] In another aspect, the invention includes methods of treating cancer in a subject by providing to the subject a compound represented by formula (VII):

A-C  (VII),

in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, and C is a NAD⁺ precursor molecule. A and C may be covalently linked.

[0065] The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may be trimetazidine, etomoxir, perhexiline, a PPAR agonist, a malonyl CoA decarboxylase inhibitor, or dichloroacetate.

[0066] The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may be PEGylated with an ethylene glycol moiety. The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may have multiple ethylene glycol moieties, such as one, two three, four, five, or more ethylene glycol moieties. The ethylene glycol moiety may be represented by (CH₂CH₂O)_x, in which x=1-15. The ethylene glycol moiety may form a covalent linkage between the compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation and the NAD⁺ precursor molecule. The ethylene glycol moiety may be separate from a covalent linkage between the compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation and the NAD⁺ precursor molecule. The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may be a PEGylated form of trimetazidine.

[0067] The NAD⁺ precursor molecule may be nicotinic acid, nicotinamide, or nicotinamide riboside.

[0068] The compound of formula (VII) may include nicotinic acid that is covalently linked to a PEGylated form of trimetazidine. The nicotinic acid may be covalently linked via the PEGylated moiety, i.e., via an ethylene glycol linkage. The nicotinic acid may be covalently linked via the trimetazidine moiety.

[0069] The compound of formula (VII) may have a structure represented by formula (X), as shown above.

[0070] The cancer may any type of cancer, such as any of those described above.

[0071] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0072] In another aspect, the invention includes methods of treating cancer in a subject by providing to the subject a compound represented by formula (VIII):

A-L-C  (VIII),

in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, L is a linker, and C is a NAD⁺ precursor molecule. A may be covalently linked to L, and L may be covalently linked to C.

[0073] The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, the linker, and the NAD⁺ precursor molecule may be as described above in relation to compounds of other formulas.

[0074] The compound of formula (VIII) may have a structure represented by formula (X), as shown above.

[0075] Any of the compounds described above may include one or more atoms that are enriched for an isotope. For example, the compounds may have one or more hydrogen atoms replaced with deuterium or tritium. The isotopically enriched atom or atoms may be located at any position within the compound.

[0076] The cancer may any type of cancer, such as any of those described above.

[0077] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0078] In another aspect, the invention includes methods of treating cancer in a subject by providing to the subject a composition that includes at least two of A, B, and C, in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation as described above, B is a compound that promotes mitochondrial respiration as described above, and C is a NAD⁺ precursor molecule as described above. The compositions may include A, B, and C. Each of components A, B, and C may be provided as a separate molecule, or two or more of the components may be covalently linked in a single molecule. For example, components A and B may be covalently linked in a single molecule, and C may be provided as a separate molecule.

[0079] The compositions may include co-crystals of two or more separate molecules that include two or more of components A, B, and C. For example, a co-crystal may include (1) a compound of formula (I), (III), (IV), or (V) and (2) nicotinic acid, nicotinamide, or nicotinamide riboside. Preferably the co-crystal includes nicotinamide.

[0080] The compounds may be provided in any suitable manner. The compounds may be provided in a single composition. Alternatively, the compounds may not be provided in a single composition. For example, one or two of the compounds may be provided in a single composition, and another compound may be provided in a separate composition. Alternatively, each compound may be provided in a separate composition. The compounds may be provided simultaneously or sequentially. The compounds may be provided at different intervals, with different frequency, or in different quantities.

[0081] The cancer may any type of cancer, such as any of those described above.

[0082] The method may include providing a second cancer therapy, such as surgery, radiation therapy, chemotherapy, or immunotherapy, as described above.

[0162] The invention provides methods for treating a subject having a cancer by providing compositions that contain compounds that shift metabolism from fatty acid oxidation to glucose oxidation Glucose oxidation and fatty acid oxidation are energy-producing metabolic pathways that compete with each other for substrates. In glucose oxidation, glucose is broken down to pyruvate via glycolysis in the cytosol of the cell. Pyruvate then enters the mitochondria, where it is converted to acetyl coenzyme A (acetyl-CoA). In beta-oxidation of fatty acids, which occurs in the mitochondria, two-carbon units from long-chain fatty acids are sequentially converted to acetyl-CoA.

[0163] The remaining steps in energy production from oxidation of glucose or fatty acids are common to the two pathways. Acetyl-CoA is oxidized to carbon dioxide (CO₂) via the citric acid cycle, which results in the conversion of nicotinamide adenine dinucleotide (NAD⁺) to its reduced form, NADH. NADH, in turn, drives the mitochondrial electron transport chain. The electron transport chain comprises a series of four mitochondrial membrane-bound complexes that transfer electrons via redox reactions and pump protons across the membrane to create a proton gradient. The redox reactions of the electron transport chain require molecular oxygen (O₂). Finally, the proton gradient enables another membrane-bound enzymatic complex to form high-energy ATP molecules, the source of energy for most cellular reactions.

[0164] Fatty acid oxidation promotes survival of cancer cells via a variety of mechanisms. For example, glucose uptake and catabolism are decreased in cells derived from solid tumors that undergo loss of attachment (LOA) to the extracellular matrix. However, fatty acid oxidation provides an alternative source of ATP that allows such cells to survive. In certain leukemias, fatty acid oxidation counters pro-apoptotic signals death in response to mitochondrial permeability to prevent programmed cell death. Fatty acid oxidation also serves as a source of NADPH, the reduced form of nicotinamide adenine dinucleotide phosphate, which combats oxidative stress in cancer cells.

[0165] In some embodiments, the compositions are compounds represented by formula (I):

A-L-B  (I),

in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, L is a linker, and B is a compound that promotes mitochondrial respiration.

[0166] Component A may be any suitable compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation. Such compounds can be classified based on their mechanism of action. See Fillmore, N., et al., Mitochondrial fatty acid oxidation alterations in heart failure, ischemic heart disease and diabetic cardiomyopathy, Brit. J. Pharmacol. 171:2080-2090 (2014), incorporated herein by reference.

[0167] One class of glucose-shifting compounds includes compounds that inhibit fatty acid oxidation directly. Compounds in this class include inhibitors of malonyl CoA decarboxylase (MCD), carnitine palmitoyl transferase 1 (CPT-1), or mitochondrial fatty acid oxidation. Mitochondrial fatty acid oxidation inhibitors include trimetazidine and other compounds described in WO 2002/064576, which is incorporated herein by reference. Trimetazidine binds to distinct sites on the inner and outer mitochondrial membranes and affects both ion permeability and metabolic function of mitochondria. Morin, D., et al., Evidence for the existence of [³H]-trimetazidine binding sites involved in the regulation of the mitochondrial permeability transition pore, Brit. J. Pharmacol. 123:1385-1394 (1998), incorporated herein by reference. MCD inhibitors include CBM-301106, CBM-300864, CBM-301940, 5-(1,1,1,3,3,3-hexafluoro-2-hydroxypropan-2-yl)-4,5-dihydroisoxazole-3-carboxamides, methyl 5-(N-(4-(1,1,1,3,3,3-hexafluoro-2-hydroxypropan-2-yl)phenyl)morpholine-4-carboxamido)pentanoate, and other compounds described in Chung, J. F., et al., Discovery of Potent and Orally Available Malonyl-CoA Decarboxylase Inhibitors as Cardioprotective Agents, J. Med. Chem. 49:4055-4058 (2006); Cheng J. F. et al., Synthesis and structure-activity relationship of small-molecule malonyl coenzyme A decarboxylase inhibitors, J. Med. Chem. 49:1517-1525 (2006); US Publication No. 2004/0082564; and WO 2002/058698, which are incorporated herein by reference. CPT-1 inhibitors include oxfenicine, perhexiline, etomoxir, and other compounds described in WO 2015/018660, WO 2008/109991; WO 2009/015485; US Publication No. 2011/0212072; and WO 2009/156479, which are incorporated herein by reference.

[0168] Another class of glucose-shifting compounds includes compounds that stimulate glucose oxidation directly. Examples of such compounds are described in US Publication No. 2003/0191182; WO 2006/117686; U.S. Pat. No. 8,202,901, which are incorporated herein by reference.

[0169] Another class of glucose-shifting compounds includes compounds that decrease the level of circulating fatty acids that supply the heart. Examples of such compounds include agonists of PPARα and PPARγ, including fibrate drugs, such as clofibrate, gemfibrozil, ciprofibrate, bezafibrate, and fenofibrate, and thiazolidinediones, GW-9662, and other compounds described in U.S. Pat. No. 9,096,538, which is incorporated herein by reference.

[0170] Component L may be any suitable linker. Preferably, the linker can be cleaved in vivo to release components A and B. The linker may be an alkoxy group. The linker may be polyethylene glycol of any length. The linker may be represented by (CH₂CH₂O)_x, in which x=1-15 or (CH₂CH₂O)_x, in which x=1-3. Other suitable linkers include 1,3-propanediol, diazo linkers, phosphoramidite linkers, disulfide linkers, cleavable peptides, iminodiacetic acid linkers, thioether linkers, and other linkers described in Leriche, G., et al., Cleavable linkers in chemical biology, Bioorg. Med. Chem. 20:571-582 (2012); WO 1995000165; and U.S. Pat. No. 8,461,117, which are incorporated herein by reference.

[0171] Component B may be any compound that promotes mitochondrial respiration. For example, component B may be an intermediate of the citric acid cycle or a molecule that can be metabolized to enter the citric acid cycle, such as succinate, fumarate, malate, oxaloacetate, citrate, isocitrate, α-ketoglutarate, pyruvate, acetone, acetoacetic acid, β-hydroxybutyric acid, β-ketopentanoate, or β-hydroxypentanoate. Intermediates of the citric acid cycle may become depleted if these molecules are used for biosynthetic purposes, resulting in inefficient generation of ATP from the citric acid cycle. However, due to the anaplerotic effect, providing one intermediate of the citric acid cycle leads to restoration of all intermediates as the cycle turns. Thus, intermediates of the citric acid cycle can promote mitochondrial respiration.

[0172] The compound may include a NAD⁺ precursor molecule. NAD⁺ is an important oxidizing agent that acts as a coenzyme in multiple reactions of the citric acid cycle. In these reactions, NAD⁺ is reduced to NADH. Conversely, NADH is oxidized back to NAD⁺ when it donates electrons to mitochondrial electron transport chain. In humans, NAD⁺ can be synthesized de novo from tryptophan, but not in quantities sufficient to meet metabolic demands. Consequently, NAD⁺ is also synthesized via a salvage pathway, which uses precursors that must be supplied from the diet. Among the precursors used by the salvage pathway for NAD⁺ synthesis are nicotinic acid, nicotinamide, and nicotinamide riboside. By providing a NAD⁺ precursor, such as nicotinic acid, nicotinamide, or nicotinamide riboside, the compound facilitates NAD⁺ synthesis.

[0173] The inclusion of a NAD⁺ precursor in compounds of the invention allows the compounds to stimulate energy production in cellular mitochondria in multiple ways. First, component A shifts cellular metabolism from fatty acid oxidation to glucose oxidation, which is inherently more efficient. Next, component B ensures that the intermediates of the citric acid cycle are present at adequate levels and do not become depleted or limiting. As a result, glucose-derived acetyl CoA is efficiently oxidized. Finally, the NAD⁺ precursor provides an essential coenzyme that cycles between oxidized and reduced forms to promote respiration. In the oxidized form, NAD⁺ drives reactions of the citric acid cycle. In the reduced form, NADH promotes electron transport to create a proton gradient that enables ATP synthesis. Consequently, the chemical potential resulting from oxidation of acetyl CoA is efficiently converted to ATP that can be used for various cellular functions.

[0174] The NAD⁺ precursor molecule may be covalently attached to the compound in any suitable manner. For example, it may linked to A, L, or B, and it may be attached directly or via another linker. Preferably, it is attached via a linker that can be cleaved in vivo. The NAD⁺ precursor molecule may be attached via a 1,3-propanediol linkage.

[0175] The compound may be covalently attached to one or more molecules of polyethylene glycol (PEG), i.e., the compound may be PEGylated. In many instances, PEGylation of molecules reduces their immunogenicity, which prevents the molecules from being cleared from the body and allows them to remain in circulation longer. The compound may contain a PEG polymer of any size. For example, the PEG polymer may have from 1-500 (CH₂CH₂O) units. The PEG polymer may have any suitable geometry, such as a straight chain, branched chain, star configuration, or comb configuration. The compound may be PEGylated at any site. For example, the compound may be PEGylated on component A, component B, component L, or, if present, the NAD⁺ precursor. The compound may be PEGylated at multiple sites. For a compound PEGylated at multiple sites, the various PEG polymers may be of the same or different size and of the same or different configuration.

[0176] The compound may be a PEGylated form of trimetazidine. For example, the compound may be represented by formula (VI):

in which one or more of the carbon atoms at positions A, B, C, D, and E and/or the nitrogen atom at position F are substituted with —(CH₂CH₂O)_nH and n=1-15. The carbon atoms at positions A, B, C, D, and E may have two PEG substituents. In molecules that have multiple PEG chains, the different PEG chains may have the same or different length.

[0177] The compounds of formula (I) may be represented by formula (II):

in which y=1-3.

[0178] The compounds of formula (I) may be represented by formula (III):

in which y=1-3.

[0179] The invention also provides compounds represented by formula (IV):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴ and R⁵ together are ═O, —O(CH₂)_mO—, or —(CH₂)_m—, in which m=2-4, or R⁴ is H and R⁵ is OR¹⁴, SR¹⁴, or (CH₂CH₂O)_nH, in which R¹⁴ is H or a (C₁-C₄)alkyl group and n=1-15; and R⁶ is a single or multi-ring structure optionally substituted at one or more ring positions by a heteroatom, in which each ring position optionally comprises one or more substituents.

[0180] R⁶ may be a single or multi-ring structure of any size. For example, the structure may contain 3-22 atoms, not including hydrogen atoms bonded to atoms in ring positions. The structure may include one or more alkyl, alkenyl, or aromatic rings. The structure may include one or more heteroatoms, i.e., atoms other than carbon. For example, the heteroatom may be oxygen, nitrogen, or sulfur, or phosphorus.

[0181] One or more ring position of R⁶ may include a substituent that includes a compound that promotes mitochondrial respiration, as described above in relation to component B of formula (I). The substituent may include a linker, as described above in relation to component L of formula (I). The substituent may include a NAD⁺ precursor molecule, as described above in relation to compounds of formula (I).

[0182] The substituent on a ring position of R⁶ may be

in which y=1-3.

[0183] The substituent on a ring position of R⁶ may be

in which y=1-3.

[0184] R⁶ may be

[0185] For some compounds of the invention that include trimetazidine prodrugs, analogs, derivatives, it is advantageous to have the trimetazidine moiety substituted with a single ethylene glycol moiety. Thus, preferred compositions of the invention include compounds of formulas (I) and (VIII) that contain linkers in which x=1, compounds of formulas (II) and (III) in which y=1, compounds of formula (V) in which z=1, compounds of formula (VI) in which n=1, and compounds of formula (VII) in which A is linked to C via a single ethylene glycol moiety. Without wishing to be bound by theory, the attachment of a single ethylene glycol moiety to the trimetazidine moiety may improve the bioavailability of trimetazidine.

[0186] The compound of formula (IV) may have structure represented by formula (IX) or formula (X):

[0187] The invention also provides compounds represented by formula (V):

in which R¹, R², and R³ are independently H or a (C₁-C₄)alkyl group; R⁴ and R⁸ together are ═O, —O(CH₂)_mO—, or —(CH₂)_m—, in which m=2-4, or R⁴ is H and R⁸ is H, OR¹⁴, SR¹⁴, or (CH₂CH₂O)_nH, in which R¹⁴ is H or a (C₁-C₄)alkyl group and n=1-15; R⁹, R¹⁰, R¹², and R¹³ are independently H or (CH₂CH₂O)_zH, in which z=1-15; and R¹¹ comprises a compound that promotes mitochondrial respiration, as described above in relation to component B of formula (I). R¹¹ may include a linker, as described above in relation to component L of formula (I).

[0188] R¹¹ may be

in which y=1-3.

[0189] R¹¹ may include a NAD⁺ precursor molecule, as described above in relation to compounds of formula (I).

[0190] R¹¹ may be

in which y=1-3.

[0191] In some embodiments described above, compounds of the invention include multiple active agents joined by linkers in a single molecule. It may be advantageous to deliver multiple active agentas components of a single molecule. Without wishing to be bound by a particular theory, there are several reasons why co-delivery of active agents in a single molecule may be advantageous. One possibility is that a single large molecule may have reduced side effects compared to the component agents. Free trimetazidine causes symptoms similar to those in Parkinson's disease in a fraction of patients. However, when trimetazidine is derivatized to include other components, such as succinate, the molecule is bulkier and may not be able to access sites where free trimetazidine can causes unintended effects. Trimetazidine derivatized as described above is also more hydrophilic and thus may be less likely to cross the blood-brain barrier to cause neurological effects. Another possibility is that modification of trimetazidine may alter its pharmacokinetic properties. Because the derivatized molecule is metabolized to produce the active agent, the active agent is released gradually. Consequently, levels of the active agent in the body may not reach peaks as high as when a comparable amount is administered in a single bolus. Another possibility is that less of each active agent, such as trimetazidine, is required because the compounds of the invention include multiple active agents. For example, trimetazidine shifts metabolism from fatty acid oxidation to glucose oxidation, and succinate improves mitochondrial respiration generally. Thus, a compound that provides both agents stimulates a larger increase in glucose-driven ATP production for a given amount of trimetazidine than does a compound that delivers trimetazidine alone.

[0192] The invention also provides compounds represented by formula (VII):

A-C  (VII),

in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, and C is a NAD⁺ precursor molecule. A and C may be covalently linked.

[0193] The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may be PEGylated with an ethylene glycol moiety. The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may have multiple ethylene glycol moieties, such as one, two three, four, five, or more ethylene glycol moieties. The ethylene glycol moiety may be represented by (CH₂CH₂O)_x, in which x=1-15. The ethylene glycol moiety may form a covalent linkage between the compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation and the NAD⁺ precursor molecule. The ethylene glycol moiety may be separate from a covalent linkage between the compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation and the NAD⁺ precursor molecule.

[0194] The compound of formula (VII) may include nicotinic acid that is covalently linked to a PEGylated form of trimetazidine. The nicotinic acid may be covalently linked via a PEGylated moiety, i.e., via an ethylene glycol linkage. The nicotinic acid may be covalently linked via the trimetazidine moiety.

[0195] The invention also provides compounds represented by formula (VIII):

A-L-C  (VIII),

in which A is a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, L is a linker, and C is a NAD⁺ precursor molecule. A may be covalently linked to L, and L may be covalently linked to C.

[0196] The compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, the linker, and the NAD⁺ precursor molecule may be as described above in relation to compounds of other formulas.

[0197] The invention also provides compositions that include at least two of (1) a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, (2) a compound that promotes mitochondrial respiration, and (3) a NAD⁺ precursor molecule. The aforementioned components of the composition may be provided as separate molecules.

[0198] The compositions may include each of a (1) a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, (2) a compound that promotes mitochondrial respiration, and (3) a NAD⁺ precursor molecule. In such compositions, each of the three components may be provided as a separate molecule. Alternatively, in such compositions, two of the components may be covalently linked as part of single molecule, and the third component may be provided as a separate molecule. For example, the compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation may be linked to the compound that promotes mitochondrial respiration, and the NAD⁺ precursor may be provided as a separate molecule.

[0199] The compounds of the invention may be provided as co-crystals with other compounds. Co-crystals are crystalline materials composed of two or more different molecules in the same crystal lattice. The different molecules may be neutral and interact non-ionically within the lattice. Co-crystals of the invention may include one or more compounds of the invention with one or more other molecules that stimulate mitochondrial respiration or serve as NAD⁺ precursors. For example, a co-crystal may include any of the following combinations: (1) a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation and (2) a NAD⁺ precursor molecule; (1) a compound that promotes mitochondrial respiration and (2) a NAD⁺ precursor molecule; (1) a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation and (2) a compound that promotes mitochondrial respiration; (1) a molecule comprising a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation covalently linked to a compound that promotes mitochondrial respiration and (2) a NAD⁺ precursor molecule. In specific embodiments, a co-crystal may include (1) a compound of formula (I), (III), (IV), or (V) and (2) nicotinic acid, nicotinamide, or nicotinamide riboside.

[0200] The compounds may include one or more atoms that are enriched for an isotope. For example, the compounds may have one or more hydrogen atoms replaced with deuterium or tritium. Isotopic substitution or enrichment may occur at carbon, sulfur, or phosphorus, or other atoms. The compounds may be isotopically substituted or enriched for a given atom at one or more positions within the compound, or the compounds may be isotopically substituted or enriched at all instances of a given atom within the compound.

[0201] The invention provides pharmaceutical compositions containing one or more of the compounds described above. A pharmaceutical composition containing the compounds may be in a form suitable for oral use, for example, as tablets, troches, lozenges, fast-melts, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, syrups or elixirs. Compositions intended for oral use may be prepared according to any method known in the art for the manufacture of pharmaceutical compositions and such compositions may contain one or more agents selected from sweetening agents, flavoring agents, coloring agents and preserving agents, in order to provide pharmaceutically elegant and palatable preparations. Tablets contain the compounds in admixture with non-toxic pharmaceutically acceptable excipients which are suitable for the manufacture of tablets. These excipients may be for example, inert diluents, such as calcium carbonate, sodium carbonate, lactose, calcium phosphate or sodium phosphate; granulating and disintegrating agents, for example corn starch, or alginic acid; binding agents, for example starch, gelatin or acacia, and lubricating agents, for example magnesium stearate, stearic acid or talc. The tablets may be uncoated or they may be coated by known techniques to delay disintegration in the stomach and absorption lower down in the gastrointestinal tract and thereby provide a sustained action over a longer period. For example, a time delay material such as glyceryl monostearate or glyceryl distearate may be employed. They may also be coated by the techniques described in U.S. Pat. Nos. 4,256,108, 4,166,452 and 4,265,874, to form osmotic therapeutic tablets for control release. Preparation and administration of compounds is discussed in U.S. Pat. No. 6,214,841 and U.S. Pub. 2003/0232877, incorporated by reference herein in their entirety.

[0202] Formulations for oral use may also be presented as hard gelatin capsules in which the compounds are mixed with an inert solid diluent, for example calcium carbonate, calcium phosphate or kaolin, or as soft gelatin capsules in which the compounds are mixed with water or an oil medium, for example peanut oil, liquid paraffin or olive oil.

[0203] An alternative oral formulation, where control of gastrointestinal tract hydrolysis of the compound is sought, can be achieved using a controlled-release formulation, where a compound of the invention is encapsulated in an enteric coating.

[0204] Aqueous suspensions may contain the compounds in admixture with excipients suitable for the manufacture of aqueous suspensions. Such excipients are suspending agents, for example sodium carboxymethylcellulose, methylcellulose, hydroxypropylmethylcellulose, sodium alginate, polyvinylpyrrolidone, gum tragacanth and gum acacia; dispersing or wetting agents such as a naturally occurring phosphatide, for example lecithin, or condensation products of an alkylene oxide with fatty acids, for example, polyoxyethylene stearate, or condensation products of ethylene oxide with long chain aliphatic alcohols, for example heptadecaethyleneoxycetanol, or condensation products of ethylene oxide with partial esters derived from fatty acids and a hexitol such a polyoxyethylene with partial esters derived from fatty acids and hexitol anhydrides, for example polyoxyethylene sorbitan monooleate. The aqueous suspensions may also contain one or more preservatives, for example ethyl, or n-propyl p-hydroxybenzoate, one or more coloring agents, one or more flavoring agents, and one or more sweetening agents, such as sucrose or saccharin.

[0205] Oily suspensions may be formulated by suspending the compounds in a vegetable oil, for example, arachis oil, olive oil, sesame oil or coconut oil, or in a mineral oil such as liquid paraffin. The oily suspensions may contain a thickening agent, for example beeswax, hard paraffin or cetyl alcohol. Sweetening agents such as those set forth above, and flavoring agents may be added to provide a palatable oral preparation. These compositions may be preserved by the addition of an anti-oxidant such as ascorbic acid.

[0206] Dispersible powders and granules suitable for preparation of an aqueous suspension by the addition of water provide the compounds in admixture with a dispersing or wetting agent, suspending agent and one or more preservatives. Suitable dispersing or wetting agents and suspending agents are exemplified, for example sweetening, flavoring and coloring agents, may also be present.

[0207] The pharmaceutical compositions of the invention may also be in the form of oil-in-water emulsions. The oily phase may be a vegetable oil, for example olive oil or arachis oil, or a mineral oil, for example liquid paraffin or mixtures of these. Suitable emulsifying agents may be naturally-occurring gums, for example gum acacia or gum tragacanth, naturally occurring phosphatides, for example soya bean, lecithin, and esters or partial esters derived from fatty acids and hexitol anhydrides, for example sorbitan monooleate and condensation products of the said partial esters with ethylene oxide, for example polyoxyethylene sorbitan monooleate. The emulsions may also contain sweetening and flavoring agents.

[0208] Syrups and elixirs may be formulated with sweetening agents, such as glycerol, propylene glycol, sorbitol or sucrose. Such formulations may also contain a demulcent, a preservative, and agents for flavoring and/or coloring. The pharmaceutical compositions may be in the form of a sterile injectable aqueous or oleaginous suspension. This suspension may be formulated according to the known art using those suitable dispersing or wetting agents and suspending agents which have been mentioned above. The sterile injectable preparation may also be in a sterile injectable solution or suspension in a non-toxic parenterally acceptable diluent or solvent, for example as a solution in 1,3-butanediol. Among the acceptable vehicles and solvents that may be employed are water, Ringer's solution and isotonic sodium chloride solution. In addition, sterile, fixed oils are conventionally employed as a solvent or suspending medium. For this purpose any bland fixed oil may be employed including synthetic mono- or di-glycerides. In addition, fatty acids such as oleic acid find use in the preparation of injectables.

[0209] The compounds of the invention are useful for improving cardiac efficiency. A variety of definitions of cardiac efficiency exist in the medical literature. See, e.g., Schipke, J. D. Cardiac efficiency, Basic Res. Cardiol. 89:207-40 (1994); and Gibbs, C. L. and Barclay, C. J. Cardiac efficiency, Cardiovasc. Res. 30:627-634 (1995), incorporated herein by reference. One definition of cardiac mechanical efficiency is the ratio of external cardiac power to cardiac energy expenditure by the left ventricle. See Lopaschuk G. D., et al., Myocardial Fatty Acid Metabolism in Health and Disease, Phys. Rev. 90:207-258 (2010), incorporated herein by reference. Another definition is the ratio between stroke work and oxygen consumption, which ranges from 20-25% in the normal human heart. Visser, F., Measuring cardiac efficiency: is it useful? Hear Metab. 39:3-4 (2008), incorporated herein by reference. Another definition is the ratio of the stroke volume to mean arterial blood pressure. Any suitable definition of cardiac efficiency may be used to measure the effects of compounds of the invention. The invention also provides methods of altering cellular metabolism in a subject to increase glucose oxidation relative to fatty acid oxidation. The methods may include providing a composition of the invention, such as any the compounds described above, including the compounds represented by formulas (I), (II), (III), (IV), or (V) or formulations thereof.

[0210] The methods may include providing a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, as described above, and a compound that promotes mitochondrial respiration, as described above. The compounds may be provided as components of a single molecule, as separate molecules in a single composition, or as separate compositions.

[0211] The methods may also include providing a NAD⁺ precursor molecule, as described above. In methods that involve providing a compound that shifts cellular metabolism from fatty acid oxidation to glucose oxidation, a compound that promotes mitochondrial respiration, and a NAD⁺ precursor molecule, compounds may be provided as components of a single molecule, two different molecules, or three different molecules. The compounds may be provided in one, two, three, or any number of different compositions. The compounds may be provided together, separately, or in any combination. The compounds may be provided simultaneously or sequentially. The compounds may be provided at different intervals, with different frequency, in different quantities, or at different dosages.

[0212] The invention also provides methods of treating cancer using compositions described herein. For example and without limitation, the cancer may be bladder cancer, brain cancer, breast cancer, carcinoma, cervical cancer, colon cancer, colorectal cancer, gastric cancer, glioblastoma, glioma, head and neck cancer, kidney cancer, leukemia, liposarcoma, liver cancer, lung cancer, lymphoma, medullablastoma, melanoma, muscle cancer, neuroblastoma, oligoastrocytoma, oligodendroglioma, osteosarcoma, ovarian cancer, pancreatic cancer, paraganglioma, prostate cancer, sarcoma, or thyroid cancer.

[0213] The methods may include providing a second cancer therapy to the subject. For example and without limitation, the second cancer therapy may be or include surgery, radiation therapy, chemotherapy, or immunotherapy.

[0214] Chemotherapy may include one or more chemotherapeutic agents. The chemotherapeutic agent may be an alkylating agent, antiemetabolite, anti-microtubule agent, topoisomerase inhibitor, or cytotoxic antibiotic. For example and without limitation, the chemotherapeutic agent may be 5-fluorouracil, abiraterone, bevacizumab, bleomycin, bortezomib, capecitabine, cetuximab, cisplatin, cyclophosphamide, dacarbazine, denosumab, docetaxel, doxorubicin, enzalutamide, epirubicin, erlotinib, etoposide, everolimus, folinic acid, human papillomavirus quadrivalent, ibrutinib, imatinib, lenalidomide, leuprorelin, methotrexate, mustine, nilotinib, nivolumab, oxaliplatin, palbociclib, pembrolizumab, pemetrexed, pertuzumab, prednisolone, procarbazine, rituximab, ruxolitinib, trastuzumab, vinblastine, vincristine, or vinorelbine.

[0215] Protocol

[0216] The effects of compounds of the invention on mitochondrial function were analyzed. HepG2 cells were dosed with test compound and in real time the extracellular oxygen levels and pH were measured using the XFe96 flux analyzer (Seahorse Biosciences). XFe Technology uses solid-state sensors to simultaneously measure both oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) to determine effects on oxidative phosphorylation (OXPHOS) and glycolysis simultaneously. The cells were then subjected to sequential exposure to various inhibitors of mitochondrial function to assess cellular metabolism.

[0217] Data Interpretation.

[0218] A compound was identified as positive mitochondrial-active compound when it caused a change in oxygen consumption rate (OCR) or extracellular acidification rate (ECAR) in the absence of cytotoxicity. Cytotoxicity was determined when both OXPHOS (OCR) and glycolysis (ECAR) were inhibited.

[0219] Definition of Mitochondrial Parameters.

[0220] Oxygen consumption rate (OCR) is a measurement of oxygen content in extracellular media. Changes in OCR indicate effects on mitochondrial function and can be bi-directional. A decrease is due to an inhibition of mitochondrial respiration, while an increase may indicate an uncoupler, in which respiration is not linked to energy production.

$OCR=\frac{\mathrm{compound}OCR-\mathrm{non}\mathrm{mitochondrial}OCR}{\mathrm{basal}OCR-\mathrm{non}\mathrm{mitochondrial}OCR}$

[0221] Extracellular acidification rate (ECAR) is the measurement of extracellular proton concentration (pH). An increase in signal means an increase in rate in number of pH ions (thus decreasing pH value) and seen as an increase in glycolysis. ECAR is expressed as a fraction of basal control (rate prior to addition of compound).

$ECAR=\frac{\mathrm{compound}ECAR}{\mathrm{basal}ECAR}$

[0222] Reserve capacity is the measured ability of cells to respond to an increase in energy demand. A reduction indicates mitochondrial dysfunction. This measurement demonstrates how close to the bioenergetic limit the cell is.

$\mathrm{reserve}\mathrm{capacity}=\frac{FCCPOCR-\mathrm{non}\mathrm{mitochondrial}OCR}{\mathrm{basal}OCR-\mathrm{non}\mathrm{mitochondrial}OCR}$

[0223] Mitochondrial Stress Test.

[0224] A series of compounds were added sequentially to the cells to assess a bioenergetics profile, effects of test compounds on parameters such as proton leak, and reserve capacity. This can be used to assist in understanding potential mechanisms of mitochondrial toxicity. The following compounds were added in order: (1) oligomycin, (2) FCCP, and (3) rotenone and antimycin A.

[0225] Oligomycin is a known inhibitor of ATP synthase and prevents the formation of ATP. Oligomycin treatment provides a measurement of the amount of oxygen consumption related to ATP production and ATP turnover. The addition of oligomycin results in a decrease in OCR under normal conditions, and residual OCR is related to the natural proton leak.

[0226] FCCP is a protonophore and is a known uncoupler of oxygen consumption from ATP production. FCCP treatment allows the maximum achievable transfer of electrons and oxygen consumption rate and provides a measurement of reserve capacity.

[0227] Rotenone and antimycin A are known inhibitors of complex I and III of the electron transport chain, respectively. Treatment with these compounds inhibits electron transport completely, and any residual oxygen consumption is due to non-mitochondrial activity via oxygen requiring enzymes.

[0228] Definition of Mechanisms.

[0229] An electron transport chain inhibitor is an inhibitor of mitochondrial respiration that causes an increase in glycolysis as an adaptive response (e.g. decrease OCR and increase in ECAR).

[0230] The inhibition of oxygen consumption may also be due to reduced substrate availability (e.g. glucose, fatty acids, glutamine, pyruvate), for example, via transporter inhibition.

[0231] Compounds that reduce the availability of substrates are substrate inhibitors. A substrate inhibitor does not result in an increase in glycolysis (e.g. OCR decrease, no response in ECAR).

[0232] Compounds that inhibit the coupling of the oxidation process from ATP production are known as uncouplers. These result in an increase in mitochondrial respiration (OCR) but inhibition of ATP production.

[0233] FIG. 1 is a table summarizing the effects of various compounds on mitochondrial function.

[0234] FIG. 2 is a table summarizing the effects of nicotinamide on various mitochondrial functional parameters.

[0235] FIG. 3 is a series of graphs showing the effects of nicotinamide on oxygen consumption rate and reserve capacity.

[0236] FIG. 4 is a series of graphs showing the effects of nicotinamide on extracellular acidification rate.

[0237] FIG. 5 is a table summarizing the effects of a combination of trimetazidine and nicotinamide on various mitochondrial functional parameters.

[0238] FIG. 6 is a series of graphs showing the effects of a combination of trimetazidine and nicotinamide on oxygen consumption rate and reserve capacity.

[0239] FIG. 7 is a series of graphs showing the effects of a combination of trimetazidine and nicotinamide on extracellular acidification rate.

[0240] FIG. 8 is a table summarizing the effects of succinate on various mitochondrial functional parameters.

[0241] FIG. 9 is a series of graphs showing the effects of succinate on oxygen consumption rate and reserve capacity.

[0242] FIG. 10 is a series of graphs showing the effects of succinate on extracellular acidification rate.

[0243] FIG. 11 is a table summarizing the effects of compound CV-8816 on various mitochondrial functional parameters.

[0244] FIG. 12 is a series of graphs showing the effects of compound CV-8816 on oxygen consumption rate and reserve capacity.

[0245] FIG. 13 is a series of graphs showing the effects of compound CV-8816 on extracellular acidification rate.

[0246] FIG. 14 is a table summarizing the effects of compound CV-8814 on various mitochondrial functional parameters.

[0247] FIG. 15 is a series of graphs showing the effects of compound CV-8814 on oxygen consumption rate and reserve capacity.

[0248] FIG. 16 is a series of graphs showing the effects of compound CV-8814 on extracellular acidification rate.

[0249] FIG. 17 is a table summarizing the effects of trimetazidine on various mitochondrial functional parameters.

[0250] FIG. 18 is a series of graphs showing the effects of trimetazidine on oxygen consumption rate and reserve capacity.

[0251] FIG. 19 is a series of graphs showing the effects of trimetazidine on extracellular acidification rate.

[0252] FIG. 20 is a table summarizing the effects of compound CV-8815 on various mitochondrial functional parameters.

[0253] FIG. 21 is a series of graphs showing the effects of compound CV-8815 on oxygen consumption rate and reserve capacity.

[0254] FIG. 22 is a series of graphs showing the effects of compound CV-8815 on extracellular acidification rate.

[0255] FIG. 23 is a table summarizing the effects of a combination of succinate, nicotinamide, and trimetazidine on various mitochondrial functional parameters.

[0256] FIG. 24 is a series of graphs showing the effects of a combination of succinate, nicotinamide, and trimetazidine on oxygen consumption rate and reserve capacity.

[0257] FIG. 25 is a series of graphs showing the effects of a combination of succinate, nicotinamide, and trimetazidine on extracellular acidification rate.

[0258] FIG. 26 is a table summarizing the effects of a combination of trimetazidine analog 2 and nicotinamide on various mitochondrial functional parameters.

[0259] FIG. 27 is a series of graphs showing the effects of a combination of trimetazidine analog 2 and nicotinamide on oxygen consumption rate and reserve capacity.

[0260] FIG. 28 is a series of graphs showing the effects a combination of trimetazidine analog 2 and nicotinamide on extracellular acidification rate.

[0261] FIG. 29 is a table summarizing the effects of a combination of trimetazidine analog 1 and nicotinamide on various mitochondrial functional parameters.

[0262] FIG. 30 is a series of graphs showing the effects of a combination of trimetazidine analog 1 and nicotinamide on oxygen consumption rate and reserve capacity.

[0263] FIG. 31 is a series of graphs showing the effects of a combination of trimetazidine analog 1 and nicotinamide on extracellular acidification rate.

[0264] FIG. 32 is a table summarizing the effects of a combination of trimetazidine analog 3 and nicotinamide on various mitochondrial functional parameters.

[0265] FIG. 33 is a series of graphs showing the effects of a combination of trimetazidine analog 3 and nicotinamide on oxygen consumption rate and reserve capacity.

[0266] FIG. 34 is a series of graphs showing the effects of a combination of trimetazidine analog 3 and nicotinamide on extracellular acidification rate.

[0267] FIG. 35 is a table summarizing the effects of a combination of succinate and nicotinamide on various mitochondrial functional parameters.

[0268] FIG. 36 is a series of graphs showing the effects of a combination of succinate and nicotinamide on oxygen consumption rate and reserve capacity.

[0269] FIG. 37 is a series of graphs showing the effects of a combination of succinate and nicotinamide on extracellular acidification rate.

[0270] Effect of Compositions on Coronary Flow, Cardiac Function, and Infarct Size.

[0271] The effect of compositions on the coronary flow, cardiac function, and infarct size was analyzed.

[0272] FIG. 38 is a schematic of the ischemia-reperfusion (IR) method used to analyze the effects of compositions of the invention on coronary flow, cardiac function, and infarct size. At time 0, mice were given (1) 20 μM trimetazidine (TMZ), (2) 2 μM each of trimetazidine, nicotinamide, and succinate (TNF), (3) 20 μM each of trimetazidine, nicotinamide, and succinate (TNS), or (4) the delivery vehicle (CON). At 20 minutes, ischemia was induced, and coronary flow was analyzed. At 50 minutes, reperfusion was initiated to restore blood flow. At 170 minutes, coronary flow and cardiac function was analyzed, and then the hearts were preserved, sectioned, and infarct size was measured by triphenyltetrazolium chloride (TTC) staining.

[0273] FIG. 39 is a graph of coronary flow of after IR. Data is expressed as ratio cardiac flow at 170 minutes to cardiac flow at 20 minutes. TNS treatment preserved coronary flow after IR. Raw data is provided in Tables 1-2.

TABLE 1
	CF20 (ml/min)	CF170 (ml/min)	CF170/CF20 (ul/m1)
CON11	2.31E+00	1.11E−01	4.81E+01
CON13	1.07E+00	4.80E−02	4.48E+01
CON14	8.28E−01	4.50E−02	5.43E+01
CON9	2.11E+00	6.96E−02	3.30E+01
CON10	1.85E+00	4.92E−02	2.66E+01
CON7	1.57E+00	5.40E−02	3.44E+01
CON8	3.22E+00	6.78E−02	2.11E+01
CON5	2.18E+00	6.60E−02	3.03E+01
CON3	2.24E+00	7.92E−02	3.53E+01
CON4	2.22E+00	7.84E−02	3.53E+01
CON2	1.68E+00	5.12E−02	3.05E+01
MEAN	1.93E+00	6.54E−02	3.58E+01
SD	6.50E−01	1.94E−02	9.72E+00
SE	1.96E−01	5.86E−03	2.93E+00
TTEST
TMZ4	2.13E+00	5.16E−02	2.42E+01
TMZ3	1.70E+00	1.00E−01	5.87E+01
TMZ1	2.18E+00	7.78E−02	3.57E+01
TMZ2	3.83E+00	1.29E−01	3.37E+01
TMZ7	1.72E+00	8.98E−02	5.21E+01
TMZ8	2.40E+00	6.56E−02	2.73E+01
TMZ5	2.14E+00	5.56E−02	2.60E+01
TMZ9	2.03E+00	1.30E−01	6.39E+01
MEAN	2.27E+00	8.74E−02	4.02E+01
SD	6.75E−01	3.06E−02	1.57E+01
SE	2.39E−01	1.08E−02	5.56E+00
TTEST
TNF1	2.24E+00	4.80E−02	2.14E+01
TNF2	2.24E+00	3.80E−02	1.69E+01
TNF3	7.32E−01	4.80E−02	6.56E+01
TNF4	8.20E−01	4.90E−02	5.98E+01
TNF5	1.09E+00	2.70E−02	2.48E+01
TNF6	9.48E−01	1.50E−01	1.58E+02
TNF7	8.08E−01	3.70E−02	4.58E+01
TNF8	1.20E+00	4.60E−02	3.83E+01
TNF9	1.45E+00	1.21E−01	8.33E+01
TNF10	1.20E+00	1.52E−02	1.27E+01
MEAN	1.27E+00	5.79E−02	5.27E+01
SD	5.56E−01	4.28E−02	4.37E+01
SE	1.76E−01	1.35E−02	1.38E+01
TTEST	2.21E−02	6.06E−01	2.26E−01
TNS1	1.52E+00	4.70E−02	3.08E+01
TNS2	9.30E−01	2.90E−02	3.12E+01
TNS3	2.24E+00	1.67E−01	7.46E+01
TNS5	5.64E−01	5.00E−02	8.87E+01
TNS6	6.28E−01	4.40E−02	7.01E+01
TNS7	1.08E+00	6.40E−02	5.95E+01
TNS8	8.72E−01	2.30E−02	2.64E+01
TNS9	1.18E+00	8.50E−02	7.23E+01
TNS10	1.70E+00	1.84E−01	1.08E+02
MEAN	1.19E+00	7.70E−02	6.24E+01
SD	5.43E−01	5.89E−02	2.82E+01
SE	1.81E−01	1.96E−02	9.42E+00
TTEST	1.35E−02	5.45E−01	8.80E−03
vs TMZ			6.82E−02

	TABLE 2
		CON	TMZ	TNF	TNS
	MEAN	36	40	53	62
	SD	10	16	44	28
	SE	3	6	14	9

[0274] FIG. 40 is graph of left ventricular developed pressure (LVDP) after IR. Blue bars indicate LVDP at 20 minutes, and orange bars indicate LVDP at 170 minutes. TMZ, TNS, and TNF treatment prevented a decline in cardiac function after IR. Raw data is provided in Tables 3-6.

TABLE 3
	pre-
	ischemia	LVESP	LVEDP	HR	LVDP	LVDP × HR
5-18-CN	CON11	6.61E+01	6.20E+00	3.28E+02	5.99E+01	1.97E+04
	CON12	8.15E+01	3.73E+00	3.56E+02	7.78E+01	2.77E+04
6-10-CN	CON13	8.00E+01	−3.74E+00	1.37E+02	8.37E+01	1.15E+04
	CON14	7.28E+01	6.12E+00	4.54E+02	6.67E+01	3.03E+04
5-15-CN	CON9	8.07E+01	5.00E+00	1.42E+02	7.57E+01	1.08E+04
	CON10	4.91E+01	1.15E+00	3.21E+02	4.80E+01	1.54E+04
5-12-CN	CON7	8.55E+01	6.35E+00	3.05E+02	7.91E+01	2.42E+04
	CON8	5.06E+01	1.68E+00	3.04E+02	4.90E+01	1.49E+04
5-9-CN	CONS	5.45E+01	5.63E+00	2.75E+02	4.89E+01	1.35E+04
	CON6	6.37E+01	4.31E+00	3.08E+02	5.94E+01	1.83E+04
5-7-CN	CON3	7.32E+01	2.70E+00	2.40E+02	7.05E+01	1.69E+04
	CON4	4.91E+01	1.65E−01	3.14E+02	4.89E+01	1.54E+04
5-5-CN	CON1	9.48E+01	7.96E+00	3.04E+02	8.68E+01	2.64E+04
	CON2	4.69E+01	1.64E−01	4.02E+02	4.67E+01	1.88E+04
	MEAN	6.77E+01	3.39E+00	2.99E+02	6.44E+01	1.88E+04
	SD	1.58E+01	3.21E+00	8.52E+01	1.46E+01	6.12E+03
	SE	4.21E+00	8.57E−01	2.28E+01	3.91E+00	1.63E+03
	TTEST				2.42E−04
5-14-TMZ	TMZ3	7.58E+01	6.53E+00	2.63E+02	6.93E+01	1.83E+04
	TMZ4	8.44E+01	5.43E+00	2.93E+02	7.90E+01	2.31E+04
5-11-TMZ	TMZ1	7.15E+01	6.76E+00	1.66E+02	6.48E+01	1.08E+04
	TMZ2	5.47E+01	1.74E+00	3.35E+02	5.30E+01	1.77E+04
5-8-TMZ	TMZ7	6.87E+01	3.58E+00	3.58E+02	6.51E+01	2.33E+04
	TMZ8	4.27E+01	4.71E+00	3.33E+02	3.80E+01	1.26E+04
5-6-TMZ	TMZ5	3.30E+01	4.77E+00	3.48E+02	2.82E+01	9.82E+03
	TMZ6	3.30E+01	1.46E+00	3.21E+02	3.15E+01	1.01E+04
5-4-TMZ	TMZ9	6.60E+01	7.25E+00	2.67E+02	5.87E+01	1.57E+04
	TMZ10	7.38E+01	2.70E+00	3.32E+02	7.11E+01	2.36E+04
	MEAN	6.03E+01	4.49E+00	3.02E+02	5.59E+01	1.68E+04
	SD	1.85E+01	2.07E+00	5.75E+01	1.77E+01	5.56E+03
	SE	5.84E+00	6.56E−01	1.82E+01	5.58E+00	1.76E+03
					3.85E−01
5-19-TNF	TNF1	5.02E+01	3.04E+00	4.09E+02	4.72E+01	1.93E+04
	TNF2	4.65E+01	1.76E−01	2.76E+02	4.63E+01	1.28E+04
6-8-TNF	TNF3	7.13E+01	1.53E+00	6.48E+01	6.97E+01	4.52E+03
	TNF4	9.97E+01	4.15E+00	1.54E+02	9.55E+01	1.47E+04
6-12-TNF	TNF5	7.14E+01	−3.42E+00	2.77E+02	7.49E+01	2.07E+04
	TNF6	8.98E+01	8.85E+00	3.10E+02	8.09E+01	2.51E+04
6-14-TNF	TNF7	6.58E+01	7.01E+00	3.98E+02	5.88E+01	2.34E+04
	TNF8	5.99E+01	1.02E+00	2.28E+02	5.89E+01	1.34E+04
6-15-TNF	TNF9	7.89E+01	2.37E−01	2.71E+02	7.87E+01	2.13E+04
	TNF10	4.01E+01	1.88E+00	3.14E+02	3.82E+01	1.20E+04
	MEAN	6.74E+01	2.45E+00	2.70E+02	6.49E+01	1.67E+04
	SD	1.90E+01	3.54E+00	1.04E+02	1.81E+01	6.32E+03
	SE	6.00E+00	1.12E+00	3.28E+01	5.73E+00	2.00E+03
					1.38E−01
5-20-TNS	TNS1	5.59E+01	5.23E+00	3.33E+02	5.07E+01	1.69E+04
	TNS2	5.54E+01	−1.83E+00	1.24E+02	5.72E+01	7.09E+03
6-7-TNS	TNS3	8.78E+01	1.53E+00	1.64E+02	8.63E+01	1.42E+04
	TNS4	1.07E+02	9.86E+00	2.41E+02	9.74E+01	2.35E+04
6-9-TNS	TNS5	8.97E+01	2.34E+00	8.35E+01	8.74E+01	7.29E+03
	TNS6	6.17E+01	6.21E+00	1.85E+02	5.55E+01	1.03E+04
6-13-TNS	TNS7	6.62E+01	4.14E+00	3.36E+02	6.21E+01	2.09E+04
	TNS8	6.54E+01	1.22E+01	1.22E+02	5.32E+01	6.47E+03
6-15-TNS	TNS9	6.16E+01	3.64E+00	3.45E+02	5.80E+01	2.00E+04
	TNS10	5.44E+01	2.47E+00	4.12E+02	5.20E+01	2.14E+04
	MEAN	7.05E+01	4.58E+00	2.35E+02	6.60E+01	1.48E+04
	SD	1.80E+01	4.09E+00	1.15E+02	1.74E+01	6.61E+03
	SE	5.69E+00	1.29E+00	3.63E+01	5.49E+00	2.09E+03
					7.89E−02

TABLE 4
	after 2h
	reperfusion	LVESP	LVEDP	HR	LVDP	LVDP × HR
5-18-CN	CON11	7.78E+01	3.68E+01	1.18E+02	4.10E+01	4.82E+03
	CON12	7.07E+01	2.23E+01	9.23E+01	4.84E+01	4.47E+03
6-10-CN	CON13	6.48E+01	5.54E+01	5.72E+02	9.39E+00	5.38E+03
	CON14	9.54E+01	5.64E+01	2.08E+02	3.90E+01	8.12E+03
5-15-CN	CON9	5.18E+01	2.71E+01	1.75E+02	2.47E+01	4.33E+03
	CON10	1.10E+02	3.13E+01	5.76E+01	7.84E+01	4.51E+03
5-12-CN	CON7	3.93E+01	1.42E+01	9.11E+01	2.51E+01	2.29E+03
	CON8	5.29E+01	9.48E+00	6.07E+01	4.34E+01	2.64E+03
5-9-CN	CONS	6.56E+01	4.89E+01	6.50E+01	1.67E+01	1.09E+03
	CON6	7.44E+01	6.56E+01	3.78E+01	8.81E+00	3.33E+02
5-7-CN	CON3	6.35E+01	9.99E+00	1.15E+02	5.35E+01	6.18E+03
	CON4	8.76E+01	5.34E+01	1.06E+02	3.43E+01	3.65E+03
5-5-CN	CON1	9.29E+01	4.38E+01	2.61E+02	4.91E+01	1.28E+04
	CON2	5.18E+01	4.43E+00	2.57E+02	4.74E+01	1.22E+04
	MEAN	7.13E+01	3.42E+01	1.58E+02	3.71E+01	5.20E+03
	SD	1.98E+01	2.02E+01	1.39E+02	1.90E+01	3.68E+03
	SE	5.29E+00	5.40E+00	3.72E+01	5.08E+00	9.83E+02
	TTEST
5-14-TMZ	TMZ3	5.07E+01	2.93E+01	1.18E+02	2.14E+01	2.52E+03
	TMZ4	7.66E+01	3.31E+01	1.19E+02	4.34E+01	5.15E+03
5-11-TMZ	TMZ1	9.19E+01	3.96E+01	1.01E+02	5.22E+01	5.28E+03
	TMZ2	4.77E+01	1.80E+01	1.51E+02	2.97E+01	4.49E+03
5-8-TMZ	TMZ7	5.18E+01	3.36E+00	6.70E+01	4.84E+01	3.24E+03
	TMZ8	4.86E+01	1.87E+00	9.22E+01	4.67E+01	4.31E+03
5-6-TMZ	TMZ5	6.09E+01	1.99E+01	2.22E+02	4.10E+01	9.11E+03
	TMZ6	1.09E+02	3.21E+01	1.70E+02	7.65E+01	1.30E+04
5-4-TMZ	TMZ9	7.38E+01	1.84E+01	1.16E+02	5.53E+01	6.44E+03
	TMZ10	7.61E+01	1.77E+00	2.38E+02	7.43E+01	1.77E+04
	MEAN	6.86E+01	1.97E+01	1.39E+02	4.89E+01	6.82E+03
	SD	2.05E+01	1.39E+01	5.58E+01	1.73E+01	4.82E+03
	SE	6.49E+00	4.39E+00	1.77E+01	5.46E+00	1.52E+03
5-19-TNF	TNF1	8.37E+01	6.66E+01	1.53E+02	1.71E+01	2.62E+03
	TNF2	6.19E+00	5.54E+00	2.13E+03	6.48E-01	1.38E+03
6-8-TNF	TNF3	8.99E+01	1.88E+01	1.05E+01	7.11E+01	7.49E+02
	TNF4	6.06E+01	1.34E+01	8.10E+01	4.72E+01	3.82E+03
6-12-TNF	TNF5	1.54E+02	4.15E+01	2.20E+01	1.13E+02	2.48E+03
	TNF6	1.30E+02	4.25E+01	3.33E+01	8.77E+01	2.92E+03
6-14-TNF	TNF7	5.70E+01	4.00E+01	4.00E+01	1.70E+01	6.80E+02
	TNF8	3.76E+01	1.87E+01	5.36E+01	1.88E+01	1.01E+03
6-15-TNF	TNF9	6.23E+01	3.38E+01	1.97E+02	2.85E+01	5.59E+03
	TNF10	7.85E+01	2.75E+01	7.85E+01	5.10E+01	4.00E+03
	MEAN	7.60E+01	3.09E+01	2.80E+02	4.52E+01	2.53E+03
	SD	4.28E+01	1.79E+01	6.54E+02	3.59E+01	1.62E+03
	SE	1.35E+01	5.65E+00	2.07E+02	1.14E+01	5.12E+02
5-20-TNS	TNS1	6.47E+01	1.78E+01	1.04E+02	4.69E+01	4.88E+03
	TNS2	8.95E+01	3.03E+01	5.55E+01	5.92E+01	3.29E+03
6-7-TNS	TNS3	7.79E+01	6.34E+01	1.28E+02	1.45E+01	1.85E+03
	TNS4	7.74E+01	2.73E+01	1.02E+02	5.01E+01	5.09E+03
6-9-TNS	TNS5	1.37E+02	5.63E+01	1.63E+01	8.08E+01	1.32E+03
	TNS6	8.59E+01	1.23E+01	1.06E+02	7.36E+01	7.79E+03
6-13-TNS	TNS7	5.76E+01	5.16E+01	1.35E+02	6.00E+00	8.07E+02
	TNS8	4.96E+01	1.53E+01	1.22E+02	3.43E+01	4.20E+03
6-15-TNS	TNS9	9.97E+01	3.00E+01	7.46E+01	6.98E+01	5.21E+03
	TNS10	4.32E+01	−4.32E+00	7.20E+01	4.75E+01	3.42E+03
	MEAN	7.83E+01	3.00E+01	9.15E+01	4.83E+01	3.79E+03
	SD	2.74E+01	2.14E+01	3.69E+01	2.45E+01	2.11E+03
	SE	8.67E+00	6.78E+00	1.17E+01	7.75E+00	6.69E+02

TABLE 5
	pre-			after 2h
	ischemia	+dp/dtm	−dp/dtm	reperfusion	+dp/dtm	−dp/dtm
5-18-CN	CON11	2.60E+03	−1.82E+03	CON11	1.44E+03	−8.67E+02
	CON12	2.95E+03	−2.58E+03	CON12	1.63E+03	−1.07E+03
6-10-CN	CON13	3.10E+03	−2.42E+03	CON13	2.25E+02	−2.22E+02
	CON14	3.08E+03	−2.10E+03	CON14	3.44E+02	−2.87E+02
5-15-CN	CON9	2.28E+03	−1.38E+03	CON9	9.45E+02	−5.54E+02
	CON10	2.06E+03	−1.50E+03	CON10	2.29E+03	−1.75E+03
5-12-CN	CON7	2.71E+03	−2.10E+03	CON7	2.51E+02	−2.55E+02
	CON8	1.58E+03	−1.10E+03	CON8	3.63E+02	−3.05E+02
5-9-CN	CONS	2.17E+03	−1.50E+03	CONS	2.39E+02	−2.41E+02
	CON6	2.25E+03	−1.62E+03	CON6	1.47E+02	−1.49E+02
5-7-CN	CON3	2.63E+03	−2.06E+03	CON3	1.63E+03	−1.06E+03
	CON4	2.05E+03	−1.38E+03	CON4	1.10E+03	−7.03E+02
5-5-CN	CON1	3.17E+03	−2.37E+03	CON1	1.03E+03	−1.12E+03
	CON2	2.10E+03	−1.50E+03	CON2	1.75E+03	−1.27E+03
	MEAN	2.48E+03	−1.82E+03	MEAN	9.56E+02	−7.04E+02
	SD	4.84E+02	4.56E+02	SD	7.08E+02	4.95E+02
	SE	1.29E+02	1.22E+02	SE	1.89E+02	1.32E+02
	TTEST			TTEST
5-14-TMZ	TMZ3	2.41E+03	−1.69E+03	TMZ3	4.14E+02	−3.57E+02
	TMZ4	2.77E+03	−2.26E+03	TMZ4	1.48E+03	−1.15E+03
5-11-TMZ	TMZ1	1.80E+03	−1.59E+03	TMZ1	1.38E+03	−7.45E+02
	TMZ2	2.15E+03	−1.80E+03	TMZ2	1.06E+03	−6.85E+02
5-8-TMZ	TMZ7	3.40E+03	−2.59E+03	TMZ7	3.44E+02	−3.39E+02
	TMZ8	1.75E+03	−1.20E+03	TMZ8	7.36E+02	−4.28E+02
5-6-TMZ	TMZ5	1.27E+03	−8.82E+02	TMZ5	1.28E+03	−8.38E+02
	TMZ6	1.24E+03	−6.59E+02	TMZ6	1.85E+03	−1.06E+03
5-4-TMZ	TMZ9	1.98E+03	−1.41E+03	TMZ9	1.13E+03	−6.38E+02
	TMZ10	2.02E+03	−1.56E+03	TMZ10	1.62E+03	−9.83E+02
	MEAN	2.08E+03	−1.56E+03	MEAN	1.13E+03	−7.22E+02
	SD	6.58E+02	5.81E+02	SD	5.01E+02	2.90E+02
	SE	2.08E+02	1.84E+02	SE	1.58E+02	9.16E+01
					5.16E−01	9.18E−01
5-19-TNF	TNF1	2.67E+03	−1.49E+03	TNF1	3.86E+02	−3.75E+02
	TNF2	2.85E+03	−1.44E+03	TNF2	1.46E+02	−1.43E+02
6-8-TNF	TNF3	1.53E+03	−7.24E+02	TNF3	2.28E+02	−2.34E+02
	TNF4	3.86E+03	−2.59E+03	TNF4	2.84E+02	−2.40E+02
6-12-TNF	TNF5	3.29E+03	−2.34E+03	TNF5	2.92E+03	−2.08E+03
	TNF6	3.03E+03	−1.90E+03	TNF6	2.48E+03	−1.84E+03
6-14-TNF	TNF7	3.22E+03	−1.62E+03	TNF7	2.53E+02	−2.48E+02
	TNF8	1.74E+03	−1.12E+03	TNF8	1.53E+02	−1.52E+02
6-15-TNF	TNF9	2.14E+03	−2.33E+03	TNF9	1.04E+03	−6.31E+02
	TNF10	1.86E+03	−9.97E+02	TNF10	2.04E+03	−1.34E+03
	MEAN	2.62E+03	−1.65E+03	MEAN	9.93E+02	−7.29E+02
	SD	7.71E+02	6.26E+02	SD	1.08E+03	7.43E+02
	SE	2.44E+02	1.98E+02	SE	3.41E+02	2.35E+02
		1.09E-03	7.48E-03
5-20-TNS	TNS1	2.37E+03	−1.60E+03	TNS1	1.79E+03	−1.12E+03
	TNS2	2.87E+03	−2.53E+03	TNS2	1.84E+03	−1.30E+03
6-7-TNS	TNS3	4.00E+03	−2.67E+03	TNS3	2.91E+02	−3.02E+02
	TNS4	3.32E+03	−2.63E+03	TNS4	1.62E+03	−1.30E+03
6-9-TNS	TNS5	3.36E+03	−2.21E+03	TNS5	2.43E+02	−2.46E+02
	TNS6	2.53E+03	−1.89E+03	TNS6	2.36E+03	−1.74E+03
6-13-TNS	TNS7	2.92E+03	−1.75E+03	TNS7	2.49E+02	−2.47E+02
	TNS8	1.12E+03	−7.42E+02	TNS8	1.29E+03	−8.50E+02
6-15-TNS	TNS9	2.29E+03	−1.75E+03	TNS9	2.06E+03	−1.59E+03
	TNS10	2.11E+03	−1.58E+03	TNS10	1.26E+03	−1.10E+03
	MEAN	2.69E+03	−1.94E+03	MEAN	1.30E+03	−9.80E+02
	SD	7.99E+02	5.95E+02	SD	7.86E+02	5.52E+02
	SE	2.53E+02	1.88E+02	SE	2.49E+02	1.75E+02
		9.96E−04	1.55E−03

	TABLE 6
			CON	TMZ	TNF	TNS
	T20	Mean	64.36	55.86	64.90	65.96
	T20	SE	3.91	5.58	5.73	5.49
	T170	Mean	37.09	48.91	45.16	48.27
	T170	SE	5.08	5.46	11.36	7.75

[0275] FIG. 41 shows images of TTC-stained heart slices after JR. TMZ and TNS treatment decreased infarct size after JR.

[0276] FIG. 42 is graph of infarct size after TR. TMZ and TNS treatment decreased infarct size after JR. Raw data is provided in Tables 7-55.

TABLE 7
CN11 raw values
1	Slide11.jpg	1649
2	Slide11.jpg	10	0.06
3	Slide11.jpg	1385	8.40
4	Slide11.jpg	2808
5	Slide11.jpg	104	0.81
6	Slide11.jpg	2525	19.78
7	Slide11.jpg	3807
8	Slide11.jpg	1014	7.99
9	Slide11.jpg	2207	17.39
10	Slide11.jpg	3952
11	Slide11.jpg	15	0.08
12	Slide11.jpg	3300	17.54
13	Slide11.jpg	3376
14	Slide11.jpg	103	0.92
15	Slide11.jpg	2816	25.02
16	Slide11.jpg	1616
17	Slide11.jpg	975	6.03
18	Slide11.jpg	409	2.53
19	Slide11.jpg	2805
20	Slide11.jpg	819	6.42
21	Slide11.jpg	1496	11.73
22	Slide11.jpg	3973
23	Slide11.jpg	1047	7.91
24	Slide11.jpg	2465	18.61
25	Slide11.jpg	3971
26	Slide11.jpg	1102	5.83
27	Slide11.jpg	2430	12.85
28	Slide11.jpg	3516
29	Slide11.jpg	1919	16.37
30	Slide11.jpg	920	7.85

TABLE 8
CN11 summary
	non-IS	26.21
	IS	70.86
	LV	97.07
	IS/LV	73%

TABLE 9
CN12 raw values
1	Slide12.jpg	1562
2	Slide12.jpg	1059	8.81
3	Slide12.jpg	485	4.04
4	Slide12.jpg	2925
5	Slide12.jpg	260	1.78
6	Slide12.jpg	2159	14.76
7	Slide12.jpg	3492
8	Slide12.jpg	263	1.88
9	Slide12.jpg	2886	20.66
10	Slide12.jpg	4855
11	Slide12.jpg	1992	16.00
12	Slide12.jpg	2292	18.41
13	Slide12.jpg	2934
14	Slide12.jpg	1405	6.70
15	Slide12.jpg	914	4.36
16	Slide12.jpg	2061
17	Slide12.jpg	81	0.51
18	Slide12.jpg	1704	10.75
19	Slide12.jpg	2966
20	Slide12.jpg	105	0.71
21	Slide12.jpg	2810	18.95
22	Slide12.jpg	4099
23	Slide12.jpg	823	5.02
24	Slide12.jpg	2350	14.33
25	Slide12.jpg	3979
26	Slide12.jpg	357	3.50
27	Slide12.jpg	2787	27.32
28	Slide12.jpg	2974
29	Slide12.jpg	490	2.31
30	Slide12.jpg	2112	9.94

TABLE 10
CN12 summary
	non-IS	23.61
	IS	71.76
	LV	95.37
	IS/LV	75%

TABLE 11
TNS1 raw values
1	Slide15.jpg	1857
2	Slide15.jpg	58	0.28
3	Slide15.jpg	1672	8.10
4	Slide15.jpg	3383
5	Slide15.jpg	901	4.53
6	Slide15.jpg	1873	9.41
7	Slide15.jpg	3460
8	Slide15.jpg	1452	13.43
9	Slide15.jpg	2272	21.01
10	Slide15.jpg	3712
11	Slide15.jpg	772	8.32
12	Slide15.jpg	2422	26.10
13	Slide15.jpg	3088
14	Slide15.jpg	498	3.87
15	Slide15.jpg	1733	13.47
16	Slide15.jpg	1762
17	Slide15.jpg	65	0.33
18	Slide15.jpg	1626	8.31
19	Slide15.jpg	3532
20	Slide15.jpg	2034	9.79
21	Slide15.jpg	1206	5.80
22	Slide15.jpg	3411
23	Slide15.jpg	1752	16.44
24	Slide15.jpg	1006	9.44
25	Slide15.jpg	4241
26	Slide15.jpg	2148	20.26
27	Slide15.jpg	1101	10.38
28	Slide15.jpg	3440
29	Slide15.jpg	2307	16.10
30	Slide15.jpg	165	1.15

TABLE 12
TNS1 summary
	non-IS	46.67
	IS	56.59
	LV	103.26
	IS/LV	55%

TABLE 13
TNS2 raw values
1	Slide16.jpg	1565
2	Slide16.jpg	1058	7.44
3	Slide16.jpg	145	1.02
4	Slide16.jpg	2654
5	Slide16.jpg	431	3.90
6	Slide16.jpg	2043	18.47
7	Slide16.jpg	3247
8	Slide16.jpg	1053	8.43
9	Slide16.jpg	1584	12.68
10	Slide16.jpg	3892
11	Slide16.jpg	2391	22.73
12	Slide16.jpg	863	8.20
13	Slide16.jpg	2505
14	Slide16.jpg	1488	14.85
15	Slide16.jpg	363	3.62
16	Slide16.jpg	1526
17	Slide16.jpg	9	0.06
18	Slide16.jpg	1357	9.78
19	Slide16.jpg	2337
20	Slide16.jpg	16	0.16
21	Slide16.jpg	1899	19.50
22	Slide16.jpg	3558
23	Slide16.jpg	1453	10.62
24	Slide16.jpg	1504	10.99
25	Slide16.jpg	4041
26	Slide16.jpg	517	4.73
27	Slide16.jpg	2763	25.30
28	Slide16.jpg	2946
29	Slide16.jpg	631	5.35
30	Slide16.jpg	1326	11.25

TABLE 14
TNS2 summary
	non-IS	39.14
	IS	60.41
	LV	99.56
	IS/LV	61%

TABLE 15
TNF1 raw values
1	Slide17.jpg	1326
2	Slide17.jpg	63	0.24
3	Slide17.jpg	1183	4.46
4	Slide17.jpg	3158
5	Slide17.jpg	825	5.49
6	Slide17.jpg	2014	13.39
7	Slide17.jpg	4805
8	Slide17.jpg	1774	12.92
9	Slide17.jpg	1722	12.54
10	Slide17.jpg	4675
11	Slide17.jpg	1984	15.28
12	Slide17.jpg	2470	19.02
13	Slide17.jpg	2754
14	Slide17.jpg	269	2.05
15	Slide17.jpg	1377	10.50
16	Slide17.jpg	1373
17	Slide17.jpg	1067	3.89
18	Slide17.jpg	43	0.16
19	Slide17.jpg	3113
20	Slide17.jpg	803	5.42
21	Slide17.jpg	2008	13.55
22	Slide17.jpg	4657
23	Slide17.jpg	1189	8.94
24	Slide17.jpg	2398	18.02
25	Slide17.jpg	4607
26	Slide17.jpg	1256	9.81
27	Slide17.jpg	1978	15.46
28	Slide17.jpg	2769
29	Slide17.jpg	2115	16.04
30	Slide17.jpg	72	0.55

TABLE 16
TNF1 summary
	non-IS	40.03
	IS	53.82
	LV	93.86
	IS/LV	57%

TABLE 17
TNF2 raw values
1	Slide18.jpg	2133
2	Slide18.jpg	1861	12.21
3	Slide18.jpg	239	1.57
4	Slide18.jpg	4037
5	Slide18.jpg	753	5.60
6	Slide18.jpg	2304	17.12
7	Slide18.jpg	4663
8	Slide18.jpg	1548	10.62
9	Slide18.jpg	2917	20.02
10	Slide18.jpg	5017
11	Slide18.jpg	2648	20.06
12	Slide18.jpg	2480	18.78
13	Slide18.jpg	3629
14	Slide18.jpg	1698	13.10
15	Slide18.jpg	348	2.69
16	Slide18.jpg	2130
17	Slide18.jpg	4	0.03
18	Slide18.jpg	1988	13.07
19	Slide18.jpg	4108
20	Slide18.jpg	253	1.85
21	Slide18.jpg	3796	27.72
22	Slide18.jpg	4612
23	Slide18.jpg	815	5.65
24	Slide18.jpg	2427	16.84
25	Slide18.jpg	4880
26	Slide18.jpg	562	4.38
27	Slide18.jpg	3535	27.53
28	Slide18.jpg	3507
29	Slide18.jpg	497	3.97
30	Slide18.jpg	1837	14.67

TABLE 18
TNF2 summary
	non-IS	38.73
	IS	80.00
	LV	118.73
	IS/LV	73%

TABLE 19
TNS3 raw values
1	Slide19.jpg	1484
2	Slide19.jpg	923	4.98
3	Slide19.jpg	714	3.85
4	Slide19.jpg	3124
5	Slide19.jpg	990	6.65
6	Slide19.jpg	1845	12.40
7	Slide19.jpg	3414
8	Slide19.jpg	1282	13.89
9	Slide19.jpg	1833	19.87
10	Slide19.jpg	3380
11	Slide19.jpg	2123	16.33
12	Slide19.jpg	1042	8.02
13	Slide19.jpg	2105
14	Slide19.jpg	957	7.73
15	Slide19.jpg	308	2.49
16	Slide19.jpg	1524
17	Slide19.jpg	10	0.05
18	Slide19.jpg	1530	8.03
19	Slide19.jpg	2860
20	Slide19.jpg	13	0.10
21	Slide19.jpg	2293	16.84
22	Slide19.jpg	3358
23	Slide19.jpg	960	10.58
24	Slide19.jpg	2639	29.08
25	Slide19.jpg	2538
26	Slide19.jpg	296	3.03
27	Slide19.jpg	1797	18.41
28	Slide19.jpg	1992
29	Slide19.jpg	1105	9.43
30	Slide19.jpg	401	3.42

TABLE 20
TNS3 summary
	non-IS	36.39
	IS	61.20
	LV	97.58
	IS/LV	63%

TABLE 21
TNS4 raw values
	1	Slide20.jpg	1524
	2	Slide20.jpg	47	0.28
	3	Slide20.jpg	1417	8.37
	4	Slide20.jpg	2478
	5	Slide20.jpg	582	5.17
	6	Slide20.jpg	1617	14.36
	7	Slide20.jpg	3284
	8	Slide20.jpg	1226	11.20
	9	Slide20.jpg	2072	18.93
	10	Slide20.jpg	3639
	11	Slide20.jpg	771	7.20
	12	Slide20.jpg	2177	20.34
	13	Slide20.jpg	3114
	14	Slide20.jpg	491	5.36
	15	Slide20.jpg	2189	23.90
	16	Slide20.jpg	1648
	17	Slide20.jpg	1244	6.79
	18	Slide20.jpg	94	0.51
	19	Slide20.jpg	2912
	20	Slide20.jpg	1446	10.92
	21	Slide20.jpg	1262	9.53
	22	Slide20.jpg	4073
	23	Slide20.jpg	2350	17.31
	24	Slide20.jpg	1049	7.73
	25	Slide20.jpg	3470
	26	Slide20.jpg	2445	23.96
	27	Slide20.jpg	1052	10.31
	28	Slide20.jpg	3219
	29	Slide20.jpg	2120	22.39
	30	Slide20.jpg	32	0.34

TABLE 22
TNS4 summary
	non-IS	55.29
	IS	57.16
	LV	112.45
	IS/LV	51%

TABLE 23
TNF3 raw values
1	Slide21.jpg	1551
2	Slide21.jpg	3	0.02
3	Slide21.jpg	1502	10.65
4	Slide21.jpg	3054
5	Slide21.jpg	922	6.34
6	Slide21.jpg	2049	14.09
7	Slide21.jpg	3374
8	Slide21.jpg	1280	12.52
9	Slide21.jpg	1566	15.32
10	Slide21.jpg	2799
11	Slide21.jpg	1476	14.77
12	Slide21.jpg	1061	10.61
13	Slide21.jpg	2330
14	Slide21.jpg	398	3.25
15	Slide21.jpg	1012	8.25
16	Slide21.jpg	1689
17	Slide21.jpg	7	0.05
18	Slide21.jpg	1544	10.06
19	Slide21.jpg	2894
20	Slide21.jpg	361	2.62
21	Slide21.jpg	1925	13.97
22	Slide21.jpg	3254
23	Slide21.jpg	1137	11.53
24	Slide21.jpg	1267	12.85
25	Slide21.jpg	2814
26	Slide21.jpg	1272	12.66
27	Slide21.jpg	1113	11.07
28	Slide21.jpg	2821
29	Slide21.jpg	1438	9.69
30	Slide21.jpg	174	1.17

TABLE 24
TNF3 summary
	non-IS	36.71
	IS	54.02
	LV	90.74
	IS/LV	60%

TABLE 25
TNF4 raw values
1	Slide22.jpg	1354
2	Slide22.jpg	72	0.37
3	Slide22.jpg	1335	6.90
4	Slide22.jpg	2892
5	Slide22.jpg	672	3.95
6	Slide22.jpg	2093	12.30
7	Slide22.jpg	3414
8	Slide22.jpg	1342	9.83
9	Slide22.jpg	2213	16.21
10	Slide22.jpg	3698
11	Slide22.jpg	1168	10.11
12	Slide22.jpg	2317	20.05
13	Slide22.jpg	2565
14	Slide22.jpg	243	2.94
15	Slide22.jpg	1398	16.90
16	Slide22.jpg	1486
17	Slide22.jpg	638	3.01
18	Slide22.jpg	583	2.75
19	Slide22.jpg	2719
20	Slide22.jpg	26	0.16
21	Slide22.jpg	2164	13.53
22	Slide22.jpg	3514
23	Slide22.jpg	568	4.04
24	Slide22.jpg	2361	16.80
25	Slide22.jpg	3908
26	Slide22.jpg	1498	12.27
27	Slide22.jpg	1805	14.78
28	Slide22.jpg	2946
29	Slide22.jpg	16	0.17
30	Slide22.jpg	1969	20.72

TABLE 26
TNF4 summary
	non-IS	23.42
	IS	70.46
	LV	93.88
	IS/LV	75%

TABLE 27
TNS5 raw values
1	Slide23.jpg	1615
2	Slide23.jpg	8	0.04
3	Slide23.jpg	1571	8.75
4	Slide23.jpg	2789
5	Slide23.jpg	1477	11.65
6	Slide23.jpg	1042	8.22
7	Slide23.jpg	3558
8	Slide23.jpg	2026	22.21
9	Slide23.jpg	1327	14.55
10	Slide23.jpg	3822
11	Slide23.jpg	1044	8.74
12	Slide23.jpg	1590	13.31
13	Slide23.jpg	3246
14	Slide23.jpg	1224	8.67
15	Slide23.jpg	705	5.00
16	Slide23.jpg	1445
17	Slide23.jpg	1228	7.65
18	Slide23.jpg	200	1.25
19	Slide23.jpg	2732
20	Slide23.jpg	1951	15.71
21	Slide23.jpg	782	6.30
22	Slide23.jpg	3858
23	Slide23.jpg	3039	30.72
24	Slide23.jpg	400	4.04
25	Slide23.jpg	3697
26	Slide23.jpg	2609	22.58
27	Slide23.jpg	943	8.16
28	Slide23.jpg	3358
29	Slide23.jpg	1492	10.22
30	Slide23.jpg	583	3.99

TABLE 28
TNS5 summary
	non-IS	69.10
	IS	36.78
	LV	105.88
	IS/LV	35%

TABLE 29
TNS6 raw values
1	Slide24.jpg	1216
2	Slide24.jpg	258	1.49
3	Slide24.jpg	770	4.43
4	Slide24.jpg	3079
5	Slide24.jpg	1436	10.26
6	Slide24.jpg	1417	10.12
7	Slide24.jpg	3677
8	Slide24.jpg	2085	11.34
9	Slide24.jpg	1122	6.10
10	Slide24.jpg	3908
11	Slide24.jpg	2151	15.96
12	Slide24.jpg	1415	10.50
13	Slide24.jpg	2371
14	Slide24.jpg	1651	14.62
15	Slide24.jpg	495	4.38
16	Slide24.jpg	1123
17	Slide24.jpg	879	5.48
18	Slide24.jpg	262	1.63
19	Slide24.jpg	3090
20	Slide24.jpg	1775	12.64
21	Slide24.jpg	1121	7.98
22	Slide24.jpg	3470
23	Slide24.jpg	2215	12.77
24	Slide24.jpg	1219	7.03
25	Slide24.jpg	3666
26	Slide24.jpg	2524	19.97
27	Slide24.jpg	1411	11.16
28	Slide24.jpg	2470
29	Slide24.jpg	1397	11.88
30	Slide24.jpg	140	1.19

TABLE 30
TNS6 summary
	non-IS	58.20
	IS	32.27
	LV	90.47
	IS/LV	36%

TABLE 31
CN13 raw values
1	Slide25.jpg	1010
2	Slide25.jpg	4	0.04
3	Slide25.jpg	1006	8.96
4	Slide25.jpg	2216
5	Slide25.jpg	756	5.80
6	Slide25.jpg	1708	13.10
7	Slide25.jpg	3122
8	Slide25.jpg	744	5.72
9	Slide25.jpg	1674	12.87
10	Slide25.jpg	3214
11	Slide25.jpg	177	1.87
12	Slide25.jpg	1678	17.75
13	Slide25.jpg	2504
14	Slide25.jpg	371	3.41
15	Slide25.jpg	770	7.07
16	Slide25.jpg	940
17	Slide25.jpg	3	0.03
18	Slide25.jpg	902	8.64
19	Slide25.jpg	1907
20	Slide25.jpg	266	2.37
21	Slide25.jpg	1439	12.83
22	Slide25.jpg	2763
23	Slide25.jpg	1036	9.00
24	Slide25.jpg	1855	16.11
25	Slide25.jpg	2930
26	Slide25.jpg	988	11.46
27	Slide25.jpg	1618	18.78
28	Slide25.jpg	2498
29	Slide25.jpg	280	2.58
30	Slide25.jpg	1839	16.93

TABLE 32
CN13 summary
	non-IS	21.14
	IS	66.52
	LV	87.66
	IS/LV	76%

TABLE 33
CN14 raw values
1	Slide26.jpg	1387
2	Slide26.jpg	40	0.23
3	Slide26.jpg	1356	7.82
4	Slide26.jpg	2994
5	Slide26.jpg	699	4.67
6	Slide26.jpg	1620	10.82
7	Slide26.jpg	3017
8	Slide26.jpg	1087	11.89
9	Slide26.jpg	1443	15.78
10	Slide26.jpg	2871
11	Slide26.jpg	2644	29.47
12	Slide26.jpg	188	2.10
13	Slide26.jpg	2504
14	Slide26.jpg	7	0.05
15	Slide26.jpg	1996	13.55
16	Slide26.jpg	1424
17	Slide26.jpg	490	2.75
18	Slide26.jpg	931	5.23
19	Slide26.jpg	2926
20	Slide26.jpg	40	0.27
21	Slide26.jpg	2231	15.25
22	Slide26.jpg	3248
23	Slide26.jpg	782	7.95
24	Slide26.jpg	2137	21.71
25	Slide26.jpg	3401
26	Slide26.jpg	348	3.27
27	Slide26.jpg	2624	24.69
28	Slide26.jpg	2079
29	Slide26.jpg	573	4.69
30	Slide26.jpg	1042	8.52

TABLE 34
CN14 summary
	non-IS	32.62
	IS	62.74
	LV	95.36
	IS/LV	66%

TABLE 35
TNF5 raw values
1	Slide27.jpg	1504
2	Slide27.jpg	22	0.13
3	Slide27.jpg	1336	7.99
4	Slide27.jpg	2786
5	Slide27.jpg	390	3.22
6	Slide27.jpg	1956	16.15
7	Slide27.jpg	3792
8	Slide27.jpg	1444	10.66
9	Slide27.jpg	2232	16.48
10	Slide27.jpg	3470
11	Slide27.jpg	587	5.41
12	Slide27.jpg	2824	26.04
13	Slide27.jpg	3002
14	Slide27.jpg	2361	16.52
15	Slide27.jpg	1329	9.30
16	Slide27.jpg	1666
17	Slide27.jpg	274	1.48
18	Slide27.jpg	1024	5.53
19	Slide27.jpg	2735
20	Slide27.jpg	9	0.08
21	Slide27.jpg	2897	24.36
22	Slide27.jpg	3575
23	Slide27.jpg	1217	9.53
24	Slide27.jpg	2163	16.94
25	Slide27.jpg	3350
26	Slide27.jpg	997	9.52
27	Slide27.jpg	1812	17.31
28	Slide27.jpg	3022
29	Slide27.jpg	12	0.08
30	Slide27.jpg	1778	12.36

TABLE 36
TNF5 summary
	non-IS	28.32
	IS	76.23
	LV	104.55
	IS/LV	73%

TABLE 37
TNF6 raw values
	1	Slide28.jpg	1114
	2	Slide28.jpg	62	0.45
	3	Slide28.jpg	879	6.31
	4	Slide28.jpg	2858
	5	Slide28.jpg	459	3.85
	6	Slide28.jpg	1713	14.38
	7	Slide28.jpg	3625
	8	Slide28.jpg	369	3.56
	9	Slide28.jpg	2924	28.23
	10	Slide28.jpg	3948
	11	Slide28.jpg	511	4.27
	12	Slide28.jpg	2866	23.96
	13	Slide28.jpg	3135
	14	Slide28.jpg	386	3.08
	15	Slide28.jpg	1447	11.54
	16	Slide28.jpg	1126
	17	Slide28.jpg	10	0.07
	18	Slide28.jpg	1043	7.41
	19	Slide28.jpg	3156
	20	Slide28.jpg	160	1.22
	21	Slide28.jpg	3062	23.29
	22	Slide28.jpg	3790
	23	Slide28.jpg	827	7.64
	24	Slide28.jpg	2644	24.42
	25	Slide28.jpg	3618
	26	Slide28.jpg	1607	14.66
	27	Slide28.jpg	2452	22.36
	28	Slide28.jpg	3440
	29	Slide28.jpg	1023	7.43
	30	Slide28.jpg	1770	12.86

TABLE 38
TNF6 summary
	non-IS	23.11
	IS	87.38
	LV	110.50
	IS/LV	79%

TABLE 39
TNS7 raw values
	1	Slide29.jpg	1713
	2	Slide29.jpg	607	4.61
	3	Slide29.jpg	782	5.93
	4	Slide29.jpg	2484
	5	Slide29.jpg	195	1.88
	6	Slide29.jpg	1842	17.80
	7	Slide29.jpg	2807
	8	Slide29.jpg	1568	12.29
	9	Slide29.jpg	380	2.98
	10	Slide29.jpg	3271
	11	Slide29.jpg	2187	20.06
	12	Slide29.jpg	350	3.21
	13	Slide29.jpg	2309
	14	Slide29.jpg	610	5.55
	15	Slide29.jpg	1008	9.17
	16	Slide29.jpg	1923
	17	Slide29.jpg	865	5.85
	18	Slide29.jpg	631	4.27
	19	Slide29.jpg	3033
	20	Slide29.jpg	1501	11.88
	21	Slide29.jpg	780	6.17
	22	Slide29.jpg	3287
	23	Slide29.jpg	2214	14.82
	24	Slide29.jpg	456	3.05
	25	Slide29.jpg	3395
	26	Slide29.jpg	2398	21.19
	27	Slide29.jpg	287	2.54
	28	Slide29.jpg	2969
	29	Slide29.jpg	1647	11.65
	30	Slide29.jpg	67	0.47