Putting your employees and company culture first keeps the focus on inclusion and innovation, giving the company an incredible competitive advantage. At least thats the mantra at the heart of MyoKardia, a California-based biotech company that is developing precision medicine for cardiovascular diseases (CVDs).

We want to change the world for people with cardiovascular disease by taking a patient-focused, scientifically driven approach, Tassos Gianakakos, MyoKardias CEO, told BioSpace. When youre addressing hard problems, you need different opinions, approaches, and expertise at the table. That is the only way to effectively deliver on the mission.

Companies are at risk of getting it wrong when they dont focus on culture early on you need to launch out of the gate with a culture mindset, Gianakakos added. You get back what you put out there, so being a mission-driven, culture-valuing company will help draw in likeminded employees. That group genius is what enables remarkable improvements to health outcomes for society.

CVD, also called heart disease, is a blanket term used to describe many diseases that affect the heart or blood vessels. Globally, heart diseases are by far the number one killer in the world, with CVDs responsible for 17.9 million deaths worldwide. These conditions are highly prevalent throughout the population 30.3 million US adults have been diagnosed with CVDs.

Credit: WHO

We lose more people in the U.S. and around the world to cardiovascular conditions than any other disease, Gianakakos. MyoKardias entire purpose is to change that. We want to be the leading company developing precision medicine for CVDs. Our approach is different; were subtyping patient populations within these large, heterogeneous conditions so that we can identify effective, targeted therapeutics. The idea is to discover and develop medicines that have transformative potential for people.

MyoKardias late-stage pipeline focuses on two CVDs: hypertrophic cardiomyopathy (HCM), where the heart muscle becomes abnormally thick (hypertrophied), making it harder for the heart to pump blood; and dilated cardiomyopathy (DCM), where the hearts main pumping chamber (called the left ventricle) stretches and thins (dilates), making it harder for the heart to pump blood.

HCM is frequently caused by gene mutations in heart muscle proteins that cause the heart muscle to squeeze with more force than needed, leading to abnormal thickening over time. It is the most common inherited heart disease, occurring in about 1 in 500 people (over 650,000 people in the US). HCM is the most common cause of cardiac arrest (where the heart suddenly stops beating), in younger people. Although certain medications, like beta blockers and blood thinners, are used to treat some HCM symptoms, there arent any drugs that specifically address the underlying problem in HCM the genetic mutation-induced thickened heart muscle.

Positive results from a Phase III clinical trial of mavacamten, MyoKardias lead drug candidate for HCM, were announced in May. MyoKardia aims to submit a New Drug Application (NDA) submission with the FDA in the first quarter of 2021 and is planning for its first product launch.

DCMs causes may be varied in addition to genetics, a number of diseases are linked to left ventricle dilation, including diabetes, obesity, high blood pressure, infections, and drug and alcohol abuse. It is a common cause of systolic heart failure (where the heart isnt pumping blood as well as it should be). Medications such as angiotensin-converting enzyme (ACE) inhibitors, beta blockers, and blood thinners can successfully treat heart failure, but none of them are specific to the heart and have systemic side effects.

MyoKardias investigational drug danicamtiv is intended to increase heart contractions without interfering with the hearts ability to fill. The company recently reported encouraging data from their Phase IIa study of danicamtiv in chronic heart failure patients. They plan to advance into two new Phase II studies in specific patient populations: genetic DCM patients and systolic heart failure patients with paroxysmal or persistent atrial fibrillation (AFib).

BioSpace spoke to Gianakakos and Ingrid Boyes, MyoKardias Senior Vice President of Human Resources, about the companys pipeline, culture, and why building a culture of diversity and inclusion is foundational to a company.

(Boyes previously spoke to BioSpace in 2015 about what MyoKardia is looking for when theyre hiring.)

COMPANY CULTURE, DIVERSITY & INCLUSION

BioSpace: Why is company culture and diversity so important to a successful company? How do you promote diversity and inclusion at MyoKardia?

Gianakakos: The diseases we are tackling know no ethnic, gender or socioeconomic boundaries. So our company culture needs to reflect this. Our teams need to reflect this and the patients we are working to help. Its hard for us to see doing good science and achieving our mission any other way. And it goes beyond the science. To have a successful and meaningful company, we need to innovate more broadly in growth strategies, commercial models, and new ways to more effectively get our therapies to patients who need it around the world.

Im proud of how we embrace each others differences gender, ethnicity and race, orientation, socioeconomic status and beliefs -- and highlight the importance of company culture. Everyone at MyoKardia shares the same mission, the same values, but we embrace and value each persons differences. We want our employees to feel safe sharing their own voice and know that different points of view are valued and respected.

Boyes: Tassos passion for company culture is a large part of why I joined the company five years ago. As a Hispanic woman, its really important to me to create an environment where people can thrive and grow. We have fun while creating a valuable community. As employee number 50, I was able to focus on how to help build a company culture with Tassos that values diversity by building on employees experiences. We were very intentional about company culture and how we evolve it. Every voice at MyoKardia counts and every person plays an important role in improving CVD patients lives.

We actively seek input from our employees and encourage them to challenge the status quo. We also invite employees to lead activities and bring their unique perspectives to work.

Gianakakos: We want to bring great people who are passionate to the company and play to their strengths. Focusing on increasing their engagement and creating an energizing work environment allows employees to do their most creative and best work. Having people build the skills they want and need by cross-training and encouraging lifelong learning improves the connectivity and the innovation within the company.

We believe this is one of the key competitive advantages at MyoKardia connecting and supporting people to engage and excite them and ensuring they have a voice that is valued. Having diverse perspectives and a commitment to listening leads us to much better decisions and results.

What kind of diversity and engagement activities do you do both within MyoKardia and externally with the general public?

Boyes: We always strive to improve the culture by actively soliciting feedback from our employees though a number of channels, including engagement surveys. Implementing employee-led initiatives has brought great features into the companys culture, such as a womens forum that brings in external women speakers and identifies female role models, a green team focused on being more sustainable, and a community volunteer team that actively supports our community. All of these activities also help to develop valuable leadership skills regardless of title within our organization.

Gianakakos: Based on employee feedback, weve also implemented several policy changes, such as increasing the companys 401k match and giving each employee a six-week sabbatical once they have been with the company for six years.

Boyes: We want to be connected with diverse organizations and participate as much as possible externally connecting with others in the community with culture-focused passion. We are always looking to connect with driven people who share our company values.

Switching gears to the science, what does CVD drug development look like right now?

Gianakakos: In many ways, CVD is where oncology was 20 years ago there were no precision medicines and non-specific treatments such as chemotherapy and radiation were used regardless of cancer type. The number of drugs in development for CVDs is woefully low relative to its global burden. There are over 1,100 oncology drugs in development, but only 200 for cardiovascular diseases, despite CVDs killing more people annually than all cancers combined. In oncology today, precision medicine approaches have given us countless targeted therapies that have completely transformed patient care. We are making this happen today in CVD, where we feel may even have advantages over oncology given the many tools now available to monitor the heart, such as wearables and patches that measure the heart rate and rhythm.

What made you focus on precision cardiac medicine? Why now?

Gianakakos: Momentum around precision medicine in other disease areas was clearly growing and resulting in important advances when MyoKardia started eight years ago. The first cystic fibrosis drug that treated the underlying cause rather than the symptoms (ivacaftor) was just launched by Vertex and a few years prior to MyoKardia our founding investors were involved in launching several exciting new companies like Foundation Medicine, Agios and bluebird bio who were developing potentially game-changing targeted therapies.

Traditionally, CVD clinical trials are massive, expensive, and often fail. When there is a lack of understanding of the underlying disease biology and its unclear exactly what the drug is doing, that can result in a large signal-to-noise ratio. This in turn, requires larger studies which are more expensive, and the therapies have to benefit large numbers of patients for the investment to make sense. This is a recipe that doesnt lead to innovative or efficient drug discovery. Identifying smaller, more homogenous subgroups of patients who all share the same disease pathology, and targeting them with drugs designed specifically to address the underlying disease biology is so powerful. Were matching the tailored treatment to address each persons underlying condition understanding how to identify the right drugs for the right patients.

CARDIOVASCULAR DISEASE DRUG DEVELOPMENT & MYOKARDIAS PIPELINE

What are the major knowledge gaps that need to be addressed to make precision cardiac medicine achievable for many patients? What does the landscape look like right now for precision cardiac medicine?

Gianakakos: There needs to be a cultural shift in the CVD field to move away from grouping broad heterogenous patients together, to focusing on smaller, well defined patient groups treated with targeted therapies and learning as much as we can from those that respond very well and, as importantly, those that do not.

Matching patient profiles to drugs that specifically address their underlying disease is key. Leaning on existing technology, such as wearables, genetic sequencing, imaging, and biomarker profiles to subtype CVD patients and deeply understand the biological drivers of disease will lead to critically important targeted therapies and much more effective clinical trials.

In terms of other precision cardiac medicine approaches in development, gene therapies are being explored. While that technology is maturing, most gene therapies for CVDs are still in early-stage research, but eventually could be helpful for certain sub-groups of patients with CVD.

Relative to other disease areas, like oncology, it has been challenging for companies to invest in new approaches to drug discovery and development in areas like CVD and neurology. However, given the staggering medical need, and with progress being made by companies like ours, I expect interest in CVD precision medicine to increase over the next 3-5 years.

What does MyoKardias pipeline look like?

Gianakakos: Our Phase III drug, called mavacamten (MYK-461), is for HCM. HCM is a genetic disease where the heart thickens due to excessive force of contraction cause by mutations in the heart muscle proteins. There are two common subtypes of HCM: obstructive, where the thickening also occurs near the base of the aorta and prevents (obstructs) blood from flowing well out of the heart; and non-obstructive, where the thick muscle makes it challenging for the heart to relax and fill, reducing the amount of blood flow out of the heart without physically obstructing blood flow. About one-third of HCM patients have the non-obstructive type.

Mavacamten is a small molecule that targets the heart muscle protein myosin reducing the excessive force of contraction, directly addressing the underlying cause of HCM. We announced positive data from our Phase III trial (EXPLORER-HCM) of mavacemten in about 250 symptomatic obstructive HCM patients and we are now able to move full steam ahead on our first regulatory submission for approval. Encouraging results from a Phase II trial (MAVERICK-HCM) of mavacamten in about 60 participants with symptomatic non-obstructive HCM were recently presented and we are going to be moving mavacamten forward in non-obstructive patients. We are also conducting a long-term extension study is also ongoing for patients who participated in either EXPLORER-HCM or MAVERICK-HCM.

We started hyper focused in a disease with a defined genetic background and will expand in a deliberate way into adjacent diseases with similar problems, such as heart failure with preserved ejection fraction. About 3 million people in the U.S. have problems filling and relaxing their hearts and we estimate that approximately 10% of them share similar pathology to HCM. Are these disease subtypes related? Do they have similar genetic mutations? We plan to start a Phase II trial in the next few months to explore if mavacamten can help that specific heart failure population and learn much more about this devastating form of heart failure.

We also have a Phase II molecule, called danicamtiv (MYK-491), for DCM that is designed to increase the force of contraction in the heart - the opposite of what mavacamten has been created to do. Danicamtiv is a small molecule that selectively increases the number of myosin-actin cross bridges, supporting heart muscle contractions to help the heart pump more efficiently. It has recently completed a Phase Ib/IIa trial in DCM or stable heart failure patients and has shown very promising early results. We are now moving into a separate Phase II study in DCM patients with certain genetic mutations. Among the most interesting new findings from our clinical study of danicamtiv is that it appears to have a direct effect on the performance of the left atrium. We were able to confirm and learn more about these findings in nonclinical studies, which is leading us to explore danicamtiv in patients with systolic dysfunction and atrial fibrillation.

MyoKardia has gone from startup to successfully completing our first Phase III trial in eight years. In the coming months, we will be submitting our first drug to the FDA this year, which if approved will bring the first every therapy designed specifically for HCM to people with this debilitating condition.

We design our therapies with the aim of targeting the underlying disease mechanism to treat and, in some cases, reverse the problem, actually slowing down or reversing disease progression. That allows patients to live full lives, free from fear and complications. We are very excited and remain super ambitious. The magic and special sauce is really our employees and our culture.

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MyoKardia: The Precision Cardiac Medicine Company with Diversity and Inclusion at its Heart - BioSpace

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