Thank you for standing by. My name is Prilla, and I will be your conference operator today. Welcome to the Cytokinetics Q2 2025 Earnings Conference Call. This call is being recorded. [Operator Instructions] I would now like to turn the call over to Diane Weiser, Cytokinetics' Senior Vice President of Corporate Affairs. Please go ahead.

Good afternoon, and thanks for joining us on the call today. Robert Blum, President and Chief Executive Officer, will begin with an overview of the quarter and recent developments. Andrew Callos, EVP and Chief Commercial Officer, will address commercial readiness activities for aficamten. Fady Malik, EVP of R&D, will provide updates related to the clinical development program and medical affairs activities for aficamten. Stuart Kupfer, SVP and Chief Medical Officer, will provide updates on the clinical development program for omecamtiv mecarbil and CK-586, which is now called ulacamten. Sung Lee, EVP and Chief Financial Officer, will provide a financial overview of the past quarter. And finally, Robert will provide closing comments and review our expected key milestones for the remainder of 2025. Please note that portions of the following discussion, including our responses to questions, contain statements that relate to future events and performance rather than historical facts and constitute forward-looking statements. Our actual results might differ materially from those projected in these forward-looking statements. Additional information concerning factors that could cause our actual results to differ materially from those in these forward-looking statements is contained in our SEC filings, including our current report regarding our second quarter 2025 financial results filed on Form 8-K that was furnished to the SEC today. We undertake no obligation to update any forward-looking statements after this call. And now I will turn the call over to Robert.

Thank you, Diane, and thanks to all for joining us on the call today. The first half of this year has been defined by solid progress as we continue to deliver on key milestones that bring us closer to realizing our vision, a vision of being the leading muscle-focused specialty biopharma company intent on meaningfully improving the lives of patients through global access to our innovative medicines. During the second quarter, we announced that the FDA extended our PDUFA date for the NDA for aficamten for the treatment of patients with oHCM to December 26, 2025. Our late-cycle review meeting has since been moved to September, consistent with the 3- month PDUFA extension. We believe this timing should have no bearing on the approvability of aficamten, and we look forward to that meeting with FDA as we expect will occur soon and inform our next steps. In the meantime, all activities expected alongside the FDA's ongoing review process continue to time line. For example, GCP inspections of clinical trial sites and also of Cytokinetics by FDA are now completed with no observations recorded. In addition, we're maintaining a productive dialogue with FDA, and we're answering questions to support their review of the NDA. Also during the quarter, we had a collaborative meeting with FDA on our submitted REMS program following their initial review. Subsequent to the meeting, we promptly submitted an updated REMS package and during or rather despite the extension to the PDUFA date, we remain confident in the U.S. regulatory position of aficamten, given the quality of our clinical data, perceived alignment on our REMS program and ongoing collaborative dialogue with FDA. We also maintain strong conviction that the data behind aficamten support its potential FDA approval, its distinct benefit risk and pharmaceutic profile and potentially differentiated label…

Thanks, Robert. With the PDUFA date extension, we've adjusted our plans and are leveraging the extra time to finalize U.S. commercial launch readiness activities as well as refine the implementation of our promotional campaign and patient support program. Recently, a key focus has been the hiring of our U.S. sales force. After our highly successful virtual recruiting event in April, we received over 8,800 applications and proceeded to hire a very experienced cardiovascular sales team with nearly all territories now filled. This exceptional level of interest in joining Cytokinetics has provided a deep and experienced talent pool, enabling us to be highly selective in assembling a best-in-class sales team. We have now hired sales professionals who have existing relationships with cardiologists and possess deep therapeutic and industry expertise, positioning us to execute a highly impactful launch. Overall, our new sales colleagues have over 21 years of industry experience and an average of 14 years of cardiovascular experience. We expect to have the sales force on board and trained in Q4, so they're ready for an early Q1 2026 U.S. launch of aficamten. Additionally, during the quarter, we also made progress in optimizing our distribution network of specialty pharmacies and distributors. This infrastructure will be key in delivering a high-quality patient-centric experience for both patients and providers alike. We also advanced the development of our bespoke patient support program. Taken together, we have a goal to create an integrated, simple and patient-centric treatment and assistance experience across all touch points, both for HCPs and their patients. As we approach potential approval later this year and commercialization, we remain focused and driven by the compelling unmet need. We believe that approximately 80% of eligible obstructive HCM patients will be treatment-naive relative to a cardiac myosin inhibitor. So symptomatic oHCM patients naive to…

Executive Vice President of Research & Development Thanks, Andrew. During the second quarter, we were pleased to report positive top line results from MAPLE-HCM, which demonstrated a statistically significant improvement in peak oxygen uptake from baseline to week 24 for aficamten compared to the standard of care beta blocker, metoprolol. Safety and tolerability profile of aficamten was also favorable in comparison to metoprolol. MAPLE-HCM is the only trial comparing a cardiac myosin inhibitor head-to-head with the long-standing standard of care therapeutic approach of beta-adrenergic receptor blockade. As we recently announced, the full results from MAPLE-HCM will be presented in a hotline session on Saturday, August 30, at the European Society of Cardiology Congress in Madrid later this month. A prespecified analysis from the trial on the effect of aficamten versus metoprolol on cardiac structure and function will also be presented on Sunday, August 31. Until then, we can't elaborate on the top line results, but we look forward to sharing much more detail in a few weeks. Why are these data important? MAPLE-HCM reads not only on the treatment effect and safety of aficamten compared to metoprolol, but also on the impact of metoprolol itself on exercise performance, gradients, symptoms and biomarkers. As you'll see when the results are presented at ESC, we believe these results may lead to their incorporation into treatment guidelines and may lead to changes in standard of care treatment algorithms in obstructive HCM. We also plan to share other data and analyses of interest at ESC, including a late- breaking clinical trial presentation on the incidence and impact of atrial fibrillation in patients with oHCM via an integrated analysis of REDWOOD-HCM, SEQUOIA-HCM and FOREST-HCM. Atrial fibrillation has been an emerging topic of conversation around the safety of cardiac myosin inhibitors, but speculation as to whether…

Thanks, Fady. First, we continued start-up activities and enrollment of COMET-HF, the confirmatory Phase III clinical trial of omecamtiv mecarbil in patients with symptomatic heart failure with severely reduced ejection fraction less than 30%. During the quarter, our first sites in Europe came online, and we continued expanding site activations in the U.S., both of which are driving progress in enrollment. We expect to continue enrolling COMET-HF through this year and to complete enrollment in 2026. Second, as we announced in today's press release, we received approval from the INN Program of the World Health Organization for ulacamten to be used as a nonproprietary name for CK-586. During the second quarter, we continued conduct of AMBER-HFpEF, the Phase II clinical trial of ulacamten in patients with symptomatic heart failure with preserved ejection fraction of at least 60%. Enrollment in the first cohort is progressing, and we're pleased by the progress we've made in activating new clinical trial sites and in engaging investigators in this important trial. Overall, we're encouraged by the clinical trials progress of both of these later-stage pipeline programs, which represent the next strategic pillars in advancing our specialty cardiology franchise. Despite the advances in heart failure care over the years, a substantial unmet need persists across the spectrum of the disease and one that we believe our potential medicines may impact. With that, I'll pass it to Sung.

Thanks, Stuart. We're pleased to report our second quarter of 2025 financial results. Starting with the balance sheet. We finished the second quarter with approximately $1.04 billion in cash, cash equivalents and investments compared to $1.09 billion at the end of the first quarter of 2025. In the second quarter, we exercised our option on the Tranche 4 loan provided by Royalty Pharma and received proceeds of $75 million. We have an option to draw $100 million on the Tranche 5 loan prior to November 25th of this year. R&D expenses for the second quarter were $112.6 million compared to $79.6 million for the same period in 2024. The increase was primarily due to advancing our clinical trials, higher personnel-related costs and medical affairs-related activities. G&A expenses for the second quarter of 2025 were $65.7 million compared to $50.8 million for the same period in 2024. The increase was primarily due to investments towards commercial readiness and higher personnel-related costs. Net loss for the second quarter of 2025 was $134.4 million or $1.12 per share compared to a net loss of $143.3 million or $1.31 per share for the same period in 2024. Turning to our financial guidance. We are maintaining our full year 2025 financial guidance with GAAP operating expense expected to be between $670 million and $710 million. Stock-based compensation that is included in GAAP operating expense is expected to be between $110 million and $120 million. Excluding stock-based compensation from GAAP operating expense results in a range of $550 million to $600 million. We continue to monitor the pace of our commercial readiness investments as we move closer to the PDUFA date for aficamten, and we will update you accordingly. With our current balance sheet and access to additional capital, we are well positioned to fund the potential launch of aficamten in the U.S. later this year and continue to advance our pipeline. With that, I'll hand it back to Robert.

Thank you, Sung. So midway through 2025, I'm pleased with the progress we've made and the position we are in ahead of a very important second half of the year. As we approach a significant inflection point, one that has been more than 25 years in the making, our company stands at the cusp of transformative growth. This moment reflects the culmination of decades of scientific innovation, strategic investment in R&D and a steadfast commitment to delivering potentially meaningful therapies to patients in need. None of this would be possible without the dedication of our teams across the organization whose tireless work is propelling us towards these long anticipated milestones. With a strong foundation, a clear vision and the right people in place, we're poised to unlock substantial value for patients and shareholders, ushering in the next chapter of maturation as a fully integrated, high-impact leader in specialty biopharma. Now I'll recap our upcoming milestones. For aficamten, we expect to advance NDA review activities with FDA to support the potential U.S. approval of aficamten in the second half of this year. We expect to advance go-to-market strategies and to continue launch preparations for aficamten in the United States in the second half of this year. We expect to continue go-to-market planning in Germany and expand commercial readiness activities throughout Europe in 2025 in preparation for the potential approval by the EMA in the first half of 2026. We expect to coordinate with Sanofi to support the potential approval of aficamten in China, pending approval by the NMPA. And we expect to present primary results from MAPLE-HCM later this month at ESC. We expect to report top line results from the primary cohort of ACACIA-HCM in the first half of 2026, while we continue enrolling the Japan cohort of ACACIA-HCM in 2025. And we expect to complete enrollment of the adolescent cohort in CEDAR-HCM in the second half of this year. For omecamtiv mecarbil, we expect to continue patient enrollment in COMET-HF throughout 2025 to enable completion of enrollment in 2026. For ulacamten, we expect to complete enrollment of the first 2 patient cohorts in AMBER-HFpEF in the second half of this year. And finally, for preclinical development and our ongoing research, we expect to continue ongoing preclinical development and research activities directed to additional muscle biology-focused programs. Operator, with that, we can now open up the call to questions, please.

[Operator Instructions] And with that, our first question comes from the line of Gena Wang with Barclays.

So I have so many, okay, but I will limit my question to one, that's regarding the ESC update. So you did mention the MAPLE data could be potentially guideline change. Can you elaborate a little bit like what kind of a magnitude of benefit like you are looking -- what are the key data points we should be focusing on? And what kind of a magnitude benefit that payer or physicians are willing to use first-line or switch those patients on beta blocker to aficamten?

So obviously, it's difficult to answer your question until you have the data that we have, but I'll ask Fady to do his best.

Executive Vice President of Research & Development Yes. I think the data -- this is really one of the few comparative efficacy trials that's conducted in cardiology. And when the data themselves will present a picture not only of the difference between the 2, but what is the absolute benefit of each of the 2 drugs themselves compared to baseline when these patients start the drug. Right now, cardiac myosin inhibitors are thought of as last line of treatment after you fail everything else. And I think when we see the data from MAPLE-HCM, that conversation will be revisited and hopefully, guidelines as well will be updated to reflect what we have already announced the superiority of aficamten versus metoprolol and exercise tolerance. But I think we'll just have to wait to be able to expand on that once the data are out.

And your next question comes from the line of Akash Tewari with Jefferies.

So look, it looks increasingly likely that you're going to get the Camzyos ODYSSEY data at ESC. What are the 2 or 3 things investors should be looking at in that data that would support the team's hypothesis that ACACIA will be successful where Camzyos wasn't and also would support a clear exposure response relationship in this population?

Yes. So I'll take a stab at that and maybe ask Fady to add. I think it's very important to distinguish between that which is related to clinical trial conduct and that which is related to potential mechanism of action as translates to that patient population. Clearly, with ACACIA, we took what we believe to be an optimized dosing regimen that was verified in a Phase II study and took that into a Phase III trial where we elected to proceed without altering a lot of other things. We took a dose optimization regimen. We took a population. We focused to centers where we already had experience. And obviously, here at Cytokinetics, we have an expert team of HCM experts that have been both academic and industry trained in order to be able to ensure that patients met the criteria. The kinds of things that we'll be focused on is related to from a study conduct standpoint and operations, how much might there have been a change between the Phase II and the Phase III study for mavacamten and how much might that have read on the outcome in Phase III versus where we think we've been quite linear in focus one to the next. Fady, anything you want to add?

Executive Vice President of Research & Development I just might add that when you see the ODYSSEY data, and we see the ODYSSEY data, we haven't seen them yet, the question will be whether the trial didn't meet its primary endpoint because of specific features of mavacamten or trial conduct versus mechanism of action. And I think ultimately, that is what will provide some confidence in terms of ACACIA's potential success. But I think as Robert mentioned, we believe strongly in ACACIA's success just based on the strength of the Phase II data we generated and the fact that ACACIA is being conducted in a manner that was very consistent with the way we conducted Phase II.

And your next question comes from the line of Tess Romero with JPMorgan.

So what does an ideal label look like for aficamten in obstructive HCM here? And Robert, can you just double-click on any specifics you can give us on the updated REMS that it sounds like you submitted versus the original one? And how these updates track to your expectations for a differentiated REMS?

Yes. So there's a lot in that question that I cannot unpack given that we are in ongoing conversations with FDA. But I think what I can say is that an ideal label for aficamten is one that tracks with its engineered properties and the way it's been studied. And both are, we believe, enabling of differentiation as could be supportive of our expected profile. We designed into aficamten features that Fady has spoken of often, and we've studied aficamten in ways that we believe elaborate on how those features read on benefit risk. And the data from our Phase II and Phase III studies and also as further substantiated in the open-label extension are supportive of what we've argued would be a potential differentiated program in the clinical setting for patients, but also for physicians. I might ask Andrew, our Chief Commercial Officer, to speak to how his market research has been pointing to the unmet need and where we believe a differentiated label could support our expectations and aspirations.

Sure, Robert. So I think you addressed well that a differentiated label really would reflect the results of the clinical trial and the properties of aficamten. In terms of market research, I think what we've seen in our research is if the REMS and the label do reflect the properties and the study that we would be expecting good uptake at the centers of excellence, where most of the prescribing is occurring now. There's already -- as I mentioned in my remarks earlier, there's a lot of 80% plus of physicians in those centers who are aware of aficamten. So very, very high awareness even before we come to market. That expansion into community cardiology and general cardiology supported by that differentiation, further supported by MAPLE, that's what we're finding in our market research leading to a preference here, even adjusted for overstatement in our market research. So ultimately, we have to wait to see what that label and REMS looks like from the FDA, but we're pretty bullish given those comments.

And your next question comes from the line of Salim Syed with Mizuho.

I guess one for us on the oHCM late-cycle meeting. So Robert, what exactly are you planning to learn or discuss in that September late-cycle meeting? And just can you remind us how much of the REMS negotiation here actually happens post the late-cycle meeting actually during the label negotiations themselves?

Salim, very good questions. I'm not sure I can answer them to your full satisfaction simply because so much has already been discussed between Cytokinetics and FDA. I would hope that come the late-cycle meeting, we're learning that everything we are assuming continues to be tracking towards potential approval and that there's nothing new that gets introduced. But as far as the activities that have occurred, we believe we've addressed them without a lot of difference or distance between what FDA might be interested in and what we could provide with supportive evidence. Case in point, the REMS. FDA and Cytokinetics convened a meeting to discuss the REMS promptly after we submitted one. And the conversation was a very fruitful one. We were able to turn around very quickly revisions that we believe were responsive to FDA's interest. And as such, I would hope that at a late-cycle meeting, we get validation that we're all good to go. But this is somewhat unchartered territory with regard to a REMS conversation, and it may be that we learn something new. I hope not, but we're very much in a position where we think we're aligned together with FDA on what it's interested in. And to that point, it was anticipated very nicely by Cytokinetics, our colleagues here such that when we heard from FDA that they did, in fact, want a REMS, we were ready to submit one right afterwards. So I guess in that regard, to answer your question, at the late- cycle meeting, I'd like to learn that we're proceeding to final label conversations and that we're expecting no other new news.

And your next question comes from the line of Cory Kasimov with Evercore ISI.

So I wanted to ask -- go back to ACACIA and wondering if you could walk us through how drug interruptions and discontinuation protocols differ versus ODYSSEY. I guess I'm particularly curious about how ACACIA differs from the 4-week dose interruption that is necessary if LVF drops below 50% as was the case in ODYSSEY. And maybe you can point out any other significant design differences you would maybe call out between the 2 studies.

Yes. So the design differences are significant. It would appear much like there are design differences in other studies. And again, how ACACIA is conducted in accordance with that design may ultimately prove to matter. So I'll ask Fady to comment now that we have ODYSSEY as published in terms of the design, and we know what we're doing with ACACIA, I think it's good to highlight some of those distinctions.

Executive Vice President of Research & Development Yes, Cory, I think with regards to what happens when LVEF falls below 50%, in the nonobstructive, you don't have a left ventricular outflow tract gradient to buffer you for that. So you really -- I think of what we do in oHCM is we're tolerating the minimum effective dose, whereas in nHCM, we're tolerating the maximum tolerated dose, which is quite a different concept. And so with EF less than 50%, it's nice that in -- with ACACIA, primarily as long as the EF is above 40%, patients can just down-titrate drug. There is no treatment interruption. For an EF below 40%, they do interrupt drug for about a week, and they would resume drug after that at a lower dose. The -- so that's a substantial difference, I think, from ODYSSEY where patients have to interrupt drug for 4 weeks and restart and leads to a lot of disruption, if you will, in the -- in treatment. Another aspect of this is that we tested all the doses, if you will, in Phase II, 5, 10, 15 and 20. And primarily the 15 and 20-milligram doses were the ones that were most commonly used. We know that in ODYSSEY, the BMS introduced doses of 1-milligram and 2.5 milligrams. Patients could down titrate to those doses. And ultimately, we don't know if the dose density, if you will, is in the range that is known to be -- is potentially effective. And in ACACIA, we are testing doses where at least we believe we saw meaningful clinical benefit in the Phase II and as we're trying now to replicate in Phase III. So I think with regard to dosing, those are in EF of less than 50%, those are the major differences. There are some differences in the entry criteria with regards to thresholds, upper limit for peak VO2 or NT-proBNP. We have a group here that is highly knowledgeable about HCM and really look at every patient echo that came into the study. And so trying to maximize, if you will, the appropriateness of the patient population. So I think there is a number of differences there. And ultimately, when we see the ODYSSEY data, we can ask ourselves how -- which of them might be impactful in terms of ACACIA's success down the road.

And your next question comes from the line of Yasmeen Rahimi with Piper Sandler.

This is [ Emma ] on for Yas. I guess one is, what are your expectations in regards to potential REMS differences between the U.S. and EU and implications of that?

So understanding that in the EU, there is not the same sort of mechanism for REMS, it would otherwise be addressed in other means. I don't think there's going to be altogether so many differences taken collectively in light of the fact that we conducted an international study and the conversations we're having with FDA and EMA are tracking very similarly. So while there's not a formal REMS in Europe, we should expect and we are anticipating labels that are encompassing from a risk mitigation, drug-drug interaction, pharmacology and otherwise dosing and indication that there's going to be so much more in common than necessarily would be different.

And your next question comes from the line of David Lebowitz with Citi.

This is Ike Lee on for David Lebowitz. I wanted to ask about the larger market opportunity in nonobstructive HCM, which we all know is there. Presumably, you will need to reach more community doctors is our understanding upon that launch. So thinking about that, how much larger do you think your sales force is going to be if and when that time comes?

Yes. Perhaps I'll ask Fady and maybe Stuart, if he wants to add with regard to how nHCM is treated and where and then maybe ask Andrew also to add his perspective to that, especially as it might ultimately read on the size of our commercial group.

Executive Vice President of Research & Development Yes. nHCM is really like the tip of the iceberg. I think we're seeing -- we see nHCM cases in clinics that are more severe, more obvious on echocardiograms and things. But it's a disease that is difficult to diagnose. And maybe, Stuart, I'll ask you to comment on what are the challenges with recognizing it and why it might be far more prevalent throughout the community than we recognize.

Well, I think as you commented previously, of course, the nonobstructive patients don't have gradients. And so that's one sort of key criterion that makes it more difficult to diagnose. And there are a number of features that make the sort of the HCM patients sort of appear like patients with heart failure preserved ejection fraction. And so it does take some discrimination to identify these patients without sort of assuming there are patients with heart failure with preserved ejection fraction. I think another important factor is unlike obstructive HCM, where there are some more specific guidelines referring to available treatments, and we can debate about the evidence base to support those treatments, but there's sort of even more -- less guidance around treatments in nonobstructive HCM. So clearly, the medical need is even higher. And I think that maybe Andrew can address that.

Sure. So when you look at nHCM versus oHCM, the initial physician target list won't be any different. So we're not expecting to increase our field force at the launch of nHCM if ACACIA is positive and it gets approved by regulatory authorities. The way we target and look at the cardiologists who are engaged in HCM, both diagnosis and treatment is through claims data and ICD-10 codes. And the physicians we're calling on for oHCM treat both nHCM and oHCM. And there's a really large overlap with those subspecialties who are advanced heart failure cardiologists as well who treat HCM. So the around 10,000 who are 80% of the HCM diagnosis and treatment is where we're focused. If we learn more about nHCM, which right now, it's about a 50-50 split between the size of the oHCM patient population and the nHCM population, then we'll certainly expand field force as needed. But at launch, we're not expecting it.

And your next question comes from the line of Paul Choi with Goldman Sachs.

This is [ Khalil ] calling in for Paul. It seems there's been a lot of questions about regulatory interactions. So I guess I'll ask about aficamten and commercial. I suppose given some other launches in cardiology recently, there's been this focus on patient access. So we're just curious whether you had any strategies in place to differentiate against perhaps Camzyos on patient access, whether that be commercial age patients or Medicare patients. That would be helpful for us.

Yes. This is an area where I think Cytokinetics has been laser-focused already for quite some time, and Andrew and his expert team have been very diligently attending to this from a market development standpoint and what we'll read on aficamten. So I'll ask him to comment.

Sure. So as Robert had mentioned, we've had our account manager field personnel talking to payers for quite some time. We've hit or have interacted with every major payer. When we look at commercial, we expect to have kind of parity of access in commercial. When we look at Medicare, we expect to have parity and access in Medicare. So really, the strategy really is to have the same access and really have differentiation and support be the differentiators. And when you look at patient support, we are designing our patient support program around this patient population and the journey they go through and the support that's needed, including REMS. When you look at the kind of programs we'll support, we certainly will have for eligible patients, commercial patients, we'll have co-pay assistance, we'll have patient assistance programs for those who are uninsured or underinsured. So I think you'll find that the patient support programs, the access, the affordability are really targeted to be at par, if not slightly differentiated positively from where [ mava ] is. The differentiation, again, is really going to be focused on the clinical data, the REMS and the patient experience.

And your next question comes from the line of Jason Butler with Citizens JMP.

Just, I guess, an extension of that. When you think about the expansion into Europe and the commercial work that you're doing there, what -- can you just maybe speak to some of the similarities and differences of what needs to be done to get ready for the European launch?

Yes. So understand our focus is on the U.S. launch, but we're taking measured and deliberate steps in Europe to prepare for what would hopefully be a launch in the first half of the year with focus to Germany and then from there. So Andrew, in leading those activities with colleagues already domiciled in Europe, are looking at this country by country and where reimbursement is going to be ungating of some significant investment. But I'll ask him to describe more in detail how we're thinking about this.

Sure. So I think the key thing is obvious is it's a country-by-country launch in Europe. You get EMA for most of Europe, exclude Switzerland and the U.K. for now. But you get EMA approval, so you get uniform approval across the majority of the European countries, and then you have to get reimbursement on a country-by-country basis. You have free pricing in Germany for 6 months while you're negotiating price. So that is a key difference in terms of launch by launch and the government is the main payer. You have to go through health technology assessments and assign pricing and reimbursement and then you launch. So beyond the regulatory gate, then you have a reimbursement gate. I think the other key difference is once that reimbursement occurs, they're usually occurring in focused centers of excellence, hospital-specific cardiology. So it's more narrow and focused prescribing generally in Europe than in the U.S. And as Robert alluded to, Europe does not have a REMS program. Risk management is typically handled as part of labeling. So I think they are the key differences. But fundamentally, in terms of the differentiation in aficamten from the clinical trial and how we communicate that, once we get that access is -- that's going to be very similar, but again, on a country-by-country basis. Most of our spend does not occur on a country-by-country basis until reimbursement occurs. So we have gated and we're building Europe slowly where the U.S. will launch all at once, hopefully, in end of this year, early next year. Europe will launch really over about 2 to 2.5 years based on that reimbursement timing.

Hopefully, we're being good students of how companies have gone to Europe, some who have done it more successfully, most who have not, frankly. And that's where Sung, working with Andrew, working with others of our executives are taking a very disciplined, deliberate approach to how we think about Europe and doing so as is informed by derisking milestones.

And your next question comes from the line of James Condulis with Stifel.

Congrats on all the progress. Maybe just a quick one on HFpEF. Just curious, we'll get those data like early next year and wondering if you can kind of frame out what a win looks like. And kind of in that context, wondering how important you think success in Phase III within nonobstructive is to kind of confirm any initial signals there, just kind of given both are driven by systolic dysfunction.

Yes. Good questions, especially the linkage between what we're doing in nHCM as could read on HFpEF. I'll ask Fady and Stuart both to comment, please.

Executive Vice President of Research & Development Yes. I mean I think the discussions we've had around ACACIA earlier are a good read on what we think will -- we hope to see in the AMBER. And I'll ask Stuart maybe to draw the parallels between the 2 conditions and how we think each one will be reinforcing of the other.

Yes. Thank you for the question. And as Fady mentioned, the nonobstructive HCM patients do inform potential benefit in these patients with HFpEF and hypercontractility. And the endpoints that we're evaluating in our Phase II AMBER-HFpEF trial will read on the potential benefit. We're evaluating for symptomatic improvement, looking at endpoints like KCCQ, NYHA Class, looking for improvement, so improvements in symptoms, cardiac biomarkers like NT-proBNP and troponin. And of course, evaluating echocardiographic parameters, looking for potential benefit in terms of diastolic function. These will all contribute to the profile, the potential benefit that will inform whether we progress to Phase III and identifying dose or doses that will result in a favorable benefit risk profile. So again, we're encouraged by what we observed with nonobstructive HCM and the benefit -- with benefits of aficamten in the Phase II REDWOOD trial and the ongoing cohort that's been evaluated in FOREST, our open-label extension. So those are some of the key findings that we'll be looking for as well as safety and tolerability.

And your next question -- your next question comes from the line of Leonid Timashev with RBC Capital Markets.

I just want to ask, as you approach commercialization, how you're thinking about the message that you're going to lead with in HCM? I guess what I'm getting at is, what do you think really drives physician and patient enthusiasm to use the drug? And is it gradient, which is readily checkable? Is it the symptomatic benefits? Is it cardiac function? You have a lot of data across a lot of these endpoints and obviously, potential convenience advantages. I guess what's the messaging that you're going to lead with to try to drive use?

Yes. I think you probably can appreciate it's not on an earnings call where we're going to be communicating our messaging and our positioning with any kind of specifics, rather instead, you should expect us to want to see the label and ultimately, we'll be promoting to label in ways that we think will be to the advantage of adoption of aficamten. But as we've discussed in the way that we've designed aficamten and the way we've studied it, we do believe there's high levels of differentiation. And it would be reasonable for this being a next cardiac myosin inhibitor for us to want to be focused on how might we be able to grow the category and grow preferential share of the category for the benefit of more patients, more physicians comfortable with cardiac myosin inhibitors. So maybe with that as a bit of a backdrop, I'll ask Andrew if there's anything further he might want to add.

Yes. I mean, to your point, we're not going to get into what our messaging is. But generally, once the product is approved by the FDA, the physicians really want to understand and lead with the efficacy component, the balance of safety relative to that efficacy and then in this instance, then the REMS. So we'll communicate clearly the differentiation. We believe we have differentiation in each of those areas as well as very, very differentiated positioning, but you'll have to wait until we get our launch and approval and our label until that kind of gets unveiled. Thanks for the question.

And your next question comes from the line of Kripa Devarakonda with Truist Securities.

This is [ Alex ] on for Kripa. Given that we might see approval in China as the first market, can you remind us of the dynamics of the China market and what type of cadence of revenue we can expect in the upcoming quarters?

Yes. So this is somewhat of an uncommon situation, isn't it, that we might could expect an approval in China even before an approval in the United States. It's not without precedent, but they are few and far between. With that said, we are working with Sanofi, our partner. And maybe I'll ask Andrew, he's one of the leaders of that collaboration to speak to your question.

You asking about market sizing and revenue. So is that right?

Yes. And the rate that we can expect adoption in the market.

So like the U.S., China would be -- aficamten would be second to market. Like -- kind of like Europe, you need to get NRDL listing, national reimbursed drug listing in China. That it occurs on an annual basis, and you have to file by the end of June of a given year to have reimbursement the following January. So likely the first period of time, reimbursement would be through cash paying market versus, say, mava having NRDL. So I would imagine that the uptake would be slow at start, but it's a large market, as you can imagine. There's over 350,000 patients who are very concentrated into about 1,300 hospitals. Obviously, we have a very sophisticated multinational partner who knows that market extremely well. So I won't comment on the phasing, but I would only say that once reimbursement occurs, I would expect an acceleration follow that national drug reimbursement. Hopefully, that answers your question.

Yes. Congrats on the progress.

Thank you.

And your next question comes from the line of Joe Pantginis with H.C. Wainwright.

First, I guess, maybe for Andrew, it's -- as you're preparing with all your broad commercial preparations, what do you feel are some of the components that you're required to do but won't necessarily need but needed to go through the motions depending on how a potential REMS may or may not play out? And secondly, potential -- for Stuart, as you're looking at COMET, with the company's broad -- very broad experience with omecamtiv long term, how would you characterize the site excitement with regard to enrollment versus all the other omecamtiv studies?

So the first question was a complicated one. I'm trying to make sure I understand it, Joe. Your question is the kinds of things we prepared for that we might not need to do. Is that what I heard?

Correct, based on how REMS may or may not play out.

Yes. So we're pretty clear-minded on how this is evolving. And frankly, it's quite aligned to the 3 meetings we had with FDA even before we submitted the NDA, although you'll remember, we did not submit originally with a REMS, we had already anticipated what we thought mattered to FDA, and we incorporated that into label. And then FDA indicated it would, in fact, like to see a REMS. So we were already prepared to execute on that in the form of a REMS. So I don't know that there's much in the way of distance between what we expected and where we're at such that we had to prepare something that may not be relevant. I think we've got a pretty good idea as to where this is going. With respect to your next question, maybe I'll ask Stuart to comment on the level of investigator interest in COMET.

Yes. Thank you. Bottom line is there's a lot of interest in COMET, and we're very pleased to see that and it's for several reasons. One is recognition of the very high unmet need in these patients with heart failure and severely reduced ejection fraction. They really don't have medical options before on the road to end-stage heart failure. So they recognize that omecamtiv mecarbil is a potential medical option to save off that outcome. Second, they are very well aware of the results of GALACTIC, which, of course, was a positive trial. And in the subgroup of patients we're targeting now in COMET, the treatment benefit was of large magnitude, risk reduction for the heart failure outcome. So there's appreciation that because of the large sample size of the subgroup of patients, and the results we observed in GALACTIC, there's a high probability of success. And third, I think they're very pleased to see we're running a very streamlined trial without much burden on investigators and their staff. And so operationally, it's going to be an easier trial to conduct. So overall, a lot of enthusiasm for COMET.

And your next question comes from the line of Jason Zemansky with Bank of America.

This is [ Jackie ] on for Jason. Congrats on the progress. So now that you've seen more of the MAPLE data, can you comment on your expectations for first-line use? How receptive do you think prescribers and payers are likely to be? And how long do you think it will take before there can be appreciable uptake in this part of the market?

Sure. So I'll start, and I think Fady and Andrew can both respond from their respective viewpoints. What I will say is that we conducted a study head-to-head of aficamten versus metoprolol. And I do believe it will raise some eyebrows as to what is currently guideline-directed first-line therapy. But maybe that shouldn't be too surprising in retrospect because those guidelines were written absent a randomized controlled study of metoprolol in this population. So this is building of a body of evidence that didn't exist before. And for having done that, we do believe that aficamten, and you'll understand maybe why we believe this after you see the results, should be part of the conversation about what medicines to reach for in what order for the treatment of these patients. Now granted, metoprolol is a generic drug, and there's ample experience with beta blockers. But I do believe in Cytokinetics fashion, we're doing rigorous clinical research to inform guidelines and the guidelines will hopefully take into consideration the way in which the study was robustly conducted and the fidelity of the results. With that, I'll ask Fady to speak to that and maybe Andrew, if he wants to also comment on how that might ultimately get reflected and over what time frame in guidelines and how that may [ afform ] adoption.

Executive Vice President of Research & Development Yes. I mean I think it's going to take a while before beta blockers are displaced as first-line treatment given the cost differential. But I think a study like MAPLE-HCM will facilitate earlier movement and hopefully elevate aficamten in the guidelines. So it's not seen as the last the last line of therapy before surgery potentially, but instead is seen on par with the other therapies that physicians can consider. And so if patients are only modestly improved, they know that they have an alternative that they can move to more quickly. And with longer time, we hope to be able to develop evidence that there are things beyond just symptom and function relief that aficamten addresses that other therapies don't, given aficamten targets the underlying path of the disease. So with that, we someday may be able to show that we reduce the progression of disease. And then it becomes, I think, a much more important question as to which therapy to start. So this is the beginning, I think, of a sort of a longer run in terms of changing the standard of care in this disease.

Yes, I would think, I mean, our expectation is launch in the first several years after launch that first-line therapy is likely not going to occur mainly because of payers. And Robert mentioned beta blockers obviously are generic. But what we do expect to occur is more patients being on aficamten than would have been otherwise without MAPLE. We expect the acceleration of an add-on of aficamten to a beta blocker and maybe weaning off a beta blocker after the start over time. So I think those are the kinds of things you'll see for the first several years. If guidelines are updated and aficamten is part of first-line therapy, then with broader use, we could see first- line therapy. But again, I think that's several years out. Thanks for the question.

Your next question comes from the line of Mayank Mamtani with B. Riley Securities.

This is William on for Mayank. I just wanted to circle back to ACACIA. Today, you've mainly focused on sort of the ODYSSEY and the Phase II to Phase III transition on how that supports potential positive results when that reads out next year. But I was also curious how new data from the MAPLE study also from past SEQUOIA, how those may -- that new data may support ACACIA and what specifically, specific endpoints you may specifically can highlight that may support those claims? And then also just in terms of REMS, how should we think about the REMS in oHCM sort of to read through to non-obstructive HCM? Would we -- should we think that those would be relatively the same or potentially differencing just based on profiles?

Yes. So you're asking us to speculate on some things that are pretty far down the road. And obviously, we can't be considering claims. But the MAPLE study was conducted in a population of oHCM where echoes are very informative to how one approaches dose titration. ACACIA is conducted absent that in a very different population. So I'll ask Fady and Stuart to comment, but I can already suggest that we don't think that there's going to be a lot of translation from one to the other. Fady?

Executive Vice President of Research & Development Yes. I think you asked whether there's anything we've learned in MAPLE or SEQUOIA that might inform ACACIA. And we've already published data from SEQUOIA that look at how aficamten improves diastolic function, the relaxation of the heart, which is probably the primary mode by which patients with nHCM will receive treatment benefit since they don't have a gradient to reduce. And similarly, you'll see data presented on diastolic function in MAPLE at the ESC. That's part of the late breaker that I described earlier. And so I think both of these data sets will inform the fact that there is a meaningful pharmacologic effect that we believe impacts the functioning of the heart in nHCM. So I think both of those studies are supportive and those analyses are supportive of ACACIA's potential success. And as to the other questions, I agree, it's kind of a little too early to speculate on those labeling or REMS, things like that. I don't know if there's anything you'd like to add, Stuart.

Well, the only thing I'll add is the safety and tolerability profile we've observed in obstructive HCM in SEQUOIA. And that would be the fact that aficamten is a drug with a shallow exposure response profile, a relatively short half-life and very quite stable PK profile. I think all that contributes to what we observed in obstructive HCM in terms of its tolerability and expectation that will carry through to nonobstructive HCM.

You didn't ask this, but I'll add. In our Phase II REDWOOD Cohort 4, we saw very large magnitude effect changes that give us confidence that if that translates in Phase III, we should anticipate a good outcome for ACACIA-HCM, but also -- and please don't lose sight of the fact that those patients roll over into FOREST. And FOREST is an open-label study, and later this year, you'll have a chance to see what we're already seeing in patients who rolled into FOREST with nHCM, and that gives us confidence in what we can expect from ACACIA next year. So we remain quite optimistic about ACACIA.

And your next question comes from the line of Serge Belanger with Needham & Company.

This is John on for Serge today. Just wanted to touch back on with omecamtiv and the COMET trial. It seems like you guys have been getting some positive feedback from investigators and KOLs. Just wanted to gauge kind of how enrollment is tracking relative to your internal expectations as you're on your way to completing enrollment next year.

Stuart, do you want to take that?

Sure. Yes. As we sort of indicated in our -- in the call today in a press release, the COMET-HF trial enrollment is on track. We plan to -- this is an 1,800-patient trial, less than 1/4 of the size of GALACTIC. So that certainly makes it easier in terms of the operational scope. However, this is a more severe patient population. So we are targeting a smaller subgroup of patients with HFrEF. Having said that, the plan is still to complete enrollment by the end of next year. We have site activations, most of them complete in the U.S., and we're on track for site activations in Europe as well. So things are going according to plan.

What's important to note with this study is it's not competing with a bunch of other studies for the same population. This is a population that we don't believe is well served by existing standard of care or other investigational treatments. And instead, we're building off a body of evidence where we've already seen in GALACTIC, a profound treatment effect in these patients, and we just want to confirm that in this next trial. So that's contributing, we believe, to momentum for the study.

And your next question comes from the line of Roanna Ruiz with Leerink Partners.

This is Mazi on for Roanna. Just one from us obviously. So from a cardiac myosin biology perspective, as you advance aficamten and more of the HCM phenotypes and develop ulacamten for HFpEF, with this distinct mechanism, can you discuss the key differentiating factors and how these myosin inhibitors differ and how they interact with sarcomere function?

Sure. Nobody better than Fady Malik to answer that question.

Executive Vice President of Research & Development Well, so it's really interesting when we look at the myosin motor protein after 20-plus years, we've now identified 3 distinct binding sites for small molecule modulators of the protein. Aficamten binds in one place, omecamtiv mecarbil and mavacamten bind in another place. And lastly, the CK-586 or ulacamten bind and even a third place. And each of them has distinct effects of -- on how they impact motor function in the sarcomere, you can describe. I won't really go into the details and specifics here. But those differences, I think as we may be seeing in the clinic lead to differences in their profiles. And I think it's still a little early to know exactly how they differ and which one may be preferred. But there are, I think, differences that are emerging. With ulacamten, we see potentially a more shallow decrease in ejection fraction, a more shallow PK/PD curve than even aficamten. And we think the reversibility of both compounds is not just a feature of the compound itself, but also potentially the mechanism where they bind. So I'd say stay tuned. I hope to someday write a paper that describes all the various different biology and how it links to clinical.

And your next question comes from the line of Ash Verma with UBS.

I wanted to ask like this late-cycle meeting push out from June to September, is that a result of your prior 3-month PDUFA extension? Or is this a separate development, which can now have a cascading effect on your PDUFA date? What I'm trying to understand is like does the September late-cycle meeting give FDA enough of a runway to now finish up the wrap-up activities on the review before the deadline?

Yes. So as we said in the scripted comments, we believe that the shift in the late-cycle meeting is consistent with the PDUFA date extension, and we don't have any reason to think that there's anything else here. And we believe that based on interactions we've been having in the meantime with FDA that we should consider still this as a hopeful approval consistent with PDUFA date. No reason to believe otherwise.

And I'm showing no further questions at this time. I would like to turn it back to the President and CEO, Robert Blum, for closing remarks.

Thank you, operator, and thanks to all the participants on our call today. We appreciate your continued support. We appreciate your continued interest in Cytokinetics. Lots going on, and we think this midyear check-in is indicative of why we continue to be quite ambitious and hopeful and planning for success with what we hope will be our first medicine to be potentially approved later this year and all that goes with it. With that, operator, we can conclude the call. Thanks very much.

Thank you, presenters. And ladies and gentlemen, this concludes today's conference call. Thank you all for joining. You may now disconnect.