Carotid Plaque Composition by Magnetic Resonance Imaging During Lipid Lowering Therapy
Phase: PHASE4
Conditions: Coronary Artery Disease, Carotid Artery Diseases, Atherosclerosis
Sponsor: University of Washington

Official Title: Carotid Plaque Composition by Magnetic Resonance 
Imaging During Lipid Lowering Therapy   
 
NCT00715273 
 
Study Protocol and Statistical Analysis Plan - 06APR2016 
This final protocol version reflects the extension of clinical events monitoring and open-
label study as supported by American Heart Association and Alpha Phi grants. 
 
Responsible Party:  
 
Principal Investigator 
Xue-Qiao Zhao [xzhao] 
Professor 
University of Washington, Seattle, WA, USA 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 1 of 25 
Study Protocol – April 2016  
Study Protocol and Procedures 
(April 2016) 
 
 
Study Title: CAROTID PLAQUE COMPOSITION BY MRI DURING LIPID-
LOWERING, supported by NHLBI (R01 HL063895)  
 
Short tile: CPC 
 
A.  Study Protocol  
A.1.  Study Objectives/Aims:  
(1) To test the primary hypothesis that intensive lipid therapy decreases carotid 
plaque lipid content assessed by CE-MRI.  To achieve this goal, we will (a) perform 
carotid CE-MRI scans for all 180 study subjects at baseline, 1, 2, and 3 years; (b) 
perform quantitative assessments of plaque lipid content; (c) compare the plaque lipid 
content between pre- and post-treatment for all 3 therapy groups; (d) demonstrate the 
time-course of plaque lipid content change during intensive lipid modification over 3 
years by assessing serial carotid CE-MRI examinations.  
(2) To test the secondary and exploratory hypotheses that intensive lipid therapy is 
associated with plaque regression and decreased plaque enhancement assessed by CE-
MRI.  To achieve this goal, we will (a) perform quantitative assessments of plaque 
volume and enhancement; (b) compare the plaque volume and enhancement between 
pre- and post-treatment for all 3 therapy groups; (c) examine the relationship between 
plaque lipid and volume and enhancement characteristics; (d) demonstrate the time-
course of plaque volume and enhancement change during intensive lipid modification 
over 3 years. 
(3) To examine the association of factors including clinical risk factors, lipids, 
lipoprotein heterogeneity, inflammatory markers, oxidative stress markers and carotid 
plaque characteristics (lipid, volume, and enhancement).  To achieve this goal, we will 
(a) perform laboratory testing on lipids, lipoprotein heterogeneity, inflammatory 
markers, oxidative stress markers at baseline and on therapy; (b) describe the change in 
each of these measurements between baseline and on treatment; (c) determine the 
statistical significance of each measured risk variable and its change in relation to the 
change in plaque characteristics. 
(4) To investigate the effects of HDL-raising and very intensive LDL-lowering on 
carotid plaque characteristics over 3 years.  To achieve this goal, we will (a) perform 
quantitative assessment of plaque lipid, volume, and enhancement at all 4 time points 
blinded to the MRI time sequence and treatment; (b) compare the change in plaque 
characteristics over 3 years between single and double therapy for HDL-raising effect, 
between double and triple therapy for more intensive LDL-lowering effect, and single 
and triple therapy for more LDL-lowering plus HDL-raising effect. 
 (5) To determine if carotid plaque characteristics predict future major 
cardiovascular events.  To achieve this goal, we will (a) continue to conduct clinical 
follow-up for a median of 5 years to collect cardiovascular events including fatal/non-
fatal MI or stroke, hospitalization/revascularization for worsening ischemia, and 
mortality; (b) determine whether plaque characteristics (lipid content, volume and 
enhancement) at baseline and its change during therapy are statistically associated with 
cardiovascular events. 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
 
This study employs the state-of-the-art technique to assess both the magnitude and 
mechanisms of benefit of lipid therapy.  It will be one of the first studies to examine the 
effects of lipid-lowering therapy on human atherosclerotic plaques in vivo and will 
provide novel insights into our understanding of atherosclerotic plaque pathology and 
the mechanisms of lipid-lowering therapy preventing ischemic events. 
 
A.2.  Study Design:  
This project is a randomized open-label study. 
 
In this research project we will perform carotid MRI studies in 180 CAD patients with a 
family history of cardiovascular disease and ApoB ≥120 mg/dl (LDL-C levels 100-190 
mg/dl).  Fifty percent of these subjects will be women.  The qualified subjects will be 
randomized to one of three treatment groups:  (1) single therapy - atorvastatin alone; (2) 
double therapy – atorvastatin plus Niacin (2 g/day); (3) triple therapy – atorvastatin, 
Niacin plus ezetimibe (10 mg/day). .   The treatment target for LDL-C will be ≤80 mg/dl 
for the single and double therapy groups and ≤60 mg/dl for the triple therapy group.  
The HDL-C target for two niacin-treated groups will be 10-12 mg/dl increase.   All 
patients will undergo MRI examination of both carotid arteries annually for three years, 
a total of 4 examinations.  If subjects are enrolled in the trial extension a “late time” scan 
may be performed at a median time of six years. 
 
Following figure illustrates the study design. 
 
*If subjects are enrolled in the trial extension a “late time” scan may be 
performed at a median time of six years. 
 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
In order to determine if carotid plaque characteristics predict future major 
cardiovascular events, we will ask the study participants who have completed the 
original 3-year protocol and carotid MRI examinations to continue on their randomized 
therapy for up to 11 more years.  We will (a) continue to conduct clinical follow-up 
during the extension to collect cardiovascular events including fatal/non-fatal MI or 
stroke, hospitalization/revascularization for worsening ischemia, and mortality; (b) 
determine whether plaque characteristics (lipid content, volume and enhancement) at 
baseline and its change during therapy are statistically associated with cardiovascular 
events. 
 
Duration: a mean of 5 years and maximum of 11 years 
 
A.3.  Primary Efficacy Parameters:  
Primary endpoint: The primary endpoint of this study is carotid plaque lipid 
composition identified by MRI. The determination of plaque lipid content for each 
carotid artery will be performed using the automated interactive system.  These 
measurements will be performed from the MRI scans at four time points blinded to time 
sequence of MRI examinations, patient treatment, lipid levels and clinical course. 
 
Secondary endpoints: 1) carotid plaque fibrous tissue and calcium compositions, 2) 
carotid lumen area and wall area by MRI.  Again, the measurements of minimum lumen 
area, maximum outer vessel wall circumference, and plaque fibrous tissue and calcium 
contents will be performed from the MRI scans at four time points blinded to time 
sequence of MRI examinations, patient treatment, lipid levels and clinical course. 
 
Cardiovascular events: Any cardiovascular events such as death from any cause, 
non-fatal myocardial infarction, stroke, and revascularization procedures (PCI or CABG) 
due to unstable ischemia will be recorded and verified. 
 
A.4.  Planned Sample Size: In order to have 180 patients with coronary artery 
disease or carotid stenosis > 15% by ultrasound to complete the study, up to 240 
subjects will be enrolled. 
 
A.5.  Operating Sites and Investigators:  
(1) UWMC/HMC Cardiology.  
(2) Yakima Heart Center.   
(3) University of Southern California. 
 
The 2 non-UW sites have their local IRB approvals. 
 
B.  Study Procedures 
B.1. Subject Recruitment:  
Potential subjects with coronary artery disease and/or carotid artery disease will be 
selected from UWMC Cath lab with Dr. Doug Stewart as the primary subject contact 
cardiologist.  Dr. Xue-Qiao Zhao is the principal investigator and contact cardiologist for 
HMC and NW hospital recruitment.  Dr. Duane Monick will act as the primary subject 
contact cardiologist from the Yakima Heart Center.  Dr. Patrick Colletti will act as the 
primary contact cardiologist from University of Southern California.   

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
 
Subjects will be selected based the following inclusion and exclusion criteria.  An initial 
contact letter will be sent out to the potential subjects by the above-mentioned 
physicians, co-investigators for this study, at each site.  In this initial contact letter, the 
research program is introduced and further study contact information is provided for 
subjects to consider.  Individuals who are interested in the research program will contact 
the study coordinators or the investigators for more information and possibly for a 
screening visit.   
 
B.2.  Inclusion and Exclusion Criteria:  
Inclusion Criteria 
1. Men 67 years of age or younger; women 70 years of age or younger. 
2. Family history of cardiovascular disease. 
3. At least one 50% stenosis or three 30% coronary lesions post MI, PCI or CABG. 
Or carotid stenosis >15%. 
4. A confirmed fasting ApoB  120 mg/dL. 
5. Willing to participate in the study and sign an informed consent form. 
6. Medically stable with no contraindications to MRI. 
7. Have not been treated with lipid-lowering therapy for more than one year. 
 
Exclusion Criteria 
1. Younger than 21 years of age. 
2. Have pacemakers or metal implants. 
3. Have immediate plans for carotid endarterectomy. 
4. History of drug or alcohol abuse in last five years. 
5. Active liver disease or hepatic dysfunction as defined by elevations of more than 
1.5 times the ULN for AST or ALT. 
6. Serum CK  three times ULN 
7. GFR  59 mL/min/1.73 m2 prior to randomization. 
8. Bowel obstruction. 
9. Hypertriglyceridemia (serum triglycerides  500 mg/dL). 
10. Peptic ulcer disease. 
11. A fasting glucose level  150 mg/dL or HbA1c  8%. 
12. Uncontrolled hypertension as defined as either a systolic reading of  200 mmHg 
and/or a diastolic reading of  95 mmHg. 
13. Women who are or have plans of being pregnant in the future. 
 
B.3. Screening and Eligibility Assessment:  
All subjects who are interested in participation will receive a telephone screening using 
an IRB-approved script to get a general idea of subject’s demographics and any major 
inclusion/exclusion criteria.  Potential subjects will be invited to one of the 5 study 
locations as described above for their screening visit.  Subjects will be given a screening 
consent by the study coordinators; the investigators will follow up with additional 
questions.  If subjects do not have further questions and are willing to be screened for 
the study, screening procedures will be carried out per protocol.  Please note that 
subjects do not need to stop their statin therapy for study screening.  Adjusted ApoB 
levels will be calculated based on the type and dose of statin that subjects are receiving.  
Carotid MRI and/or ultrasound exams will be performed using the pre-designed 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
imaging protocol that will be provided later under MRI scan protocol and ultrasound 
sub-study protocol.   
 
After receiving all the screening information, subject’s eligibility will be assessed by a 
team of investigators and study coordinators.  A checklist on inclusion and exclusion 
criteria will be completed and signed by one of the investigators including Drs. Zhao, 
Stewart, Hatsukami, Monick, or Colletti.    
 
All screened subjects will be given the screening results and will be informed regarding 
their eligibility for the study. 
 
B.4. Subject Enrollment:  
The qualified subjects will be invited to take the next step - baseline evaluation and 
study randomization.    
 
Subjects who are willing to consider participating in the study will be given a main study 
informed consent by the study coordinators; the investigators will follow up with 
additional questions.  The informed consent process will take as long as needed.  The 
following items will be discussed in detail:  study purpose, procedures, what 
randomization means, medication(s), any possible side effects, anticipated risk and 
discomfort, subject’s right to withdraw from the program at any time, and additional 
questions.     
 
After obtaining the study consent, vital signs including blood pressure, heart rate, 
weight, height, and waist circumference will be taken.  Blood sample will be collected for 
laboratory measurements required by the study design.  Canadian Angina Function 
Class will be used to assess subjects’ ischemia status.  Subjects will be also asked to 
confirm if they have on-going conditions such heartburn, nausea, intestinal gas, muscle 
aching, flushing, glucose increase and fatigue.  The baseline evaluation will be by a team 
of investigators including Drs. Zhao, Hatsukami, Monick, or Colletti and coordinators 
and/or nurses at each site.        
 
B.5. Randomization:  
As mentioned in the study design, subject’s lipid therapy will be randomly assigned to 
one of three treatment groups:  (1) single therapy - atorvastatin alone,; (2) double 
therapy – atorvastatin plus Niacin (2 g/day); (3) triple therapy – atorvastatin, Niacin 
plus ezetimibe (10 mg/day). .     
 
This randomization will also be stratified based on (a) gender, (b) diabetes (yes or no), 
(c) smoking (yes in past 2 months or no), and (d) triglycerides ≥200 mg/dl (yes or no) to 
ensure the clinical and lipid characteristics will evenly distributed among the 3 
treatment groups. 
 
Randomization will be conducted using a computer program with information entered 
by the study coordinators. 
  
B.6. Atorvastatin Dosage Determination and Adjustment: 
The first dose of Atorvastatin is determined based on the following conditions: 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
(1) Subjects post Acute Coronary Syndrome (ACS) will continue their high dose 
atorvastatin, 40-80 mg daily, prescribed by their physicians.  If a subject is taking a 
different statin, such as simvastatin, the subject will discontinue simvastatin and 
begin atorvastatin, 40-80 mg, if tolerated.     
(2) In subjects without ACS, first dose of atorvastatin is determined based on subjects’ 
LDL-C levels at screening visit.  The adjusted LDL-C level can be calculated based on 
the type of statin and dosage that subject is currently taking.  If LDL-C ≥110 mg/dl, 
atorvastatin 40 mg daily will be initiated.  If LDL-C < 110 mg/dl, atorvastatin 20 mg 
daily will be initiated. 
 
The treatment target for LDL-C will be ≤80 mg/dl for the single and double therapy 
groups and ≤60 mg/dl for the triple therapy group.  In order to reach the LDL-C target, 
atorvastatin titration during the study will be conducted as followings: 
(1) Titration up: At 3 month follow-up visit, a blood sample is taken and LDL-C 
assessed.  If subject’s LDL-C did not reach the predefined target of ≤ 80 mg/dl for 
single and double therapy groups or ≤ 60 mg/dl for the triple therapy group, the 
atrovastatin dose will double.  This process will be repeated at 5, 8 and 12 months 
and every 4 months after through out the study. 80mg atorvastatin is the highest 
possible dose that will be administered. 
(2) Titration down: At 3 month follow-up visit, a blood sample will be taken and LDL-C 
assessed.  If subject’s LDL-C < 40 mg/dl and > 25 mg/dl with normal AST/ALT lab 
values and does not report nausea or fatigue, careful monitoring will be conducted.  
No change will be made in the atorvastatin dosage.  If subject has symptoms of 
fatigue and/or nausea and/or AST/ALT elevation per safety protocol, atorvastatin 
will be halved or stopped depending on the decision of the investigator.  If subject’s 
LDL-C < 25 mg/dl and no symptoms or liver enzyme elevation, atorvastatin will be 
halved.  If subject has symptoms or AST/ALT elevation per safety protocol, 
atorvastatin will be stopped.  This process will be repeated at 5, 8 and 12 months and 
every 4 months after throughout the study. 
 
B.7.  Niacin Dosing Up Schedule  
Based on our 20 years of experience of using niacin in our previous studies, we designed 
a dosing-up schedule to help subjects to build the niacin tolerance and to better handle 
the side effects.  This will also help to define a tolerable dose for each subject. 
 
Medication initiation:  take 500 mg, 1 tablet, with dinner daily. 
1-month F/U visit:      take 1000 mg, 2 tablets, with breakfast and dinner daily. 
2-month F/U visit:      take 1500 mg, 3 tablets, 1 at breakfast and 2 with dinner daily. 
3-moth F/U visit: 
     take 2000 mg, 4 tablets, 2 with breakfast and 2 with dinner daily. 
 
This dosing-up can last as long as 6 months based on how well the subjects can tolerate 
each dosage level. 
 
Aspirin (81-325mg) is recommended 30 minutes before taking niacin. 
 
B.8.  Study Medication Information and Instruction 
In addition to the medication information listed in the study informed consent form, we 
will also provide subjects a separate document as shown below with the drug 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
information for the 3 medications used in CPC.  Pertinent 
Medication Information for the Carotid 
Plaque Composition by MRI During Lipid-
lowering Study 
 
 
There are three study medications 
used in this study. 
 
 
1. Lipitor (atorvastatin) 
  
A member of the drug class known as statins, used for lowering cholesterol. 
Lipitor helps decrease the amount of LDL or ‘bad’ cholesterol in the blood by 
blocking an enzyme called HMG-CoA reductase, an enzyme that makes 
cholesterol. Statins reduce total cholesterol, as well as LDL-cholesterol, in the 
blood, which slows the progression of heart disease. Lipitor is generally well 
tolerated. In less than 1% of people, it may cause muscle aches or certain 
abnormalities of muscle-related blood tests. These problems are rare and are 
reversible by stopping the medication. In the study, blood sugar, liver function 
and muscle tests are taken often. 
 
 
2. Slo-Niacin (slow-release niacin) 
  
Slo-niacin is a medication used to raise levels of HDL or ‘good’ cholesterol and 
lower triglycerides. The risks from Slo-Niacin include a warm flushing 
sensation that occurs shortly after taking the medication, which may be 
difficult to tolerate. Slo-niacin may uncommonly (2-4% of users) cause a skin 
rash, increased blood sugar or cause mildly abnormal liver tests. Fatigue, 
nausea, loss of appetite and muscle aches may be drug-associated side effects, 
although generally rare. 
 
 
3.  Zetia (ezetimibe) 
  
. 
Ezetimibe works by preventing cholesterol absorption in the intestine.  It is generally 
well tolerated.  Side effects may include headache, dizziness, diarrhea, sore throat, 
runny nose, sneezing and joint pain.  Rare side effects include hives, rash, itching or 
swelling, hoarseness, upset stomach, tiredness, unusual bleeding, pain, flu-like 
symptoms, muscle pain or weakness or chest pain. 
 
 
 
 
 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
 
 
The medication instruction sheet as shown below is also provided to all subjects at the 
study medication initiation visit. 
Directions for CPC Study Medication Schedule 
 
Morning Dosing Directions (AM): 
 
Take One ezetimibe pill and   1-2 pills of Slo-niacin (or half of the daily dose indicated on the bottle) as 
instructed, with breakfast. 
 
Evening/Night Dosing Directions (PM): 
 
 
Take 1-2 Atorvastatin pills with dinner, as indicated on the bottle.  Take 1-2 pills of Slo-niacin (or half of the        
daily dose indicated on the bottle) with dinner or before bed. 
 
Valuable Information: 
 
Niacin can sometimes cause a flushing feeling when you first start taking it. If this occurs, there are a few 
suggestions to help stop or reduce this feeling. The flushing feeling usually goes away over time if you continue 
to take niacin. 
 
Some helpful ideas for reducing niacin-related flushing: 
 
1. Take your medication in the morning and right before bed. 
2. If you use a daily aspirin, take it 30 minutes before your niacin (either morning or evening). Do not take 
more than 325 mg Aspirin daily without first talking to your doctor. 
3. ‘Flushing’ is reduced by food in your stomach. Enjoy a low-fat snack before you take niacin. An ounce of 
cheese with a few crackers, a cup of milk or yogurt with fresh fruit are a few examples.  
4. Avoid hot drinks, alcohol and spicy foods with dinner as this can sometimes encourage flushing from 
niacin. 
 
 
 
 
 
 
 
 
 
 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
The study medication dispensing process is described under B.11. 
 
B.9. Clinical and Laboratory Follow-up Procedures:   
After randomization, the study subjects will be seen monthly for six months and bi-
monthly for the remaining 30 months of the 36-month protocol.  A total of 22 visits will 
be conducted for this study as shown in the procedure table below.  This clinic visit 
protocol is developed based on the successful FATS and HATS (RO1 HL49546) clinic 
visit models.  The clinical visits will be done by a team of investigators, coordinators and 
nurses as well at each of 3 study sites.   
 
Participants who complete the first 3 years of the study and are willing to continue on 
the randomized therapy and will be followed every 4 months for up to 11 more years.   
Table. Clinical Follow-up Protocol 
 
Visit 
Entry 
Criteria 
Con-
sent 
Med. 
Hx 
Family 
Hx 
Vital 
Signs 
Diet 
Coun- 
seling 
AE/ 
Side 
Effects
Drug 
Disp. 
Com-
pliance 
Safety 
Moni- 
toring 
Meds 
Adj. 
Screening 
X 
X 
 
 
X 
 
 
 
 
 
 
Baseline 
 
X 
X 
X 
X 
X 
 
X 
 
 
 
Non-blood  
draw visits* 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
Blood draw  
visits** 
 
 
 
 
X 
X 
X 
 
X 
X 
 
*: C1, 2, 4, 6, 10, 14, then every 4 months up to C130. **: C3, 5, 8, 12, then every 4 
months up to C132. 
 
At these visits, subjects will undergo questioning about side effects and symptomatic 
state, and vital signs will be taken.  At approximately 60% of the visits, blood will be 
drawn (<50 ml).  The Table below provides the laboratory parameters 
collected/measured in this study.  
 
Table. Laboratory Measurement Schedule for the Carotid Plaque Composition Study 
 
Visit 
S 
C 
R. 
C 
0 
C 
3/ 
5/ 
8 
C 
12 
C 
16/ 
20 
C 
24 
C 
28/
32 
C 
36 
Non-annual Visits 
C40/44/52/56/64
/68/76/80/88/92
/100/104/112/116
/124/128 
Annual 
Visits 
C48/60/ 
72/84/96/ 
108/120/132 
T 
X 
TC/TG/LDL/ 
HDL/VLDL 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HDL2&3/IDL/ 
LDLT/HDLT 
 
X 
 
X 
 
X 
 
X 
 
X 
 
ApoB, A1, A2,  
ApoE, Lp(a) 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
AST/ALT, CPK 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
BILI/ ALK 
PHOS/T4/TSH 
 
X 
 
 
 
 
 
 
 
 
 
Creatinine/ 
Uric Acid 
 
X 
 
X 
 
X 
 
X 
 
X 
 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
Fasting glucose/ 
HgA1C** 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Insulin/ 
Fibrino./ 
HsCRP 
 
X 
 
X 
 
X 
 
X 
 
X 
 
Plasma storage 
 
X 
 
X 
 
 
 
X 
 
X 
 
*: SCR=screening; C0 = baseline; C3, 10, 24, 36,…… = 3, 10, 24, 36,…… months in the 
study.  TX = test for possible side effects of the study treatment.  **: This schedule is for 
diabetic subjects.  For non-diabetic patients fasting glucose is measured at S, C0, C12, 
C24, C36, C48, C60, and every 12 months up to C132.   
 
Dietary counseling will be targeted at weight reduction with goals based on the level of 
obesity, with additional emphasis on the use of mono-unsaturated fats in a fat-limited 
(25-30%) diet.  Dietary counseling will be provided to subjects by a certified research 
dietitian.   
  
One week in advance of the next scheduled visits, subjects will receive a form letter from 
the study coordinators reminding them of the date and time, whether to fast, and to 
return unused drug supplies.  One or two days before the visit they will again be 
reminded by telephone call from research assistance or the study coordinators, and the 
visit confirmed or changed.  All scheduling is initiated by a computer program with 
capability to shift dates, making the associated adjustments in compliance calculations 
and drug distribution.  Each clinical visit will take about 30 minutes. 
 
 
 
 
 
B.10. Study Medication Dispensing 
All three medications are FDA approved drugs.  Pfizer, Upsher-Smith, and Merck, Sharp 
and Dohme Corp  are the three companies providing the medications (atorvastatin, 
Niacin, and ezetimibe ).  A drug supply record on each medication keeps tracking the 
quantity requested and received.  All medication is stored at Harborview Investigational 
Drug Services (HMCIDS), as well as all documentation of drug dispensing. 
 
 
With instruction from the UWMC Investigational Drug Services and Harborview 
Investigational drug Services, a study medication dispensing procedure has been 
developed as following. 
 
(1) A medication card as shown below with the study name, drug information, and 
emergency contact information will be provided to each enrolled subject at the study 
medication initiation visit and repeat on their annual visits. 
 
 
 
Study Name: Carotid Plaque Composition 
Study Investigator: Xue-Qiao Zhao, MD (206-744-8305) 
 
 
Study Coordinator: 1-866-866-0175 
1. Lipitor (atorvastatin): 10-80mg/day 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
2. Slo-niacin (niacin): 1.5-2g/day 
3. Zetia (erxetimibe) 10 mg/day  
   
(2) The medication bottles/kits will be labeled with (a) study name, (b) subject name, (c) 
subject Harborview ID number, (d) medication name, (e) dispensing date, (f) expiration 
date, (g) total quantity, (h) instruction, and (i) a federal statement limiting use to the 
given study.  
 
(3) For each enrolled subject at each scheduled study visit, a study medication 
prescription which is signed by the study doctor will be generated from our computer 
system based on the randomization, atorvastatin dosage determination and niacin 
dosing-up schedule, and duration between visits.   
 
(4) Prescription requests are delivered to HMCIDS prior to the study visit and are then 
dispensed by HMCIDS.  
 
(5) Each medication dispensing record will be saved in the subject medication folder. 
 
(6) Medications will be dispensed to subjects in person at the end of each scheduled 
visit.  All medication information and instruction will be reviewed with the subject at 
time of dispensing by an investigator.  
 
(7) Subjects will receive two pill organizers, one for ezetimibe  and niacin taken in the 
morning and one for atorvastatin and niacin at bed time, to help them to remember to 
take the study medications.  We will also recommend placing the morning pill organizer 
in the kitchen and the night pill organizer maybe in the bathroom, this will help subjects 
to link the medication taking with their routine activities for optimal compliance.  
 
(8) Subjects will be required to bring back all unused medications for compliance 
calculation. Unused medication will be returned to HMCIDS for destruction  
 
C.  Safety Monitoring and Procedures 
C.1. Subject Safety and Monitoring Plan:  
Objectives: 
(1) Monitor study progress and subject safety 
(2) Assure adverse event recording and reporting 
(3) Assure investigator communication with IRB and NHLBI 
(4) Assure protocol compliance 
(5) Assure data accuracy 
(6) Verification of initial study design and further modifications 
 
Level of risk assessment: low level of risk 
(1) It is therapeutic study using all FDA approved drugs (Atorvastatin, Niacin, 
Ezetimibe). 
(2) Not an IND study 
(3) The study doesn’t include vulnerable populations. 
(4) Study subjects are not at high risk, they are either with stable CAD or with sub-
clinical atherosclerosis. 

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Study Protocol – April 2016  
(5) Primary endpoint of the study is carotid plaque lipid composition as assessed by 
MRI. 
 
Safety monitoring will be provided by: study team 
(1) Investigators and study coordinators 
(2) Real time monitoring plan on management of risk to subjects 
(3) Annual review and report to IRB due to the lower level of risk 
 
C.2. Safety Parameters:  
(1) Vital signs 
(2) Liver function: ALT/AST 
(3) Muscle enzyme: CPK 
(4) Fasting glucose levels  
 
C.3. Safety Monitoring Procedures:  
Clinical monitoring: 
As discussed previously, at each of the clinical follow-up visits, subjects will undergo 
questioning about side effects and symptomatic state and vital signs will be taken.  If any 
expected conditions or symptoms possibly related to the medications are reported as 
severe at C1 visit or persistently being moderate at ≥ 3 visits, the study safety monitor, 
Dr. Xue-Qiao Zhao, will be informed.  Then, Dr. Zhao will provide specific instructions 
on study medication change based on both his professional opinion and predefined 
monitoring protocol.  For example, flushing and itching are most common side effects 
from niacin.  In addition to a recommendation of taking aspirin 30 minutes prior taking 
niacin, taking niacin after dinner will further reduce these side effects, etc.             
 
Laboratory monitoring: 
There are three safety aspects we stress in this study: ALT/AST for liver function; CPK 
for muscle side effect; and glucose levels for diabetes control.  If any of these is outside 
of the normal range, appropriate procedures will be taken: 
 
(1) Compare current results to baseline or previous values.  This helps the investigators 
determine whether or not study medications could be the possible cause of the abnormal 
lab value. 
 
(2) Be thorough in evaluation of patient’s side effects and confirm no other changes in 
life style or other medications could be the cause of such lab value change. 
 
(3) Determine if the result is only slightly elevated (less than 1.5 x Upper Limit of 
Normal (ULN) or glucose <160 mg/dl), monitor patient closely and repeat the test at the 
next visit usually within 2-4 months per protocol. 
 
(4) If the result is 1.5-2.5 x ULN ALT/AST or CPK (or glucose ≥ 160 mg/dl), a repeat 
blood draw will be ordered within 1 month and subject will be closely monitored by 
telephone follow-up.  Subject’s primary care physician will be notified and patient will 
continue the study medications. 
 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 13 of 25 
Study Protocol – April 2016  
(5) If the result is ≥ 3 x ULN ALT/AST or CPK, a repeat blood draw will be ordered 
within 2 weeks and subject’s primary care physician will be notified, the study 
medications will be reduced or stopped, patient will be monitored closely by telephone 
follow-up and repeat lab test(s) will be ordered until the values normalize.  If glucose 
>200 mg/dl, home glucose monitoring will be ordered and niacin will be reduced to half 
dose.  If >240 mg/dl, home glucose monitoring will be ordered and niacin will be 
stopped until glucose levels return to <160 mg/dl.   
 
Steps 3-5 are also outlined in the Table below for Lab Safety Monitoring. 
 
Lab Safety Monitoring Protocol in CPC 
 
Sample at 3 months 
Sample at 5 months 
Sample at 8 months and all 
blood draw visits thereafter 
 
Condition 
Strategy 
Condition 
Strategy 
Condition 
Strategy 
 
 
If <1.5X 
ULN 
Careful 
Monitoring 
& repeat test 
@ C5 
If <1.5X 
ULN 
Careful 
Monitoring 
& repeat test 
@ C8 
If <1.5X 
ULN 
Careful 
Monitoring  
& repeat test  
@ C12 
AST  
ALT 
CPK 
Safety: 
 
If 1.5-2.5X 
ULN 
Monitoring. 
Letter to PCP 
& repeat test 
within 1 M 
 
If 1.5-2.5X 
ULN 
Monitoring. 
Letter to PCP 
& repeat test 
within 1 M 
 
If 1.5-2.5X 
ULN 
Monitoring. 
Letter to PCP & 
repeat test 
within 1 M 
 
 
If >3.0X 
ULN 
Monitoring. 
Letter to PCP 
& repeat test 
within 2 Wk. 
Lower or 
stop meds 
 
If >3.0X 
ULN 
Monitoring. 
Letter to PCP 
& repeat test 
within 2 Wk. 
Lower or 
stop meds 
 
If >3.0X 
ULN 
Monitoring. 
Letter to PCP & 
repeat test 
within 2 Wk. 
Lower or  
stop meds 
 
If 126-159 
mg/dl 
Careful 
monitoring 
If 126-159 
mg/dl 
Careful 
monitoring 
If 126-159 
mg/dl 
Careful 
monitoring 
 
If ≥160 
mg/dl 
Letter to PCP 
& repeat test 
within 1 M 
If ≥160 
mg/dl 
Letter to PCP 
& repeat test 
within 1 M 
If ≥160  
mg/dl 
Letter to PCP 
& repeat test 
within 1 M 
Glucose 
Safety: 
If >200 
mg/dl 
Repeat test 
within 2 Wk. 
Half niacin 
dose 
If >200 
mg/dl 
Repeat test 
within 2 Wk. 
Half niacin 
dose 
If >200  
mg/dl 
Repeat test 
within 2 Wk. 
Half niacin 
dose 
 
If >240 
mg/dl 
Glucose 
monitoring & 
stop niacin 
If >240 
mg/dl 
Glucose 
monitoring & 
stop niacin 
If >240 mg/dl 
Glucose 
monitoring & 
stop niacin 
ULN=Upper Limit of Normal 
 
In addition, the following Table (Dosage Adjustment Protocol for CPC) provides 
basic guidance for dosage adjustment related to both reaching LDL-C and HDL-C 
targets and dealing with potential drug side effects. 
 
Dosage Adjustment Protocol for CPC (Updated 01Aug2010) 
 
 
Sample at  
3 months 
 
Sample at  
5 months 
 
Sample at  
8 months 
Sample at 12 
months and all 
visits thereafter 
 
Target 
Strategy 
Target 
Strategy 
Target 
Strategy 
Target 
Strategy 
Single 
 
 
 
If >80, 
 
If >80, 
 
If >80, 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
Rx 
Group: 
LDL-C≤ 
80 
mg/dl 
-- 
LDL-C 
≤80 
mg/dl 
double 
statin dose, 
or 
(max dose 
80mg) 
LDL-C 
≤80 
mg/dl 
double 
statin dose, 
or  
(max dose 
of 80mg) 
LDL-C≤ 
80 
mg/dl 
double 
statin dose, 
or  
(max dose 
80mg) 
Double 
Rx 
Group: 
LDL-C 
≤ 80 
mg/dl 
 
-- 
HDL-
C+5 
from 
base. 
Improve 
compliance 
HDL-
C+8 
from 
base. 
Improve 
compliance 
HDL-
C+10 
from 
base. 
Improve 
compliance 
 
 
-- 
 
-- 
 
LDL-
C≤80 
mg/dl 
If >80 
mg/dl, 
double 
statin dose, 
or 
(max. dose 
80 mg) 
 
LDL-
C≤80 
mg/dl 
If >80 
mg/dl, 
double 
statin dose, 
or 
(max. dose 
80 mg) 
 
LDL-
C≤80 
mg/dl 
If >80 
mg/dl, 
double 
statin dose, 
or 
(max. dose 
80 mg) 
Triple 
Rx 
Group: 
-- 
-- 
HDL-
C+5 
from 
base. 
Improve 
compliance  
HDL-
C+8 
from 
base. 
Improve 
compliance  
HDL-
C+10 
from 
base. 
Improve 
compliance  
 
 
LDL-C≤ 
60 
mg/dl 
 
-- 
 
LDL-C≤ 
60 
mg/dl 
If >60, 
double 
statin dose, 
or 
(max. dose 
80) 
 
LDL-C≤ 
60 
mg/dl 
If >60, 
double 
statin dose, 
or 
(max. dose 
80) 
 
LDL-C≤ 
60 
mg/dl 
If >60, 
double 
statin dose, 
or 
(max. dose 
80) 
 
If 
SX/LCF 
or 
LDLC<
25 
Half statin 
dose  
or  
stop meds 
If 
SX/LCF 
or 
LDLC<
25 
Half statin 
dose  
or  
stop meds 
If 
SX/LCF 
or 
LDLC<
25 
Half statin 
dose  
or  
stop meds 
If  
SX/LCF 
or 
LDLC< 
25 
Half statin 
dose  
or  
stop meds 
LDL 
Safety: 
If ASX 
and 
LDLC<
40  
 
Careful 
monitorin
g 
If ASX 
and 
LDLC<
40  
 
Careful 
monitoring 
If ASX 
and 
LDLC<
40  
 
Careful 
monitoring 
If ASX 
and 
LDLC< 
40 
 
Careful 
monitoring 
 
If SX 
LDLC<
40 
Half statin 
dose or 
stop meds 
If SX 
LDLC<
40 
Half statin 
dose or stop 
meds 
If SX 
LDLC<
40 
Half statin 
dose or stop 
meds 
If SX 
LDLC<
40 
Half statin 
dose or stop 
meds 
SX=symptomatic, ASX=asymptomatic,  
LCF=low cholesterol flu-like symptoms including muscle aching, nausea 
and fatigue. 
 
 
Please note that renal function monitoring is described under Carotid Imaging Protocols 
below. 
 
D.  Carotid Imaging Protocols 
D.1.  MRI Scan Protocol: 
Prior to the carotid MRI scans, subjects will be required to fill-out the Magnetic 
Resonance (MR) Procedure Screening Form provided by the MRI center (Attachment 
1).  This form will be reviewed by both the study coordinator and by the MRI center staff 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
to ensure subject’s eligibility for MRI scans.  For subjects with coronary stents, we will 
check MRI safety compatibility of a particular stent or surgical implant by visit 
www.mrisafety.com or contacting the manufacturer directly. 
 
Subjects from the UW and Yakima sites will receive their carotid MRI scans at the Bio-
Molecular Imaging Center (BMIC) (Chun Yuan, Director) for high-resolution animal 
and human imaging.  A 3T Philips Achieva Quasar Dual 3.0T (Software Release 1.2.2) 
whole body scanner is available for use at this center as a full time research scanner.  
This scanner also includes the Philips ViewForum Workstaton (Software Release 4.1).  
Subjects enrolled at the USC site will receive their MRI scans at the USC Imaging Center 
of Department of Radiology using a standard scan protocol designed by the Vascular 
Imaging Lab at the University of Washington.   
 
Subjects will be placed in the supine position in the MR scanner with the neck extended 
to bring the carotid arteries into a more superficial location relative to the skin.  A 
custom designed head holder will be used to minimize patient movement.  Two separate 
phased-array carotid coils will be used for simultaneous bilateral carotid imaging.  A 
standard 3-plane localizer will be used to identify the carotid arteries.  Then, 6 more 
sequences will be applied to generate carotid images.  Ten cc of gadolinium contrast 
material will be administrated intravenously though a power injector.  Images of 4 
locations, centered either on the carotid bifurcation or on the plaque, will be 
simultaneously acquired using axial 2D spoiled gradient-recalled echo imaging without 
cardiac gating.  These images will be obtained at 10 time points separated by a repetition 
interval of 15 seconds.  Post-contrast T1-weighted images will be acquired 5-7 minutes 
after gadolinium contrast administration.  The total scan time for each patient will be 
about 50 minutes.   Following figure is an example of carotid arteries oblique and cross-
sectional views by MRI.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D.2.  Renal Function Monitoring:  
A gadolinium agent used in this study is FDA-approved.  However, in a very small 
percentage of patients with impaired kidney function, gadolinium has been suspected to 
cause a side effect called nephrogenic systemic fibrosis, or nephrogenic fibrosing 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
dermopathy (NSF/NFD).  To monitor the renal function, calculated creatinine clearance 
will be drawn and glomerular filtration rate (GFR) will be measured within 4 weeks of 
use of gadolinium agent during the carotid MRI scans.  If GFR< 30ml/min/1.73m2 is 
found at any measurement, or a ≥ 50% drop in GFR from the previous testing point, the 
subject will be excluded from the study and renal function measurement will be 
repeated and recorded.  If necessary, the subject will be referred to nephrology for 
further evaluation and treatment.   
 
D.3. MRI Analysis Protocol 
1. Image Blinding and Matching Process 
The MR image analysis will be carried out at the Vascular Image Lab, directed by Drs. 
Yuan and Hatsukami, in Department of Radiology at the University of Washington.  The 
original MRI examination identification (ID) number, image date/time, and series 
information will be replaced with a new and randomly generated MRI analysis ID 
number.  A master log file containing both original and new image information, and 
study subject ID, will be generated at the time of renaming.  This blinding process will 
ensure that MRI reviewers are fully blinded to patient information and time sequence 
during the image analysis.  It will also protect patient confidentiality in accordance to 
HIPAA guidelines. 
 
Prior to image review, all across-sectional images from TOF, T1, PD, T2, and post-CE T1 
weightings will be co-registered using the carotid bifurcation as a physical landmark. 
 
2. Visual Assessment of Atherosclerotic Lesion Type 
A previously published MRI-based AHA lesion classification scheme will be used for this 
evaluation: type I-II = near-normal wall thickness; type III = diffuse wall thickening or 
small eccentric plaque; type IV-V = plaque with a necrotic core; type VI = complex 
plaque with a possible surface defect, hemorrhage, or thrombus; type VII = calcified 
plaque; and type VIII = fibrotic plaque without a necrotic core. 
 
3. Quantitative Measurements of Plaque Volume and Tissue Composition 
(a) Plaque Volume Measurement: Contours will be placed around the lumen and 
outer-wall boundaries of carotid artery.  These contours may be created manually or 
automatically.  The arterial wall area = outer-wall area – lumen area.  The wall volume 
will be calculated as: wall area x 2 mm (slice thickness).  Wall/outer wall ratio will be 
used as a normalized wall index that is adjusted for differences in carotid artery size in 
the common carotid, bifurcation, and internal carotid arteries.   
(b) Plaque Tissue Content Measurement Using Automated Plaque Tissue 
Segmentation: As introduced in the preliminary studies, the Vascular Imaging 
Laboratory at the University of Washington has developed an semi-automated system 
(MEPPS) and has shown that MEPPS is capable of achieving accuracy similar to results 
achieved by manual review by expert reviewers for quantifying plaque composition.  The 
automated segmentation is based on the fact that various tissue contents such as lipid, 
calcium, loose matrix and fibrous tissue have different signal characteristics from each 
weighting as shown in the Table below.  The system first determines the probability that 
each MRI pixel belongs to each of the 4 tissue types (lipid, calcification, loose matrix, 
and fibrous tissue).  Then, it uses the competing active contours to identify the 
boundaries of high-probability regions for each tissue type. 

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
 
Table. Tissue Classification Criteria 
 
TOF 
T1W 
PDW 
T2W 
>80% SIPost contrast 
T1W 
LRNC with (A) No or little 
Hemorrhage 
           (B) Fresh Hemorrhage 
                 (C) Recent 
Hemorrhage 
o 
 
+ 
   
+ 
o/+ 
 
+ 
   
+ 
-/o 
 
-/o 
 
+ 
-/o 
 
-/o 
 
+ 
- 
 
- 
   
+ 
Calcification 
- 
- 
- 
- 
- 
Loose Matrix 
o 
-/ o 
+ 
+ 
+ 
Dense (Fibrous) Tissue 
- 
o 
o 
o 
+ 
The classification into the subgroups is based on the following signal intensities (SI) 
relative to adjacent muscle. LRNC = Lipid-Rich/Necrotic Core. + = hyper-intense,  o = 
iso-intense,  -  = hypo-intense. 
 
The steps for measuring plaque volume and automated segmentation include the 
following: 
        
Step 1. Image matching: After loading the 5 MRI sequences (pre-contrast T1, post-
contrast T1, T2, PD, TOF) onto the CASCADE computer interface, the images will be 
manually matched to each other by using the carotid bifurcation as a landmark.  An 
example is shown in Figure 1 below. 
 
Step 2. Lumen and wall boundary detection: Using information available from 
the multi-contrast weighted images, the lumen and wall boundary of the carotid artery 
will be identified and outlined by expert reviewers.  An example is shown in Figure 2 
with lumen boundary in red and outer wall boundary in blue. 
 
Step 3. Registration: After manual boundary detection, the CASCADE Program will 
automatically identify and outline the lumen and wall boundary of the carotid artery in 
the remaining 4 sequences.  An example is shown in Figure 3 below.  Expert readers will 
review the outlines generated by CASCADE, and have the opportunity to manually 
override errors in the automated outlines that may occur as a result of marginal image 
quality or flow artifact. 
 
Step 4. Auto-segmentation:  The CASCADE Program will automatically identify and 
quantify the tissue component within the arterial wall.  Expert readers will then review 
the output of CASCADE to insure correct classification of the plaque  
components.  An example is shown in Figure 4 below with loose matrix in purple and 
lipid content in yellow. 
 
The image analysis for this study will be performed at the time of completing both MRI 
examinations.  By doing so, a region of each carotid artery, covered by both baseline and 
2-year scans, will be identified and image analysis will be performed within the region.  
This will allow the same reviewers to analyze all images and therefore to reduce the 
inter-reader variability.  The analysis will be performed at Vascular Imaging Lab using 
CASCADE with automated tissue segmentation capability using MEPPS.  

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 18 of 25 
Study Protocol – April 2016  
 
(c) Plaque Tissue Composition: This will be calculated based on each identified 
tissue volume and wall volume at each given location: tissue volume/wall volume x 
(100%), and presented as percentage. 
 
(d) Summary of Plaque Variables: CASCADE can produce a list of comprehensive 
plaque assessments.  Plaque burden measurements will include the carotid lumen, wall, 
and outer-wall area in mm2, wall thickness in mm, and wall/outer-wall ratio (a 
normalized wall index that is adjusted for carotid artery size difference) that is 
equivalent to the % of atheroma area used in the coronary intravascular studies.  The 
plaque tissue characteristics will be presented as absolute measurement in mm2 and as a 
proportion of the corresponding vessel wall area, expressed as in % lipid, % loose matrix, 
% calcium, % fibrous tissue and % hemorrhage.  Additionally, the plaque integrity will 
also be evaluated and described as ruptured, thin or thick fibrous cap, with and without 
ulceration, with and without thrombus.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D.4.  Carotid  
 
 
Ultrasound Examination:   
 
 
A carotid ultrasound sub-study for assessment of carotid intima media thickness (CIMT) 
has been added to this study protocol as a sub-study.  If the patient agrees after 
reviewing the informed consent, the carotid ultrasound exams will take place on the 
same date as the carotid MR scans: baseline, C12, C24 and C36 post randomization.   
 
 
All ultrasound scans will be done using the SonoSite Micromaxx System (Bothell, WA) 
and equipped with a 10.0 Mhz transducer.  This system was used in the ARBITER-2/3 
and 6 studies.  B-mode scans of the right and left common carotid arteries, carotid bulbs 
and internal carotid arteries will be performed as illustrated in the follow-up figure.  Any 
plaque or wall thickness > 1.5 mm will be identified using both oblique and cross-
sectional views and recorded using a carotid artery map for location.  Then, common 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 19 of 25 
Study Protocol – April 2016  
carotid arteries and carotid bulbs will be focused on IMT scans using both anterior and 
lateral angles to cover about 60% of the carotid wall.  A digital cine-loop of each vessel 
will be recorded digitally.  The images will be transferred and stored onto CDs at the 
Coronary Atherosclerosis Research Lab.    
 
 
 
 
 
 
 
 
 
 
 
 
CIMT measurements will occur on desktop computers (Dell 2.4 GHz, Pentium 4, 1 GB 
RAM) using an automated IMT detection program by SonoSite.  The CIMT of the 10mm 
adjacent segment distal to the carotid bulb of the far wall of the common carotid artery  
at both anterior and lateral angles of both the right and left side will be measured from 
4-6 reprehensive images with automated IMT detection and the mean CIMT will be 
reported.  A carotid IMT example is shown below.  Both the sonographer and person 
performing the IMT measurement will be blinded to the treatment group.  Inter-
observer and intra-observer variability will be determined on a subset of cases and 
reported for the automated CIMT analysis.   
 
 
 
 
 
 
 
 
 
 
 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 20 of 25 
Study Protocol – April 2016  
 
 
 
 
 
 
 
Cardiology fellows, for example, Dr. Binh An Phan, performed the carotid ultrasound 
exams and IMT measurements as their research projects. 
 
E.  Study Documentations 
E.1. Regulatory Documents  
(1) Grant Application and Sponsor Communications – including the original grant, 
award notifications, study communications with NHLBI and industry supporters, and 
study progress reports.  
 
(2) IRB Binder – including the IRB applications and modifications, both submitted 
materials and approved documents.  Each of the study sites has a site-specific IRB 
binder.   
 
(3) Approved Consent Binder – starting with a consent/HIPAA log showing all approved 
consent forms for this study and HIPAA Authorization as well as hard copies of consent 
forms and HIPAA forms. 
 
(4) Investigators Binder – including a study responsibility and delegation log, CVs for 
each investigator and copies of their licenses.  Human subject protection training 
certificates are also included in this binder.  
 
(5) Protocol Binder – including protocols for the main study, sub-studies and extensions 
and procedure manual as well.  
  
(6) Laboratory Binder – including lab certifications, laboratory reference ranges and 
blood sample handling forms. 
 
Please note that this study does not require FDA 1572 since there is no IND. 
    
E.2. Subject Files 
Each enrolled subject will have documentation folder.  The left hand side of the folder 
contains:  
(a) Singed consent forms and HIPAA Authorization forms, and a consent process 
document that describes how the consent been conducted has been added since 
December 2010;  
(b) Screening material including medical records for vascular disease or carotid image 
evaluations;  
(c) Screening and baseline lab results;  
(d) Eligibility assessment checklist;  
(e) Medical history and concurrent medication list;  
(f) Family history;  

Carotid Plaque Composition by MRI during Lipid Lowering 
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Study Protocol – April 2016  
(g) Subject contact information including primary care physician or vascular care 
specialty contacts if available;  
(h) Clinical and imaging schedules;  
(i) Procedure checklist;   
(j) Progress notes for non-scheduled visits, telephone calls, and other subject-related 
communications.   
 
The right hand side includes all scheduled clinical follow-up notes, data collection and 
AE reports.  The CRF pages and AE record sheet used in this study are included as 
Attachment 2.  
       
E.3. Lab Results 
Each enrolled subject will have a lab results folder.  As described earlier, designated 
study coordinators will review all lab results upon receiving the report in hard copies or 
phone report for any urgent critical results.  If an abnormal result been identified, study 
safety monitor (Dr. Xue-Qiao Zhao) will be notified.  Actions will be taken per the safety 
monitoring protocol.        
 
E.4. Study Medication Records 
Each enrolled subject will have study medication folder containing study medications 
dispensing information at each visit.  HMCIDS also keeps study drug receipt, 
dispensing, and destruction logs in its pharmacy starting July 2012.  
 
F.  Data Collection and Statistical Analysis  
F.1. Data Collection: 
Data is collected from subjects on their health history and familial health history.  Data 
will be collected throughout the study from subjects regarding their health status and 
concomitant medications usage.  Lab values resulting from analysis of blood samples 
will be collected at about one-half of study visits.  All lab samples are identified by a 
study number only.  Subjects will have four MR scans recorded on CDs during the study.  
Individually identifiable data is recorded in individual study charts for each subjects, 
and in a password-protected study database.  Individually identifiable data will be 
accessible only to the study investigators.   
 
F.2. Database Management: 
A multi-dimensional ACCESS database will be designed by a database manager based on 
the specific study design, protocols and procedures.  It will be co-managed by the 
database manager and a study coordinator.  The following is an overview of the database 
with all necessary functions for the data input and output required by the study design.  
Attachment 3 is a multi-relational data table in CPC Study Database.   
 
Available CPC Database modules for Data Entry and Study Management 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 22 of 25 
Study Protocol – April 2016  
 
 
Data entry will be completed by study coordinators after each scheduled or non-
scheduled visit, for each adverse event, and for all lab results.  Study coordinators will 
initial and date at each of the data entry.  The accuracy of data entry will be checked 
periodically by database manager or by other study coordinators.     
 
F.3. Statistical Analysis: 
1. Descriptive Statistics:  Prior to more formal analysis we will explore the data to 
detect outliers or other distribution problems and display the data in graphical and 
tabular format using histograms, boxplots, scatterplots, frequency listings for 
dichotomous and categorical variables and descriptive statistics for all patients and 
subcategories of patients.  We will also calculate the various outcome measures, such as 
percent lipid in the carotid arterial wall, as a mean per MRI slice, in order to control for 
the varying number of MRI slices per subject. Throughout the analyses we will take 
account of potential differences in MRI measurements due to the effect of scan platform 
or study site.  The site effect is a difference among measurements that cannot be 
explained away by subject characteristics, such as age and gender or study site.  We can 
formally test for a site effect, describe its magnitude and adjust for it using random 
effects models.  Similarly, the platform (fixed) effect can be addressed by using a dummy 
variable for the platform. The site and platform effects are confounded (because groups 
of sites use one of the two platforms).  Even so, the site effect can be addressed by a 
model that nests the sites within platform.  
 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 23 of 25 
Study Protocol – April 2016  
2. Difference between baseline and 3 years:  Differences of primary and 
secondary endpoints between baseline and 3 years after intensive lipid-lowering therapy 
will be compared using paired 2-tailed t tests to determine the significance.  A 
multivariate analysis will be performed based on a logistic regression model with plaque 
lipid composition as the dependent variable to detect the independent patient or therapy 
variables that are predictive of plaque lipid composition change over a 3-year interval. 
 
3.  Treatment effect with different lipid therapies:  This set of analyses addresses 
the primary and secondary endpoints of determining the treatment effect on lipid 
composition, plaque wall volume and wall thickness.  The simplest form of this analysis 
will be a t-test or nonparametric Mann-Whitney test comparing the two treatment 
groups on the change in an outcome variable between baseline and the 3-year MRI 
assessment.  In order to control for important covariates, we will carry out multivariate 
linear regression, with the 3-year change in the outcome, such as percent of wall volume 
that is lipid-rich necrotic core, being the dependent variable and independent variables 
of treatment group (dichotomous).  We will also evaluate baseline value of the outcome 
variable, and any other variables that need to be controlled, such as age and gender.  We 
can also test for an interaction between variables in affecting the outcome by using an 
interaction term in the model.  We will not automatically test all possible interactions.  If 
main effects are included in a final regression model, it would be natural to test to see if 
there is an interaction between some of the main effects.  Choice of which interactions to 
try will be driven by biological plausibility.  For example, if treatment and baseline lipid 
composition are important and statistically significant main effects in a model, it would 
be natural to test to see if their interaction is also important.  In general, quite large 
sample sizes are needed to detect interactions, unless they are very strong.  However, the 
sign and magnitude and even marginal statistical significance of an interaction are 
informative, even if the interaction term is not ultimately included in the model.  This 
comment on use of statistical interaction terms applies to the regression analyses for all 
of our aims.  We routinely carry out statistical diagnostics on these analyses, such as 
examining residuals.   
 
4.  Risk of cardiovascular events:  This set of analyses will focus on the risk of CV 
events in relation to plaque characteristics and the changes over time in the plaque.  We 
will use methods of survival analysis (failure-time analysis) for this part of the study.  
We will use Kaplan-Meier plots, the log rank test and the Cox proportional hazards 
model for these analyses.  The outcome variable is time to a first CV event during the 
study period, and those who do not have an event by the end of follow-up surveillance 
will be considered as censored.  The two branches of this endeavor are (i) the relation of 
plaque volume and characteristics at one cross-sectional moment in time (such as 
baseline) to the risk of a subsequent event; and, (ii) the relationship between plaque 
“velocity”—the rate of change of plaque characteristics over time—to subsequent risk of 
an event.  The velocity and cross-sectional status of plaque are two quite different 
biological concepts, and it may happen that one or the other alone, and not both, are 
important.  For the first analysis, (i), each patient will have up to two time intervals: 
baseline to an event or to the 3-year MRI assessment, and then from the 3-year MRI 
assessment forward to the end of follow-up.  By using two intervals per person, one 
initiated at baseline and the other initiated at 3 years, we will always be using the most 
recent MRI data on plaque status to compare to subsequent follow-up.  This analysis is 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 24 of 25 
Study Protocol – April 2016  
carried out by using time-varying covariates.  For the analysis of CV risk in relation to 
plaque “velocity”, (ii), the methodology is the same, except that each person will have 
only one interval, from the 3-year MRI scan onward.  Independent variables will be the 
rate of change of plaque characteristics during the first 3 years (e.g., annual % change in 
lipid composition), as well as the value of plaque variables at the 3-year point, a new 
“baseline”.  For both the baseline and velocity part of these analyses we will attempt to 
build a multivariate model(s) that will allow us to characterize the CV risk for a given 
patient. These models will use not only the MRI variables but currently identified risk 
factors as well, such as age and gender.  Our modeling will also address an important 
issue: Do the plaque variables, even if statistically significant, really add to the 
prediction of cardiovascular risk? In other words, are the plaque variables really adding 
something independent of what is already known about risk?  We can address this issue 
by comparing a Cox proportional hazards model with traditional risk factors only, such 
as age, gender, and smoking status, to a model that includes these traditional factors and 
also includes any important plaque variables that have detected.  We can use either the 
change in a pseudo-R2 statistic (based on likelihood) or use logistic regression and note 
the increase in the area under the ROC curve when the plaque variables are added into 
the model with the traditional risk factors.  This comment applies to any analyses where 
there are traditional (known) risk factors available.  While statistical significance of a 
plaque variable may help us to understand the biology better, it is also helpful to know if 
the use of plaque variables notably increases the prediction of CV events for individuals.   
 
5.  Correlation among baseline plaque, plaque changes and laboratory 
variables:  This set of analyses deal with correlation between baseline plaque 
characteristics and plaque progression or between laboratory measurements, such as 
lipids and inflammatory markers, and plaque composition and progression.  The 
simplest form of these analyses will be the Pearson or Spearman correlation (and 
scatterplots) between pairs of variables, such as the change over two years in plaque 
lipid composition vs. the corresponding change in HDL-C concentration.  The 
correlations will be based on a pair of variables, one each selected from these separate 
sets of variables: (a) baseline plaque variables, (b) baseline laboratory measurements, 
(c) rate of change of plaque variables over time, (d) rate of change of laboratory 
measurements over time.  Each different pair of variables and their correlation test a 
hypothesis of interest.  For example, selection of the change in plaque over time and 
change in a laboratory variable over time tests the hypothesis that these items progress 
or regress in parallel.  These analyses are readily expanded to include covariates in 
multivariate models.  For example, if baseline HDL-Cand baseline plaque lipid 
composition are both related to progression, we would want to try including them as 
independent variables in a model for progression in order to tease out the independent 
effect of each of the two variables.  
 
The study will be able to detect even rather weak correlations.  With our sample size of 
at least 180 patients who have compete data for up to 3 years we will be very likely to 
detect a true correlation of r = ±0.18 or larger between variables of interest.  We are 
assuming 80% power, 2-sided test, p<0.05.  
 
Drs. Zhao, Yuan, Hatsukami at the University of Washington, and Polissar 
(biostatistician at Mountain-Whisper-Light Statistics) developed the statistical analysis 

Carotid Plaque Composition by MRI during Lipid Lowering 
Page 25 of 25 
Study Protocol – April 2016  
plan.  Analyses will be carried out in SAS, STATA, R and SPSS and performed by the 
Mountain-Whisper-Light Statistics.