Assessment of Individual Risk of Cardiovascular Events by Platelet FcGammaRIIa
Conditions: STEMI, NSTEMI
Sponsor: Prolocor, Inc

Prolocor, Inc.* 
Study Protocol, Amendment 3.1 
Protocol Number: PRL-0001 
Assessment of Individual Risk of Cardiovascular 
Events by Platelet FcGammaRIIa 
NCT05175261 
A Prospective Observational Cohort Study 
 
*Prolocor, Inc. is an organization based in the United States of America and is the legal entity acting as 
the sponsor for this study. The term “sponsor” is used throughout the protocol to represent Prolocor, Inc; 
the sponsor is identified on the Contact Information page that accompanies the protocol.   
 
 
Status: 
Final 
Date: 
December 21, 2022 
Prepared by: Prolocor, Inc. 
Protocol Version number: 
PRL-0001, 4.1 
 
GCP Compliance:  This study will be conducted in compliance with Good Clinical Practice, and applicable regulatory 
requirements.  
Confidentiality Statement 
The information provided herein contains Company trade secrets, commercial or financial information that the Company 
customarily holds close and treats as confidential.  The information is being provided under the assurance that the recipient 
will maintain the confidentiality of the information under applicable statutes, regulations, rules, protective orders or 
otherwise. 

Assessment of Individual Risk of Cardiovascular Events by Platelet FcGammaRIIa 
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Table of Contents 
REVISION HISTORY ................................................................................................................................................. 4 
ABBREVIATIONS ....................................................................................................................................................... 7 
STATEMENT OF COMPLIANCE ............................................................................................................................. 8 
1 
PROTOCOL SUMMARY ............................................................................................................................... 9 
1.1 
Synopsis ................................................................................................................................................ 9 
1.2 
Study Schematic ................................................................................................................................ 11 
1.3 
Schedule of Activities ........................................................................................................................ 11 
2 
INTRODUCTION .......................................................................................................................................... 12 
2.1 
Background......................................................................................................................................... 12 
2.2 
Study hypothesis ............................................................................................................................... 15 
2.3 
Evidence For Use of FcɣRIIa as a Tool .......................................................................................... 15 
2.4 
Risk/Benefit Assessment .................................................................................................................. 22 
2.4.1 
Known Potential Risks ................................................................................................... 22 
2.4.2 
Known Potential Benefits .............................................................................................. 22 
3 
OBJECTIVES AND ENDPOINTS .............................................................................................................. 22 
4 
STUDY DESIGN ........................................................................................................................................... 22 
4.1 
Overall Design .................................................................................................................................... 22 
4.2 
End of Study Definition ..................................................................................................................... 24 
4.3 
Substudy ............................................................................................................................................. 24 
5 
STUDY POPULATION ................................................................................................................................ 25 
5.1 
Inclusion Criteria ................................................................................................................................ 25 
5.2 
Exclusion Criteria ............................................................................................................................... 25 
5.3 
Screen Failures .................................................................................................................................. 25 
5.4 
Recruitment ........................................................................................................................................ 25 
6 
STUDY INTERVENTION ............................................................................................................................ 25 
6.1 
Medications......................................................................................................................................... 25 
7 
SUBJECT DISCONTINUATION/WITHDRAWAL FROM THE STUDY ................................................ 26 
7.1 
Lost to Follow-Up ............................................................................................................................... 26 
8 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................................... 26 
8.1 
Efficacy and Safety Assessments ................................................................................................... 26 
8.2 
Adverse Events and Serious Adverse Events ............................................................................... 26 
8.2.1 
Definition of Adverse Events (AE) ............................................................................... 26 
8.2.2 
Definition of Serious Adverse Events (SAE) .............................................................. 27 
8.2.3 
Classification of an Adverse Event .............................................................................. 27 
8.2.3.1 
Severity of Event ................................................................. 27 
8.2.3.2 
Relationship to Study Procedure ...................................... 27 
8.2.4 
Serious Adverse Event Assessment and Follow-Up ................................................ 28 
8.2.5 
Serious Adverse Event Reporting ............................................................................... 28 
8.2.6 
Data Safety Monitoring .................................................................................................. 28 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 28 
9.1 
Statistical Hypotheses ....................................................................................................................... 28 
9.2 
Sample Size Determination .............................................................................................................. 28 
9.3 
Population for Analyses .................................................................................................................... 29 
9.4 
Statistical Analyses............................................................................................................................ 29 
9.4.1 
General Approach .......................................................................................................... 29 
9.4.2 
Analysis of the Primary Objective ................................................................................ 29 

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9.4.3 
Analysis of the Secondary Objectives ......................................................................... 29 
9.4.4 
Safety Analyses .............................................................................................................. 30 
9.4.5 
Baseline Descriptive Statistics ..................................................................................... 30 
9.4.6 
Sub-Group Analyses ..................................................................................................... 30 
9.4.7 
Substudy Analyses ........................................................................................................ 30 
10 
REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS .................................... 30 
10.1 
Informed Consent Process ............................................................................................................... 30 
10.2 
Study Discontinuation and Closure ................................................................................................. 30 
10.3 
Confidentiality and Privacy ............................................................................................................... 31 
10.4 
Use of Blood Samples ...................................................................................................................... 31 
10.5 
Principal Co-Investigators and Study Goverance ......................................................................... 32 
10.6 
Clinical Monitoring ............................................................................................................................. 32 
10.7 
Quality Control ................................................................................................................................... 32 
10.8 
Data Collection and Record Retention ........................................................................................... 32 
10.9 
Protocol Deviations............................................................................................................................ 33 
10.10 
Publication Policy ............................................................................................................................... 33 
11 
REFERENCES ............................................................................................................................................. 34 
12 
APPENDIX 1 – Study Endpoint Event Definitions ................................................................................... 38 
INVESTIGATOR AGREEMENT ............................................................................................................................. 41 
 
 
 
 

Assessment of Individual Risk of Cardiovascular Events by Platelet FcGammaRIIa 
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REVISION HISTORY 
 
Ver. 
No. 
Description of Change(s) 
Effective Date 
2.0 
Section 1.3, Schedule of Activities and Section 4.1, Overall 
Design:   
The amount of blood obtained for analysis of platelet FcγRIIa 
changed from ‘approximately 30 ml or 2 tablespoons’ to 
‘approximately 3 ml to 6 ml.’ 
1 December 2021 
Section 1.1 Synopsis, Section 4.1 Overall Design and Section 
4.2 End of Study Definition:   
The duration of subject follow-up was clarified.  Text was 
changed from ‘the last subject enrolled has completed 18 
months of follow-up’ to ‘the last subject enrolled has 
completed at least 18 months of follow-up.’ 
Section 9.1 Statistical Hypotheses: 
Updated study hypotheses to match those in Section 2.2 
Study Hypothesis.  Text updated to read as follows: 
1. Platelet expression of FcγRIIa is associated with risk of 
MI, stroke, and death 
2. Incorporating platelet expression of FcγRIIa into 
existing risk scores improves identification of patients 
at high risk of MI, stroke, and death 
3. Platelet expression of FcγRIIa is not associated with 
risk of major bleeding 
Miscellaneous minor changes to punctuation, grammar and 
abbreviations made throughout document. 
3.0 
Section 1.1 Synopsis: 
The age of subjects eligible and type of MI (type 1) were 
clarified.  Text updated to read as follows: 
Approximately 800 male and female subjects ≥ 18 years of 
age with confirmed type 1 MI [ST-segment elevation MI 
(STEMI) or non-ST-segment elevation MI (NSTEMI)] will be 
enrolled before hospital discharge for the index event 
3 February 2022 
Section 5.1 Inclusion Criteria: 
The age of subjects eligible and type of MI (type 1) were 
clarified.  Text updated to read as follows: 
1. Male or female subjects ≥ 18 years of age hospitalized 
with confirmed type 1 MI (STEMI or NSTEMI), referred 
to as the index event (described in Appendix 1) 
Section 1.2 Study Schematic, Section 4.1 Overall Design, and 
Figure 5 Schematic Overview of the Study:   
Specified that the type of MI for study eligibility is type 1 MI.  
 
 

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Ver. 
No. 
Description of Change(s) 
Effective Date 
4.0 
Section 1.1 Synopsis, Section 2.3 Evidence for Use of FcγRIIa 
as a Tool, and Section 4.1 Overall Design: 
Updated to allow for limited enrollment of select subjects 
receiving anticoagulants.  Text has been added as follows: 
Enrollment of subjects who are receiving anticoagulants for 
atrial fibrillation or venous thromboembolic disease will be 
limited to approximately 100 subjects. 
20 October 2022 
Section 1.1 Synopsis and Section 4.1 Overall Design: 
Increased the number of participating sites from 
‘approximately 10’ to ‘approximately 10-20’. 
Section 1.3 Schedule of Activities, Section 4.1 Overall Design 
and Section 8.1 Efficacy and Safety Assessments: 
Expanded the time window for blood draw for quantification of 
FcγRIIa.  The following text has been added: 
Blood can be taken up to 2 weeks post-study enrollment. 
Section 5.2 Exclusion Criteria: 
Deleted Exclusion Criterion 1 ‘Requirement for treatment with 
full dose-anticoagulant therapy (e.g., for atrial fibrillation). 
4.1 
(Site 
Specific) 
1.1 Synopsis: Added information on the substudy including 
objective, endpoint and study population.  The following text 
has been added: 
Substudy:  A substudy will be performed at some sites. 
Substudy Objective:  Demonstrate that the FcγRIIa assay 
provides a consistent measure of platelet expression of 
FcγRIIa by measuring a second blood sample after study 
enrollment. 
Substudy Endpoint:  Measurement of platelet expression of 
FcγRIIa 2 to 6 weeks after study enrollment which will be 
compared to FcγRIIa results from the first/baseline blood 
sample. 
Study Population:  Subjects enrolled in the parent study are 
eligible 
See Header 
1.3 Schedule of Activities:  Added blood sample to quantify 
FcγRIIa 2 to 6 weeks after enrollment into the study. 
Section 4.3 Substudy.  New section added to describe the 
background, objective, endpoint and subject eligibility of the 
substudy.  The following text has been added: 
Platelet function tests exhibit substantial intra-individual 
variability when measures are repeated 2 to 6 weeks after 
initial testing (Frelinger 2013, Hochholzer 2014, Nührenberg 
2015).  Results from a study in healthy subjects suggest that 
FcɣRIIa will vary by <10% over the course of 2 to 6 weeks 
(McMahon 2019).  
The objective of the substudy is to demonstrate that the 
FcγRIIa assay provides a consistent measure of platelet 
expression of FcγRIIa by measuring a second blood sample 
after study enrollment and the first/baseline blood sample is 

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taken.  The substudy endpoint is the measurement of platelet 
expression of FcγRIIa 2 to 6 weeks after study enrollment.    
The substudy will be performed at some sites identified by 
early study start-up and prior experience in similar studies.  
Subjects enrolled in the parent study are eligible for the 
substudy.  A second sample of blood will be obtained by 
phlebotomy 2 to 6 weeks after the subject is enrolled in the 
study.  The results from this second sample of blood will be 
compared to FcγRIIa results from the first/baseline blood 
sample.   
See Section 2.4 for the risk/benefit assessment associated 
with phlebotomy and the second blood draw. 
 
Section 9.4.7 Substudy Analyses.  New section added 
regarding substudy analyses.  The following text has been 
added: 
Details on the substudy statistical analyses will be 
summarized in the SAP.  
 
 

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ABBREVIATIONS 
 
ACS 
Acute Coronary Syndrome 
AE 
Adverse Event 
ASA 
Acetylsalicylic Acid; Aspirin 
BARC 
Bleeding Academic Research Consortium 
ARCTIC 
Assessment by a Double Randomization of a Conventional Antiplatelet Strategy versus a 
Monitoring-guided Strategy for Drug-Eluting Stent Implantation and of Treatment Interruption 
versus Continuation One Year after Stenting 
CFR 
Code of Federal Regulations 
CKD 
Chronic Kidney Disease 
CI 
Confidence Interval 
CRF 
Case Report Form 
CV 
Coefficient of Variation 
DAPT 
Dual Antiplatelet Therapy 
DM 
Diabetes Mellitus 
Fc 
Fragment Constant 
eCRF 
Electronic Case Report Form 
FcγRIIa 
FcGammaRIIa 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GFR 
Glomerular Filtration Rate 
GRAVITAS 
Gauging Responsiveness with A VerifyNow assay-Impact on Thrombosis And Safety 
HIPAA 
Health Insurance Portability and Accountability Act 
HR 
Hazard Ratio 
ICH 
International Conference on Harmonisation  
Ig 
Immunoglobulin 
IRB 
Institutional Review Board 
MI 
Myocardial infarction 
ml 
milliliter 
MVD 
Multi-Vessel Coronary Artery Disease 
ng 
nanogram 
nM 
nanomolar 
NSTEMI 
Non-ST-segment elevation myocardial infarction 
PCI  
Percutaneous Coronary Intervention 
QC 
Quality Control 
REDCap 
Research Electronic Data Capture 
REDUCE 
Evaluation of short-term dual antiplatelet therapy in patients with acute coronary syndrome 
treated with a new-generation stent 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SMART-
DATE 
6-month versus 12-month or longer dual antiplatelet therapy after percutaneous coronary 
intervention in patients with acute coronary syndrome 
STEMI 
ST-segment elevation myocardial infarction 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TIMI 
Thrombolysis in Myocardial Infarction 
TWILIGHT 
Ticagrelor with or without Aspirin in High-Risk Patients after PCI 
µg 
microgram 
U 
Units 
US 
United States 
 
 
 

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STATEMENT OF COMPLIANCE 
 
This study will be carried out in accordance with International Conference on 
Harmonisation Good Clinical Practice (ICH GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies 
(45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, and/or 21 CFR Part 312.)  
 
The protocol, informed consent form(s), recruitment materials, and all participant 
materials will be submitted to the Institutional Review Board (IRB) for review and 
approval.  Approval of both the protocol and the consent form must be obtained before 
any subject is enrolled.  Any amendment to the protocol will require review and approval 
by the IRB before the changes are implemented to the study.  In addition, all changes to 
the consent form will be IRB-approved; a determination will be made regarding whether 
a new consent needs to be obtained from subjects who provided consent, using a 
previously approved consent form. 
 
 

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1 
 
PROTOCOL SUMMARY 
1.1 SYNOPSIS  
Title: 
Assessment of Individual Risk of Cardiovascular Events by Platelet 
FcGammaRIIa (FcγRIIa) 
Study Description: 
A Prospective, Observational Multicenter Non-Interventional Cohort 
Study 
Objectives: 
 
The primary objective is to determine whether platelet expression of 
FcγRIIa is associated with risk of myocardial infarction (MI), stroke 
and death.   
Secondary objectives include:  
• 
Develop a score that combines clinical characteristics plus 
platelet expression of FcγRIIa to determine the risk of MI, 
stroke, and death. 
• 
Determine whether platelet expression of FcγRIIa is 
associated with risk of major bleeding.   
Endpoints: 
The primary endpoint is the composite of death, MI, and stroke. 
A secondary endpoint is the incidence of clinically significant 
bleeding according to the Bleeding Academic Research Consortium 
(BARC) scale type 2-5. 
Study Population: 
Approximately 800 male and female subjects ≥ 18 years of age with 
confirmed type 1 MI [ST-segment elevation MI (STEMI) or non-ST-
segment elevation MI (NSTEMI)] will be enrolled before hospital 
discharge for the index event.  Subjects with increased risk of an 
event, defined as ≥2 of the following risk factors, will be eligible: 
• 
Age ≥65 
• 
Multi-vessel coronary artery disease (MVD) defined as ≥2 
vessels or left main with a stenosis ≥50% 
• 
Chronic Kidney Disease (CKD) defined as estimated 
glomerular filtration rate (GFR) ˂60 ml/min/1.73 m2 
• 
Diabetes mellitus (DM) 
• 
Prior MI 
 
 
 
Phase: 
Enrollment of subjects who are receiving anticoagulants for atrial 
fibrillation or venous thromboembolic disease will be limited to 
approximately 100 subjects.  
Not Applicable 
Number of Sites 
Approximately 10-20 sites in the United States will participate in this 
study. 
Study Intervention: 
Not Applicable 
Study Duration: 
It is anticipated that it will take approximately 12 months to enroll 
approximately 800 subjects.  The study and subject follow-up will 
continue until 1) at least 80 ischemic events (MI, stroke, and death) 
have occurred, and 2) the last subject enrolled has completed at 
least 18 months of follow-up. 
Participant Duration: 
After enrollment, all subjects will be followed until the end of the 
study that will be at least 18 months after enrollment of the last 
subject.  Based on an annual ischemic event rate of 10%, the overall 
length of participation in the study is anticipated to be up to 3 years. 
 
 

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Substudy: 
A substudy will be performed at some sites. 
 
Substudy Objective: 
Demonstrate that the FcγRIIa assay provides a consistent measure 
of platelet expression of FcγRIIa by measuring a second blood 
sample after study enrollment. 
 
Substudy Endpoint: 
Measurement of platelet expression of FcγRIIa 2 to 6 weeks after 
study enrollment which will be compared to FcγRIIa results from the 
first/baseline blood sample 
 
Study Population: 
Subjects enrolled in the parent study are eligible. 
 
 

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1.2 STUDY SCHEMATIC 
Figure 1 
 
Schematic Overview of the Study 
   
 
      ~ 1 year   
 
 
 
 
 
      up to 2 years 
 
 
 
 
 
 
 
 
 
 
 
MI=myocardial infarction; NSTEMI= non-ST-segment elevation MI, STEMI= ST-segment elevation MI 
* Subjects who experience an endpoint event will continue to be followed throughout the entire study and any 
subsequent events will also be confirmed and recorded. 
 
 
 
1.3 SCHEDULE OF ACTIVITIES 
 
Procedures 
Day 1 (prior to or 
on day of hospital 
discharge)a 
Week 2 to 
Week 6 
after study 
enrollment 
Telephone Study Visit 
every 6 months (+/- 4 
weeks) 
Final Telephone Study Visit  
(+ 2 weeks after at least 80 
ischemic events accrued)  
Informed Consent 
X 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
Clinical Characteristics 
X 
 
 
 
Enrollment 
X 
 
 
 
Anti-thrombotic Medication 
Review 
X 
 
X 
X 
Blood Sample to Quantify 
FcγRIIab 
X 
Xd 
 
 
Assess for Study 
Endpointsc 
 
 
X 
X 
Complete Case Report 
Forms (CRFs) 
X 
 
X 
X 
 
a: 
Procedures can be done at any time after confirmation of myocardial infarction index event 
and prior to hospital discharge.  Day 1 is defined as the day the subject is enrolled into the 
study and must occur prior to or on the day of hospital discharge. 
b:     Approximately 3 ml to 6 ml blood sample.  Blood can be taken up to 2 weeks post-study 
enrollment. 
c:     Endpoints include Ischemic events (MI, stroke, death) and clinically significant bleeding 
BARC type 2-5. 
d:     For sites participating in the substudy, a 3 ml to 6 ml blood sample will be drawn 2 to 6 
weeks after enrollment into the study 
Subjects 
hospitalized with 
Index type 1 MI 
(STEMI or NSTEMI) 
Subjects enrolled 
into study (Day 1) 
before hospital 
discharge 
Telephone visits every 
6 months  
Final study 
telephone visit 
Enrollment Period 
Study Follow-Up Period 
  Specific anti-thrombotic treatment, dose and duration per subject’s health care provider. 
• 
Informed consent 
• 
Inclusion/Exclusion 
Criteria 
• 
Clinical characteristics 
• 
Quantify FcγRIIa 
• 
Assess for study endpoints* 

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2 
 
INTRODUCTION 
 
2.1 BACKGROUND 
The American Heart Association estimates that during 2020 approximately 720,000 Americans 
will have a first coronary event (defined as first hospitalized myocardial infarction (MI) or 
coronary heart disease death), and approximately 335,000 will have a recurrent event 
(Benjamin 2019).  A retrospective cohort study of 78,085 Medicare beneficiaries ≥ 66 years of 
age found that 20.6% of patients with MI had at least one re-hospitalization during the 10 years 
after their index MI (Levitan 2016).   
According to Patel and colleagues, a diverse array of therapeutic options is available to 
clinicians (Patel 2018) and they propose that what is needed now is effective precision medicine 
strategies to enable clinicians to target patients with high residual risk with more powerful 
therapy (Patel 2018).  The current study is designed to use translational research to develop 
biomarkers that may effectively guide individualized therapy based on the hypothesis that 
platelet expression of FcγRIIa will identify patients at high and low risk of subsequent MI, stroke, 
and death.  Validation of platelet expression of FcγRIIa as a biomarker of residual 
cardiovascular risk will support subsequent studies designed to use platelet expression of 
FcγRIIa as a precision medicine tool. 
Strategies to Reduce Recurrent Ischemic Events/Bleeding 
Strategies designed to reduce the risk of recurrent ischemic events and bleeding are predicated 
on the following assumptions:  1) The benefit-risk of a treatment should be assessed by 
comparing the absolute risk differences of the benefit and harm endpoints. 2) A treatment’s 
benefit is generally consistent across population on a relative scale.  For this reason, on an 
absolute scale, benefit is generally greater in high-risk populations. 3) A treatment’s harm is 
generally consistent across populations on an absolute scale.  For this reason, benefit-risk is 
generally greater in a high-risk population. 4) Accordingly, a marker that identifies a high-risk 
population can enable a treatment to be used in a way that increases its benefit-risk profile.  
One strategy designed to reduce the risk of recurrent ischemic events is the continuation of dual 
antiplatelet therapy (DAPT).  Two large multicenter randomized trials have demonstrated that 
long-term DAPT reduces the risk of subsequent cardiovascular events.  Treatment with aspirin 
(ASA) plus clopidogrel reduced the risk of major adverse cardiovascular and cerebrovascular 
events from 5.9% with ASA monotherapy to 4.3% (p<0.001) with ASA plus clopidogrel (Mauri 
2014). Continued DAPT increased the risk of moderate or severe bleeding (2.5% vs. 1.6%, 
p=0.001). Treatment with ASA plus ticagrelor (60 mg twice daily) reduced the risk of 
cardiovascular events to 7.8% compared with 9.0% with ASA alone (Bonaca 2015).  The risk of 
Thrombolysis in Myocardial Infarction (TIMI) major bleeding was higher with ticagrelor (2.3% 
with 60 mg twice daily) compared with ASA alone (1.1%).  Accordingly, the benefits of long-term 
treatment with DAPT are at least partially offset by an increase in bleeding.  Because of this 
trade-off, the use of DAPT long-term is limited. The promise of precision medicine is to reduce 
the overall incidence of bleeding by individualizing therapy, targeting patients with high residual 
cardiovascular risk for long-term DAPT. 

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The “Ticagrelor with or without Aspirin in High-Risk Patients after PCI (TWILIGHT)” study tested 
a strategy of ticagrelor monotherapy compared with aspirin plus ticagrelor and demonstrated a 
reduced risk of bleeding events without an increase in ischemic events with ticagrelor 
monotherapy (Mehran 2019).  While this strategy reduced bleeding, it did not provide guidance 
on which patients will derive the greatest benefit from long term treatment with more powerful 
antiplatelet therapy.  Further, because treatment with more powerful anti-thrombotic therapies 
has been consistently associated with a greater incidence of bleeding, it is likely that 
monotherapy with ticagrelor will be associated with greater bleeding than ASA monotherapy. 
A strategy designed to limit the risk of bleeding events is the early transition from DAPT to ASA 
monotherapy.  The 6-month versus 12-month or longer dual antiplatelet therapy after 
percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (SMART-
DATE) randomized patients with acute coronary syndrome (ACS) to either 6 months of DAPT or 
at least 12 months of DAPT (Hahn 2018).  MI (1.8% vs 0.8%; p=0.02) and stent thrombosis 
(1.1% vs 0.7%, p=0.09) were more common in the 6-month DAPT group.  Bleeding Academic 
Research Consortium (BARC) type 2–5 bleeding occurred in 2.7% of the 6-month DAPT group 
and 3.9% of the 12-month or longer DAPT group (p=0.09). In the “Evaluation of short-term dual 
antiplatelet therapy in patients with acute coronary syndrome treated with a new-generation 
stent (REDUCE)” trial a composite (ischemia and bleeding) endpoint was non-inferior in 3 
months compared with 12 months of DAPT among patients with ACS (De Luca 2019).  Once 
again, a tradeoff was apparent between the risk of bleeding and the risk of thrombosis with 
numerically fewer bleeding events (3.3% vs 4.0%, p=0.46) associated with a numerically higher 
incidence of cardiac mortality (1.8% vs 1.1%, p=0.28) and stent thrombosis (1.6% vs 0.8%, 
p=0.16) with shortened DAPT. 
The critical gap facing clinicians is demonstrated by the combination of 1) trials demonstrating 
that prolonged treatment with DAPT can reduce the incidence of ischemic/thrombotic events at 
the cost of bleeding; and 2) trials demonstrating that shortened DAPT can reduce the incidence 
of bleeding at the cost of a greater risk of ischemic events.  Consensus guidelines recommend 
treatment with DAPT after MI and coronary stenting, however, specific guidance on the duration 
of DAPT is not possible based on available evidence (Bittl 2016).  The guideline committee 
recommended a minimum duration with DAPT of 3 to 6 months but also noted that extension of 
DAPT beyond 12 months entailed a tradeoff between a risk of bleeding and ischemic events.  A 
precision tool that can be used to guide clinical decision making would improve care.  Patients 
at low risk should benefit from shortened treatment with more powerful antiplatelet therapy 
whereas patients at high risk should derive greater absolute benefit from long term treatment 
with more powerful antiplatelet therapy. 
Current Clinical Risk Scores 
Clinical risk scores do not bridge the critical gap to enable clinicians to individualize long-term 
treatment with DAPT. For example, Yeh and colleagues developed a predictive score, the 
DAPT score, which is a tool designed to simultaneously predict ischemic and bleeding risk (Yeh 
2016).  Registry data from Sweden (2006 to 2014) that followed 41,101 patients demonstrated 
that the score had a discrimination of 0.54 for cardiovascular and cerebrovascular events, and 

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0.49 for fatal or major bleeding (Ueda 2018).  Thus, the DAPT score supports individualization 
of therapy, however, the predictive accuracy is not sufficient to effectively guide therapy.  
Schneider et.al. applied the DAPT score to patients enrolled in a single center pilot study 
(Schneider 2020).  Patients with DAPT score ≥ 2 had a predicted event rate of 7.6% and an 
observed event (MI, stroke, death) rate of 10.1%.  High platelet FcγRIIa expression was evident 
in 55% of patients with DAPT ≥ 2.  The combination of DAPT ≥ 2 plus high platelet FcγRIIa 
expression was associated with an event rate of 15.4% whereas the combination of DAPT ≥ 2 
plus low platelet FcγRIIa expression was associated with an event rate of 3.7% (p<0.05).  The 
broad distribution of platelet FcγRIIa expression in patients with both high and low clinical risk 
scores and these study results suggest that platelet FcγRIIa expression can be used to 
discriminate higher and lower risk among patients categorized as high risk by clinical risk tools. 
Platelet Function Testing 
Because increased platelet reactivity has consistently identified patients at greater risk of 
subsequent cardiovascular events (Breet 2010, Wisman 2014, Reny 2016), large clinical trials 
were designed to determine whether platelet function testing could effectively guide antiplatelet 
therapy.  Two trials failed to demonstrate that currently available tests of platelet function can be 
used to guide treatment (Price 2011, Collet 2012).  Specifically, the GRAVITAS trial (Gauging 
Responsiveness with A VerifyNow assay-Impact on Thrombosis And Safety) randomized 
patients with high platelet reactivity to standard compared with high dose clopidogrel (Price 
2011).  One proposed reason for the lack of efficacy in this study was that effective suppression 
of high platelet reactivity with high dose clopidogrel was not confirmed.  The ARCTIC trial 
(Assessment by a Double Randomization of a Conventional Antiplatelet Strategy versus a 
Monitoring-guided Strategy for Drug-Eluting Stent Implantation and of Treatment Interruption 
versus Continuation One Year after Stenting) addressed this concern by employing a treatment 
strategy in which platelet function testing was used to confirm suppression of high platelet 
reactivity by augmenting treatment followed by confirmation that high platelet reactivity was 
suppressed (Collet 2012).  The failure of ARCTIC suggests inadequate suppression of high 
platelet reactivity was not the mechanism responsible for failure.  Thus, currently available 
platelet function tests are not capable of guiding individualized care.  Intra-individual variability in 
platelet function over time is substantial and may be a major contributor to the failure (Frelinger 
2013, Hochholzer 2014, Nührenberg 2015) as evidenced in the ELEVATE-TIMI 56 study where 
more than 40% of patients exhibited a greater than 20% change in platelet function over the 
course of 2 weeks (Hochholzer 2014). 
Summary 
Cardiovascular disease is prevalent and recurrent cardiovascular events are a major cause of 
morbidity and mortality.  An expanding armamentarium of therapeutic options that reduce 
cardiovascular risk underscores the promise of precision medicine that effectively tailors therapy 
to subsequent risk.  Clinical risk tools and currently available tests of platelet function are not 
sufficient to effectively guide therapy. 
 

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2.2 STUDY HYPOTHESIS 
Platelet expression of FcγRIIa is hypothesized to be a novel biomarker that, when quantified, 
can be used to identify patients at high and low risk of cardiovascular events.  This hypothesis is 
based on the premise that currently available platelet function tests are analogous to a random 
glucose measurement and that platelet expression of FcγRIIa is analogous to an HbA1C, 
reflecting platelet reactivity over a longer interval of time.  Because FcγRIIa amplifies platelet 
activation (Boylan 2008, Lova 2002) increased platelet expression of FcγRIIa will identify 
patients with consistently high platelet reactivity (Serrano 2007).  Accordingly, high platelet 
expression of FcγRIIa leverages the clinical risk of increased platelet reactivity demonstrated by 
more than 100 studies and over 22,000 patients (Breet 2010, Wisman 2014, Reny 2016).  
Moreover, quantification of platelet FcγRIIa expression eliminates factors that cause variability 
with platelet function tests including the preparation of blood and the in vitro activation of 
platelets.  The measurement of platelet expression of FcγRIIa does not require activation of 
platelets and platelet FcγRIIa does not exhibit the magnitude of intra-individual variability seen 
with platelet function tests. 
Specifically, the study hypotheses are: 
1. 
Platelet expression of FcγRIIa is associated with risk of MI, stroke, and death. 
2. 
Incorporating platelet expression of FcγRIIa into existing risk scores improves 
identification of patients at high risk of MI, stroke, and death. 
3. 
Platelet expression of FcγRIIa is not associated with risk of major bleeding. 
 
2.3 EVIDENCE FOR USE OF FCƔRIIA AS A TOOL 
FcγRIIa, a member of the Fc family, is expressed on the surface of platelets and amplifies 
platelet activation (Boylan 2008, Lova 2002). Because FcγRIIa amplifies platelet activation 
(Boylan 2008, Lova 2002), greater expression increases platelet reactivity (Serrano 2007).  In a 
single center pilot study, Schneider et.al. found that high platelet expression of FcγRIIa (≥ 
11,000/platelet) was associated with a greater risk (odds ratio > 4) of MI, stroke, and death 
(Schneider 2018).  Platelet expression of FcγRIIa does not require activation of platelets, is not 
affected by antiplatelet and anticoagulant agents, and does not exhibit the magnitude of intra-
individual variability seen with platelet function tests (McMahon 2019).  Further, clinical risk 
scores have demonstrated overlap between the risk of thrombotic/ischemic events and the risk 
of bleeding events (Hsieh 2017).  Increased platelet expression of FcγRIIa was not associated 
with a greater risk of bleeding (Schneider 2018) and may distinguish thrombotic risk from 
bleeding risk.   
Evidence in support of platelet expression of FcγRIIa as an effective precision tool: 
1. Platelet function tests demonstrate substantial intra-individual variability (Frelinger 2013, 
Hochholzer 2014, Nührenberg 2015), with more than 40% of patients exhibiting a > 20% 
change in platelet function over the course of 2 weeks (Hochholzer 2014).  Platelet FcγRIIa 
expression exhibits substantially less intra-individual variability (McMahon 2019).  Platelet 
expression of FcγRIIa is determined by megakaryocyte production that was demonstrated to 

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be increased by interferon γ (Schneider 2009).  Thus, expression of FcγRIIa should be 
consistent throughout the life of the platelet.  Less intra-individual variability would be 
expected and has been observed (Figure 1).  Consistent with these results, Calverley and 
colleagues found an average change in platelet FcγRIIa expression of less than 10% in 248 
patients with cardiovascular disease when repeat determinations were performed 6-52 
weeks later (Calverley 2002). 
2. Greater platelet expression of FcγRIIa is associated with increased platelet reactivity 
because FcγRIIa amplifies platelet activation (Boylan 2008, Lova 2002). Unlike currently 
available tests of platelet function that measure platelet reactivity in response to a select 
agonist or group of agonists, platelet expression of FcγRIIa predicts increased platelet 
reactivity in response to a variety of agonists (Figure 2). 
3. Because determination of platelet FcγRIIa expression entails quantification of a surface 
marker, it is less sensitive to perturbations related to assay conditions (Table 1) (McMahon 
2019). Neither anticoagulants nor a P2Y12 antagonist alter platelet expression of FcγRIIa 
(McMahon 2019, Table 1). 
 
 
 
 
 
 
 
 
 
 
 
Figure 1:  Intra-individual variability in platelet expression of FcγRIIa over the course of 1 month in healthy subjects 
(n=10).  Because platelet function is known to exhibit diurnal variation, platelet expression of FcγRIIa was assessed 
in the morning and afternoon as well as after 1 week and 1 month (McMahon 2019).   

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Figure 2:  Activation of platelets identified by surface expression of P-selectin with the use of flow cytometry.  
Patients with end stage renal disease (n=33) were stratified into 2 groups on the basis of median expression of 
FcγRIIa.  The percentage of platelets expressing P-selectin on their surface in the absence of agonist and in 
response to the collagen mimetic convulxin (1 ng/ml), platelet activating factor (PAF, 1 nM), adenosine diphosphate 
(ADP 0.2 µM), or thrombin (1 nM) is shown.  High platelet expression of FcγRIIa was associated with greater 
activation of platelets in response to each agonist (Serrano 2007). 
Table 1:  Intra-assay coefficient of variation (CV) for assay of platelet FcγRIIa expression 
CV same anticoagulant 
1.9% ± 0.5% 
CV between anticoagulants 
1.7% ± 0.5% 
CV citrate anticoagulant vs citrate + cangrelor 
0.7% ± 0.2% 
Blood was taken from 3 subjects and anticoagulated with corn trypsin inhibitor (32 μg/ml), trisodium citrate (3.2%), 
unfractionated heparin (1.2 U/ml), and bivalirudin (8 µg/ml).  Cangrelor (500 nM) as added to blood anticoagulated 
with citrate.  Duplicate determination of platelet FcγRIIa expression in each condition (McMahon 2019). 
In summary, platelet expression of FcγRIIa is a novel biomarker that appears to identify patients 
at high and low risk of subsequent cardiovascular events (Schneider 2018).  Because FcγRIIa 
amplifies the activation of platelets (Boylan 2008, Lova 2002) it is a marker of consistently 
increased platelet reactivity.  Thus, platelet expression of FcγRIIa leverages results from 
multiple studies demonstrating that greater platelet reactivity is associated with a greater risk of 
cardiovascular events (Breet 2010, Wisman 2014, Reny 2016) with an assay not affected by 
antiplatelet or anticoagulant therapy that reproducibly identifies consistently increased platelet 
reactivity and may effectively discriminate residual cardiovascular risk and guide individualized 
treatment. 
FcγRIIa as a novel biomarker 
FcγRIIa was identified as the low‐affinity receptor for the fragment constant (Fc) portion of 
immunoglobulin (Ig) G (Karas 1982).  Binding to FcγRIIa activates platelets. For example, 
platelets can coat an Ig‐bound (opsonized) entity such as a bacterium via FcγRIIa and this 
no agonist
convulxin
PAF
ADP
thrombin
percentage of platelets activated
(surface expression of P-selectin)
0
10
20
30
40
50
60
low FcRIIa
high FcRIIa
p<0.01
p<0.05
p<0.01
p<0.05

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binding triggers platelet activation and release of secondary mediators that amplify the platelet 
response to a wide range of bacteria (Cox 2011, Arman 2014). In addition, platelet FcγRIIa is 
involved in heparin-induced thrombocytopenia and thrombosis, and the principal cellular target 
for anti-platelet factor 4/heparin antibodies is the platelet FcγRIIa receptor (Kelton 1988, Reilly 
2001). FcγRIIa and glycoprotein VI are linked on human platelets, and ligands acting at either 
receptor activate dual proteolytic regulatory pathways (Gardiner 2008).  FcγRIIa markedly 
enhances thrombus formation when platelets are perfused over a collagen-coated flow chamber 
under conditions of arterial and venous shear (Zhi 2013).  More recently, an additional important 
function of platelet FcγRIIa has been defined.  Phosphorylation of FcγRIIa amplifies the 
activation of platelets (Boylan 2008, Lova 2002). These observations led to assessing platelet 
reactivity in patients with end stage renal disease because these patients were known to exhibit 
increased platelet expression of FcγRIIa (El-Shahawy 2007).  The reactivity of platelets with 
higher and lower platelet expression of FcγRIIa was compared and found that platelets with 
more FcγRIIa exhibited greater activation in response to sub-maximal concentrations of multiple 
agonists (Figure 2, Serrano 2007).  Taken together, these results led to the hypothesis that high 
platelet expression of FcγRIIa is a novel biomarker of increased platelet reactivity. 
Platelets from healthy young people carry 1,000-4,000 molecules of FcγRIIa (Karas 1982).  
Calverley and colleagues found that platelet expression of FcγRIIa was increased in patients 
with an acute coronary or cerebrovascular events as well as in patients with diabetes and 
individuals without cardiovascular events who had with two or more cardiac risk factors 
(Calverley 2002).  In addition, they found limited intra-individual variability when repeat 
determination was performed after 6-52 (average 20) weeks (Calverley 2002).  These results 
suggest that, unlike measures of platelet function that exhibit marked intra-individual variability 
(Frelinger 2013, Hochholzer 2014, Nührenberg 2015), platelet expression of FcγRIIa is a 
consistent marker of increased platelet reactivity. 
Flow cytometry is a powerful tool capable of assessing expression of FcγRIIa on the platelet 
surface.  Platelets are identified by their size as well as a surface marker.  Without a 
standardized measure of fluorescence intensity, results of analyses can be described only in 
relative terms of fluorescence intensity.  The interpretation of fluorescence intensity 
measurements can be complicated by multiple factors including daily instrument variation, 
differences in hardware (laser power, filter sets), as well as the density of fluorochrome labeling 
of antibodies.  A goal is to develop a clinically validated tool that can be used broadly in the care 
of patients, therefore external standards will be employed in the current study to enable the 
standardization of fluorescence intensity units (Kay 2006, Quadrini 2016).  Accordingly, platelet 
expression of FcγRIIa will be quantified with the use of external standards to quantify the 
number of molecules on the platelet surface rather than relative platelet expression of FcγRIIa. 
Prior study to evaluate FcγRIIa 
Schneider et.al. completed a single center prospective trial designed to determine whether 
platelet expression of FcγRIIa would discriminate cardiovascular risk (Schneider 2018).  
Patients (n=197) were enrolled shortly before discharge from a hospitalization for MI (both ST 
elevation and non-ST elevation were included).  Although inclusion criteria allowed patients who 

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had been treated with PCI, coronary artery bypass grafting, or medically, all patients enrolled 
were treated with PCI.  The primary endpoint, a composite of MI, stroke, death, and coronary 
revascularization, was lower in patients with platelet expression of FcγRIIa <11,000 (Figure 3).  
All patients were treated with ASA (81 mg) and treatment with clopidogrel (~64%) and ticagrelor 
(~36%) was balanced in patients with high and low platelet expression of FcγRIIa (Serrano 
2007).   
 
Figure 3:  Summary of prospective single center study (Schneider 2018) 
CVA=cerebrovascular accident, MI=myocardial infarction, Revasc=revascularization 
Clinical characteristics of patients with high and low platelet expression of FcγRIIa were well 
balanced with the exception of older age, diabetes, and prior revascularization being more 
prominent in the high expression group.  Cox multivariate analysis for the combination of MI, 
stroke, revascularization, and death demonstrated a hazard ratio of 3.0 (p=0.02) for platelet 
expression of FcγRIIa >11,000 when age, diabetes, and prior revascularization were included 
as covariates. 
The incidence of revascularization was similar in patients with high and low platelet expression 
of FcγRIIa (low platelet FcγRIIa n=3, 3.2%; high platelet FcγRIIa n=4, 3.8%, p=0.815).  Patients 
with platelet expression of FcγRIIa ≥11,000 had a greater risk of MI, stroke, and death that 
became apparent after 6 months (Figure 4).    
Cox regression analysis was performed and platelet expression of FcγRIIa was the sole 
covariate (hazard ratio 3.9, p=0.035) associated with freedom from MI, stroke, and death. 

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Figure 4: Kaplan-Meier curves of the probability of freedom from MI, stroke, and death.  The average 
duration of follow-up was 20 months (range 6-29 months). 
MI=myocardial infarction 
The predictive capacity of platelet expression of FcγRIIa was evaluated.  The sensitivity of high 
expression to identify patients with cardiovascular events was 0.82 (95% CI 0.57 - 0.92) and the 
specificity was 0.51 (95% CI 0.43 - 0.58).  MI, stroke, and death were uncommon (8% of all 
patients) in patients who had had an MI.  The negative predictive value of low platelet 
expression of FcγRIIa was 0.97 (95% CI 0.89 - 0.98) and the positive predictive value of high 
platelet expression of FcγRIIa was 0.14 (95% CI 0.10 - 0.46).  While identification of patients at 
high risk has great value, the identification of patients at low risk is important to reassure 
clinicians that they can safely withhold therapy that is associated with a risk of complications.  
As is often the case for low prevalence events, the negative predictive value of platelet FcγRIIa 
expression (97% [95% CI 89% - 98%]) offers potentially important guidance to clinicians. 
A key objective of this study is to determine the optimal threshold of platelet FcγRIIa expression 
that classifies patients as high and low risk that will, in turn, be incorporated into an 
individualized score designed to predict patient risk. Assessment of platelet FcγRIIa expression 
as a continuous variable is expected to be more predictive than as a dichotomous variable.  If 
assessment of platelet FcγRIIa expression as a dichotomous variable is nearly as predictive as 
a continuous variable, then the simplicity associated with the definition of a threshold for high 
and low risk could be preferred.   
Clinical criteria that identify patients at increased risk of thrombosis also identify an increased 
risk of bleeding (Lindholm 2019).  A key feature predisposing to both thrombosis and bleeding is 
older age.  Not surprisingly, patients identified as having an increased risk of ischemic events 
also exhibit a higher risk of bleeding events (Hsieh 2017, Lindholm 2019).  In this pilot study, 
increased platelet expression of FcγRIIa was not associated with a greater risk of bleeding 

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(Schneider 2018).  Further, a meta-analysis of platelet function tests demonstrated that patients 
with high platelet reactivity were at lower risk of bleeding events compared with those who 
exhibit low platelet reactivity (Aradi 2015).  
In summary, preliminary results demonstrate: 
• 
Increased platelet FcγRIIa expression is associated with consistently increased platelet 
reactivity 
• 
With appropriate calibration platelet expression of FcγRIIa can be quantified to enable 
comparison between centers and to assess changes over time 
• 
Unlike platelet function tests, measurement of platelet expression of FcγRIIa is not 
substantially affected by conditions of the assay, antiplatelet therapy nor anticoagulant 
therapy 
• 
Platelet expression of FcγRIIa ≥ 11,000/platelet identifies patients with ~4-fold greater risk of 
MI, stroke, and death 
Current Study 
Confirmation of results seen in the single center pilot study is necessary in a larger multicenter 
trial to validate the results of the pilot study and to determine whether platelet expression of 
FcγRIIa can be used to guide individualized precision therapy and improve outcomes.  Results 
from the current study will determine the prognostic implications of platelet FcγRIIa expression 
as well as the optimal manner in which to use platelet FcγRIIa expression.  The analysis plan 
will include assessment of platelet FcγRIIa expression as a continuous variable as well as a 
sensitivity analysis designed to determine whether FcγRIIa ≥ 11,000/platelet is the optimal 
threshold for discrimination of risk.  In addition, it will it provide key preliminary evidence 
regarding prognostic implications of platelet FcγRIIa expression associated with anti-thrombotic 
regimens and support plans for a subsequent clinical trial designed to use platelet FcγRIIa 
expression as a precision tool. 
To identify subjects at greater risk of events, subjects will be enrolled who have an increased 
risk of cardiovascular events based on results from the SWEDEHEART registry that analyzed 
100,879 patients (Lindholm 2019).  Hospitalized MI subjects with ≥ 2 of the following risk 
factors; age ≥ 65, prior MI, diabetes mellitus, multivessel coronary artery disease (two or more 
vessels or left main with a stenosis ≥50% at coronary angiography) and chronic kidney disease 
(an estimated glomerular filtration rate below 60 ml/min/1.73 m2) will be enrolled in the current 
study. In the SWEDEHEART registry, patients with ≥ 2 risk factors comprised 47% of patients 
and their risk of death, MI and stroke was 9.7/100 patient years.  In the pilot study, 55% of 
subjects with increased risk based on clinical risk scores exhibited platelet expression of 
FcγRIIa ≥11,000 (Schneider 2020).  In the current study. enrollment of subjects receiving 
treatment with anticoagulant therapy (i.e., for treatment of atrial fibrillation, venous 
thromboembolism) will be limited to approximately 100 subjects.  Subjects with non-
cardiovascular conditions expected to limit survival to less than 2 years will be excluded in the 
current study. 
Because high platelet expression of FcγRIIa increases platelet reactivity (Boylan 2008, Lova 
2002), it is anticipated that despite an association between high platelet expression of FcγRIIa 

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and older age (Schneider 2018), there will not be a significantly increased incidence of clinically 
significant bleeding, defined as BARC type 2-5, among patients with high platelet expression of 
FcγRIIa.    
Lastly, to ensure consistent results, platelet expression of FcγRIIa will be quantified at a core 
laboratory.  At clinical sites, citrate anticoagulated blood will be added to fixative tubes.  These 
tubes will be shipped to the core laboratory for quantification of platelet FcγRIIa expression.   
2.4 RISK/BENEFIT ASSESSMENT   
 
2.4.1 KNOWN POTENTIAL RISKS  
There is a limited potential for risks associated with phlebotomy, a commonly performed 
procedure that will be performed exclusively by individuals specially trained in this procedure.  
Standard phlebotomy techniques to minimize venipuncture side effects (hand hygiene, glove 
use, skin antisepsis, and the use of sterile, single-use needles will minimize the risk of infection; 
appropriate angle of needle entry to avoid hematoma, application of pressure for 3-5 minutes 
after drawing blood).  There is a risk of discomfort, bleeding which is generally mild, bruising, 
and a remote risk of infection that will be minimized by using these techniques 
2.4.2 KNOWN POTENTIAL BENEFITS  
Subjects enrolled in this study will not derive direct benefit.  Data from this study may help 
inform future studies or provide information for individualized therapy. 
 
3 
OBJECTIVES AND ENDPOINTS 
The primary objective of the study is to determine whether platelet expression of FcγRIIa is 
associated with risk of MI, stroke, and death.   
Secondary objectives are  
• 
Develop a score that combines clinical characteristics plus platelet expression of FcγRIIa 
to determine the risk of MI, stroke, and death.  
• 
Determine whether platelet expression of FcγRIIa is associated with risk of major 
bleeding.   
The primary endpoint is the composite of death, MI, and stroke.  A secondary endpoint is 
clinically significant bleeding according to BARC type 2-5. 
 
4 
STUDY DESIGN  
 
4.1 OVERALL DESIGN 
This is a prospective, observational multicenter non-interventional cohort study designed to 
integrate into the regular standard of care (Figure 5, Schematic Overview).  Subjects who are 
admitted to the hospital with an MI will be screened. Screening will entail review of the medical 

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record for selected entry criteria. If the subject meets entry criteria, written informed consent will 
be obtained.  Subjects will be enrolled into the study (called Day 1) before discharge from a 
hospitalization for a confirmed type 1 MI (STEMI or non-STEMI), referred to as the index event.   
Subjects will not have their care altered by participation in the study; subjects’ medical regimens 
will be determined by their health care provider.  Enrollment of subjects who are receiving 
anticoagulants for atrial fibrillation or venous thromboembolic disease will be limited to 
approximately 100 subjects. 
After informed consent is obtained and the subject eligibility is confirmed, each subject will be 
assigned a unique identifier.  Clinical characteristics and biochemical results will be associated 
with the unique identifier. The association between the subject’s identity and the unique 
identifier will be kept in a secure file.  Clinical characteristics will be recorded and blood 
(approximately 3 ml to 6 ml) will be obtained for analysis of platelet FcγRIIa expression. Blood 
can be taken up to 2 weeks post-study enrollment. The samples for platelet FcγRIIa expression 
will be assayed by a core laboratory to ensure standardization.   
Subjects will be contacted by telephone every 6 months and asked a standardized set of 
questions to determine whether they have had a cardiovascular event (MI, stroke), bleeding 
event or have died.  At each study visit, subjects will be queried about their medications with a 
specific focus on their anti-thrombotic regimen.  Changes to their anti-thrombotic regimen will be 
documented in association with the time when changes were made.  All subjects will be 
contacted at the end of the study for a final telephone visit.  Medical records will be reviewed to 
confirm subject reported endpoints. 
The primary endpoint will be the composite of death, MI, and stroke.  MI will be defined in 
accordance with the 4th universal definition (Thygesen 2018) and stroke consistent with 
consensus guidelines (Sacco 2013). The incidence of clinically significant bleeding will be 
determined using the Bleeding Academic Research Consortium (BARC) scale (Mehran 2011) 
and is defined as BARC type 2-5.  Study endpoint events will be confirmed by the review of 
medical records by the investigator and all relevant medical records will be obtained by the site 
for submission to the sponsor (as described in Section 10.8).  Subjects who experience an 
endpoint event will continue to be followed throughout the entire study and any subsequent 
endpoint events will also be confirmed and recorded.  See Appendix 1 for study endpoint event 
definitions. 
A total of approximately 800 subjects will be enrolled at approximately 10-20 sites in the US.  It 
is anticipated that it will take about 12 months to enroll the total number of subjects.  The study 
and subject follow-up will continue until 1) at least 80 ischemic events (MI, stroke, and death) 
have occurred, and 2) the last subject enrolled has completed at least 18 months of follow-up.    
Based on an annual ischemic event rate of 10%, the overall length of participation in the study is 
anticipated to be up to 3 years.  Results will be monitored during the course of the study. 
 
 
 

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Figure 5 
 
Schematic Overview of the Study 
   
 
      ~ 1 year   
 
 
 
 
 
      up to 2 years 
 
 
 
 
 
 
 
 
 
 
 
MI=myocardial infarction; NSTEMI= non-ST-segment elevation MI, STEMI= ST-segment elevation MI 
* Subjects who experience an endpoint event will continue to be followed throughout the entire study and any 
subsequent events will also be confirmed and recorded. 
 
4.2 END OF STUDY DEFINITION 
The study will be stopped when 1) at least 80 ischemic events (MI, stroke, and death) have 
been confirmed and 2) the last subject enrolled has completed at least 18 months of follow-up.  
The study will be considered complete once all subjects have had their last telephone visit. 
 
4.3 SUBSTUDY 
 
Platelet function tests exhibit substantial intra-individual variability when measures are repeated 
2 to 6 weeks after initial testing (Frelinger 2013, Hochholzer 2014, Nührenberg 2015).  Results 
from a study in healthy subjects suggest that FcɣRIIa will vary by <10% over the course of 2 to 
6 weeks (McMahon 2019).  
 
The objective of the substudy is to demonstrate that the FcγRIIa assay provides a consistent 
measure of platelet expression of FcγRIIa by measuring a second blood sample after study 
enrollment and the first/baseline blood sample is taken.  The substudy endpoint is the 
measurement of platelet expression of FcγRIIa 2 to 6 weeks after study enrollment.    
 
The substudy will be performed at some sites identified by early study start-up and prior 
experience in similar studies.  Subjects enrolled in the parent study are eligible for the substudy.  
A second sample of blood will be obtained by phlebotomy 2 to 6 weeks after the subject is 
enrolled in the study.  The results from this second sample of blood will be compared to FcγRIIa 
results from the first/baseline blood sample.   
 
Subjects 
hospitalized with 
Index type 1 MI 
(STEMI or NSTEMI) 
Subjects enrolled 
into study (Day 1) 
before hospital 
discharge 
Telephone visits every 
6 months  
Final study 
telephone visit 
Enrollment Period 
Study Follow-Up Period 
  Specific anti-thrombotic treatment, dose and duration per subject’s health care provider. 
• 
Informed consent 
• 
Inclusion/Exclusion 
Criteria 
• 
Clinical characteristics 
• 
Quantify FcγRIIa 
• 
Assess for study endpoints* 

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See Section 2.4 for the risk/benefit assessment associated with phlebotomy and the second 
blood draw. 
 
5 
STUDY POPULATION 
 
Subjects meeting all the inclusion criteria and none of the exclusion criteria are eligible for 
enrollment into the study.   
 
5.1 INCLUSION CRITERIA 
 
1. Male or female subjects ≥ 18 years of age hospitalized with confirmed type 1 MI (STEMI 
or NSTEMI), referred to as the index event (described in Appendix 1). 
2. Must have ≥ 2 of the following risk factors: 
a) Age ≥ 65 
b) Multi-vessel coronary artery disease (MVD) defined as ≥2 vessels or left main 
with a stenosis ≥50% 
c) Chronic kidney disease (CKD) defined as estimated glomerular filtration rate 
(GFR) ˂ 60 ml/min/1.73 m2 
d) Diabetes mellitus (DM) 
e) Prior MI 
3. Must agree to participate in the study, to comply with all study procedures and follow-up 
contact 
4. Signed the informed consent form 
 
5.2 EXCLUSION CRITERIA 
 
1. Participation in another trial in which the subject is known to receive or could receive 
anticoagulant or antiplatelet treatment as part of the trial intervention. 
2. Non-cardiovascular conditions that, in the judgment of the investigator, will limit survival 
to less than 2 years 
 
5.3 SCREEN FAILURES 
 
Subjects who do not meet the criteria for participation in this study (screen failure) may not be 
rescreened during the same hospital admission period.  The reason for the screen failure should 
be recorded in the site study log. 
 
5.4 RECRUITMENT 
 
Efforts will be made to enroll an ethnically diverse cohort with appropriate representation from 
women. 
 
6 
STUDY INTERVENTION 
 
There is no study intervention.  Treatment decisions are entirely at the discretion of the subject’s 
health care provider.   
 
6.1 MEDICATIONS 
 

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Anti-thrombotic therapy will be recorded in the case report form (CRF).   
 
7 
SUBJECT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
 
Subjects are free to withdraw from participation in the study at any time upon request.  The 
reason for subject discontinuation or withdrawal from the study will be recorded on the CRF.  
 
7.1 LOST TO FOLLOW-UP 
 
Every effort will be made to minimize the number of subjects who are lost to follow-up.  The 
following actions must be taken if a subject misses a required study visit: 
• 
The site will attempt to contact the subject and reschedule the missed visit and counsel 
the subject on the importance of maintaining the assigned visit schedule and ascertain if 
the subject wishes to and/or should continue in the study. 
• 
Before a subject is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the subject (3 telephone calls and, if necessary, a 
certified letter to the subject’s last known mailing address or local equivalent methods). 
These contact attempts should be documented in the subject’s medical record or study 
file.  
• 
Should the subject continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up. 
• 
Electronic medical records may be used to assess vital status (alive or dead) at the end 
of the study provided the subject has not withdrawn consent for follow-up. 
 
8 
STUDY ASSESSMENTS AND PROCEDURES 
 
8.1 EFFICACY AND SAFETY ASSESSMENTS  
This is an observational non-interventional study, therefore there is no evaluation of efficacy or 
safety.  Blood will be taken prior to discharge from the hospital for the index MI event (see 
separate Laboratory Sample Manual for details on sample collection, storage, and shipment to a 
core laboratory) and will used to quantify FcγRIIa.  Blood can be taken up to 2 weeks post-study 
enrollment.  Risks associated with phlebotomy include discomfort, bleeding, and a remote risk 
of infection. 
Subjects will receive medications as determined by their health care provider and as part of 
regular standard of care.  Subjects will be followed throughout the duration of the study to 
assess for study endpoints including MI, stroke, death, and bleeding events (BARC type 2-5).   
Subjects who experience an endpoint event will continue to be followed throughout the entire 
study and any subsequent events will also be confirmed and recorded. 
  
8.2 ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
8.2.1 DEFINITION OF ADVERSE EVENTS (AE) 
Because this in a non-interventional study and only phlebotomy, a commonly performed 
procedure, will be performed, an adverse event for this study is defined as any untoward 

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medical occurrence associated with venipuncture.  Given the routine nature of phlebotomy, only 
those AEs that meet the criteria for serious will be required to be reported and followed to 
resolution or until considered stable.   
For this study, stroke, MI, death, and bleeding events will be reported as endpoint events and 
will not be considered or reported as adverse events. 
 
8.2.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
An AE is considered "serious" if it results in any of the following outcomes: death, a life-
threatening adverse event, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant incapacity or a congenital anomaly/birth defect. Important medical 
events that may not result in death, be life-threatening, or require hospitalization may be 
considered serious when, based upon appropriate medical judgment, they may jeopardize the 
participant and may require medical or surgical intervention to prevent one of the outcomes 
listed in this definition.  
For this study, only SAEs related to phlebotomy will be reported. 
 
8.2.3 CLASSIFICATION OF AN ADVERSE EVENT 
8.2.3.1 SEVERITY OF EVENT 
The following definitions will be used to describe severity of an SAE:  
 
• 
Mild – Events require minimal or no treatment and do not interfere with the subject’s 
daily activities.  
• 
Moderate – Events result in a low level of inconvenience or concern. Moderate events 
may cause some interference with functioning. 
• 
Severe – Events interrupt a subject’s usual daily activity and may require systemic drug 
therapy or other treatment. 
 
8.2.3.2 RELATIONSHIP TO STUDY PROCEDURE 
 
All SAEs related to phlebotomy must have their relationship to this procedure assessed by the 
investigator who will evaluate the event based on temporal relationship and clinical judgment.  
 
• 
Related – The event is known to occur with the study procedure, there is a reasonable 
possibility that the study procedure caused the SAE, or there is a temporal relationship 
between the study procedure and event. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the study procedure and the SAE. 
• 
Not Related – There is not a reasonable possibility that the study procedure caused the 
event, there is no temporal relationship between the study procedure and event onset, or 
an alternate etiology has been established. 
 
 

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8.2.4 SERIOUS ADVERSE EVENT ASSESSMENT AND FOLLOW-UP 
All SAEs will be captured in the CRF. Information to be collected includes event description, 
investigator’s assessment of severity, relationship to study procedure, and 
resolution/stabilization date. All SAEs will be followed to resolution or until considered stable. 
8.2.5 SERIOUS ADVERSE EVENT REPORTING  
Investigators will monitor subjects for SAEs related to phlebotomy and must immediately report 
an SAE to the sponsor. In the event a subject experiences a Suspected Unexpected Serious 
Adverse Reaction (SUSAR) due to venipuncture, the sponsor must notify the Food and Drug 
Administration (FDA) and all participating investigators of this safety report, as soon as possible, 
but in no case later than 15 calendar days after the sponsor determines that the information 
qualifies for reporting.  Furthermore, the sponsor must also notify FDA of any unexpected fatal 
or life-threatening suspected adverse reaction as soon as possible but in no case later than 7 
calendar days after the sponsor's initial receipt of the information. 
8.2.6 DATA SAFETY MONITORING  
Because of the limited risk of this non-interventional trial, data safety and monitoring will be 
managed without a formal data safety and monitoring committee.  Investigators at each site will 
report SAEs related to study procedures (only phlebotomy) to the sponsor.   The sponsor will 
bring SAEs to the attention of the co-principal investigators, Dr. Schneider and Dr. Harrington 
(see Section 10.5).  Drs. Schneider and Harrington will be primarily responsible for the oversight 
of data and safety. 
 
9 
STATISTICAL CONSIDERATIONS  
 
9.1 STATISTICAL HYPOTHESES 
Specifically, the study hypotheses are: 
1. Platelet expression of FcγRIIa is associated with risk of MI, stroke, and death. 
2. Incorporating platelet expression of FcγRIIa into existing risk scores improves 
identification of patients at high risk of MI, stroke, and death. 
3. Platelet expression of FcγRIIa is not associated with risk of major bleeding. 
 
9.2 SAMPLE SIZE DETERMINATION 
This study is designed to provide a sufficient number of events to build and evaluate a 
prediction model. The planned sample size of 800 subjects will continue until at least 80 
ischemic events have occurred. Under the guideline from Steyerberg of 10 events required per 
predictor (Steyerberg 2019), this sample size will allow a model with FcγRIIa and up to seven 
additional predictors to be built.   Preliminary results (Schneider 2018) suggest that a 4-fold 
greater incidence of events will be seen in subjects with high platelet expression of FcγRIIa.  For 

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the primary endpoint, there will be at least 95% power to detect a 2-fold greater incidence of 
cardiovascular endpoints (MI, stroke, and death) with a two-sided α<0.01 assuming 8% of 
subjects experience the endpoint.  With the planned sample size of 800 a hazard ratio (HR) of 
1.9 with a p=0.04 (lower bound of the 95% CI of 1.2) can be detected. For the secondary 
endpoint, there will be 95% power to detect a hazard ratio of 1.93 when comparing bleeding risk 
in subjects with high compared with low FcγRIIa expression when assuming a two-sided α=0.05 
and 5% of subjects experience bleeding in the low FcγRIIa expression group. 
9.3 POPULATION FOR ANALYSES 
All enrolled subjects who are eligible based on the inclusion/exclusion criteria will be included in 
the population for analysis. 
9.4 STATISTICAL ANALYSES 
 
9.4.1 GENERAL APPROACH 
The planned statistical analyses will be included in a study Statistical Analysis Plan (SAP). 
9.4.2 ANALYSIS OF THE PRIMARY OBJECTIVE 
Cox proportional hazards models will be fit to compare the risk of the primary endpoint based on 
platelet expression of FcγRIIa as a continuous variable.  Subjects will be followed until their 
earliest MI, stroke, or death. Patients who do not experience the composite endpoint will be 
censored at their last telephone follow-up. Time to the primary endpoint will be calculated as 
days from study enrollment. Models will be adjusted for potential confounders including sex and 
other subject demographics and medical history collected at baseline. In the pilot study, it was 
observed that older age, diabetes mellitus, and prior revascularization were associated with 
higher platelet FcγRIIa expression. 
A set of sensitivity analyses will evaluate FcγRIIa as a binary endpoint, which each analysis 
using a different threshold for classifying FcγRIIa as high or low. In particular, these analyses 
will explore whether a binary or a continuous measure of FcγRIIa provides greater predictive 
value, and whether or not a threshold of ≥ 11,000/platelet is optimal.  
9.4.3 ANALYSIS OF THE SECONDARY OBJECTIVES 
First Secondary Objective:  Negative predictive value, positive predictive value, sensitivity, and 
specificity will be calculated. Prediction will be performed using a Cox regression model with the 
following predictors: platelet expression of FcγRIIa, sex, age, MVD, CKD, DM, and prior MI. 
Evaluation of the model’s error rates will be based on a leave-one-out cross-validation 
approach. Additional models will evaluate the performance of the predictive model using a 
continuous measure of FcγRIIa with the performance of predictive models using various binary 
measures of FcγRIIa. 
Second Secondary Objective:  The adjusted Cox proportional hazards model described for the 
primary objective analysis will be used to compare the bleeding risk as a function of FcγRIIa 
expression, both as a continuous and as a binary variable. 

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9.4.4 SAFETY ANALYSES 
 
Not applicable as there is no study intervention. 
 
9.4.5 BASELINE DESCRIPTIVE STATISTICS 
 
Descriptive statistics will be used to summarize clinical characteristics. 
 
9.4.6 SUB-GROUP ANALYSES 
 
Not applicable. 
 
9.4.7 SUBSTUDY ANALYSES 
 
Details on the substudy statistical analyses will be summarized in the SAP. 
 
10 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
10.1 INFORMED CONSENT PROCESS 
Prior to the start of the study and enrollment of any subjects, investigators must have the IRB’s 
written approval for the protocol and the written informed consent form(s) and any other written 
information to be provided to the subjects.  
Informed consent is a process that is initiated prior to the subject’s agreeing to participate in the 
study and continues throughout the subject’s study participation. The subject will be asked to 
read and review the informed consent document. The investigator will explain the study to the 
subject and answer any questions.  The subject should have the opportunity to discuss the 
study with their family or surrogates or think about it prior to agreeing to participate. The subject 
will sign the informed consent document prior to any procedures being done specifically for the 
study. Subjects must be informed that participation is voluntary and that they may withdraw from 
the study at any time, without prejudice. A copy of the informed consent document will be given 
to the subject. The informed consent process will be conducted and documented in the source 
document (including the date), and the form signed, before the subject undergoes any study-
specific procedures. The rights and welfare of the subjects will be protected by emphasizing to 
them that the quality of their medical care will not be adversely affected if they decline to 
participate in this study. 
10.2 STUDY DISCONTINUATION AND CLOSURE 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the sponsor to investigators, study subjects and regulatory 
authorities.  The study may resume if the cause of the temporary suspension has been 
sufficiently addressed to satisfy the sponsor, IRB and/or regulatory authorities. 
 
 

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10.3 CONFIDENTIALITY AND PRIVACY 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s) and their representatives. This confidentiality is extended to cover 
testing of blood samples in addition to the subject’s clinical information. Therefore, the study 
protocol, documentation, data, and all other information generated will be held in strict 
confidence. No information concerning the study or the data will be released to any 
unauthorized third party without prior written approval of the sponsor.  
The sponsor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), or regulatory agencies may inspect all documents and records 
required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital). The clinical study site will permit access to such records upon 
request. 
The subject’s contact information will be securely stored at each clinical site for internal use 
during the study. At the end of the study, all records will continue to be kept in a secure location 
for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor 
requirements. 
Study subject research data will be used for statistical analysis and scientific reporting, however 
this will not include the subject’s contact or personal identifying information. Individual subjects 
and their research data will be identified by a unique study identification number.  
After informed consent is obtained, each subject will be assigned a unique identifier.  Clinical 
characteristics and biochemical results will be associated with the unique identifier. The 
association between the subject identity and the unique identifier will be kept in a secure file.  
Access to that information will be restricted to study personnel obtaining the information from 
the subject and key study personnel.  Blood and derived specimens will be labeled with the 
unique identifier only.   
Additionally, all study sites operate in full compliance with Health Insurance Portability and 
Accountability Act (HIPAA) regulations. 
10.4 USE OF BLOOD SAMPLES 
Blood samples taken for this study will be prepared, labeled, and shipped to the central 
laboratory for testing (see separate Laboratory Sample Manual for details).  Blood, derived 
specimens, and biochemical results will be labeled and associated with the unique identifier 
only.  Blood and derived specimens will be consumed during the assay process and any 
remaining samples will be appropriately destroyed at the end of the study. Samples will be 
assayed at a core laboratory and only study personnel will have access to the samples.  After all 
assays have been completed and results confirmed, any remaining sample will be destroyed in 
accordance with the institutional biohazard disposal process. Samples will not be stored for use 
or testing beyond that described for this study.  During the conduct of the study, an individual 
subject can choose to withdraw consent to have their blood sample tested, however, withdrawal 
of consent may not be possible after the sample has been tested.  

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10.5 PRINCIPAL CO-INVESTIGATORS AND STUDY GOVERANCE 
The overall study Principal Co-Investigators are David J. Schneider, MD and Robert A. 
Harrington, MD (contact information below).  
David J. Schneider, MD 
Professor of Medicine  
Medical Director of Cardiovascular Services 
Director of Cardiovascular Research Institute 
University of Vermont/University of Vermont Health Network 
Burlington, VT  05401 
 
Robert A. Harrington, MD 
Arthur L. Bloomfield Professor of Medicine 
Chair, Department of Medicine 
Stanford University 
Mail: 300 Pasteur Drive, S-102 
MC: 5110 
Stanford, CA  94305 
Drs. Schneider and Harrington will be primarily responsible for the oversight of data and safety.   
There are no leadership committees and no Medical Monitor for this study.  
10.6 CLINICAL MONITORING 
Remote, centralized, and targeted data review will be conducted to ensure that the reported 
clinical data are accurate and complete, and that the conduct of the study is in compliance with 
the currently approved protocol/amendment(s).  CRFs will be submitted periodically to the 
sponsor for review, database entry and endpoint event tracking.  Source documents of endpoint 
events will be collected by the site and submitted for review by the sponsor.  The investigator 
will confirm the endpoint event and there will be no adjudication by a separate committee.  
 
10.7 QUALITY CONTROL 
Quality control (QC) procedures will be implemented beginning with built in checks at data entry 
and in routine reports and QC checks that will be run on the database. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution. 
10.8 DATA COLLECTION AND RECORD RETENTION 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of 
the site investigator. The investigator is responsible for ensuring the accuracy, completeness, 
legibility, and timeliness of the data reported.  Source data will be captured in the subject’s 
medical record, either electronic or hard copy in a neat, legible manner to ensure accurate 
interpretation of data.   

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Data recorded in the CRF derived from source documents should be consistent with the data 
recorded on the source documents.  For subjects who experience an endpoint event, source 
documentation to confirm the event will be sent to the sponsor with any subject personal 
identifiable information redacted. 
Sites will enter data directly into REDCap (Research Electronic Data Capture) Cloud, a secure 
web-based application designed to support data capture for research studies (Harris 2009).  
Data will be entered into an electronic CRF (eCRF) using REDCap Cloud and transmitted to the 
sponsor on a routine basis.  REDCap Cloud databases are routinely backed-up and address the 
risk of storing sensitive clinical research data on the user's computer. 
Study documents should be retained for a minimum of 2 years after the completion of the study.  
These documents should be retained for a longer period, however, if required by local 
regulations. No records will be destroyed without the written consent of the sponsor, if 
applicable. 
10.9 PROTOCOL DEVIATIONS 
For this study, the only deviation to the protocol is if any of the inclusion are not met or if any of 
the exclusion criteria are met. 
10.10 PUBLICATION POLICY 
There is a commitment to submit results of this study for publication within 18 months after 
database lock. 

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12 APPENDIX 1 – STUDY ENDPOINT EVENT DEFINITIONS 
Definition for Acute Myocardial Infarction (types 1, 2 and 3 MI) [Thygesen 2018] 
The term acute myocardial infarction should be used when there is acute myocardial injury with clinical 
evidence of acute myocardial ischemia and with detection of a rise and/or fall of cTn values with at least 
1 value above the 99th percentile URL and at least 1 of the following:  
• Symptoms of myocardial ischemia;  
• New ischemic ECG changes;  
• Development of pathological Q waves;  
• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a 
pattern consistent with an ischemic etiology;  
• Identification of a coronary thrombus by angiography or autopsy (not for types 2 or 3 MIs).  
Postmortem demonstration of acute atherothrombosis in the artery supplying the infarcted 
myocardium meets criteria for type 1 MI. Evidence of an imbalance between myocardial oxygen supply 
and demand unrelated to acute atherothrombosis meets criteria for type 2 MI. Cardiac death in patients 
with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes before cTn 
values become available or abnormal meets criteria for type 3 MI. 
 
Definition for Stroke [Sacco 2013] 
The term stroke should be used when there is focal ischemia within the perfusion territory of an artery 
that is stenosed or occluded, and cell death is localized to this region. In focal cerebral ischemia, cell 
death is maximal in the ischemic focus and may extend to the penumbra, with all cellular elements 
including both neurons and supportive cells affected. Clinical evidence of stroke includes both of the 
following: 
• Symptoms of focal ischemia (e.g., unilateral weakness of an arm or leg) and  
• Imaging evidence (CT or MRI) of CNS infarction 
 
 

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Bleeding Academic Research Consortium (BARC) Definition for Bleeding [Mehran 2011] 
Type 0: no bleeding 
Type 1: bleeding that is not actionable and does not cause the patient to seek unscheduled 
performance of studies, hospitalization, or treatment by a healthcare professional; may include 
episodes leading to self-discontinuation of medical therapy by the patient without consulting a 
healthcare professional 
Type 2: any overt, actionable sign of hemorrhage (eg, more bleeding than would be expected for 
a clinical circumstance, including bleeding found by imaging alone) that does not fit the criteria for 
type 3, 4, or 5 but does meet at least one of the following criteria: (1) requiring nonsurgical, 
medical intervention by a healthcare professional, (2) leading to hospitalization or increased level 
of care, or (3) prompting evaluation 
Type 3: 
Type 3a: 
Overt bleeding plus hemoglobin drop of 3 to <5 g/dL* (provided hemoglobin drop is 
related to bleed) 
Any transfusion with overt bleeding 
Type 3b: 
Overt bleeding plus hemoglobin drop ≥5 g/dL* (provided hemoglobin drop is related to 
bleed) 
Cardiac tamponade 
Bleeding requiring surgical intervention for control (excluding 
dental/nasal/skin/hemorrhoid) 
Bleeding requiring intravenous vasoactive agents 
Type 3c: 
Intracranial hemorrhage (does not include microbleeds or hemorrhagic transformation, 
does include intraspinal) 
Subcategories confirmed by autopsy or imaging or lumbar puncture  
Intraocular bleed compromising vision 
Type 4: CABG-related bleeding 
Perioperative intracranial bleeding within 48 h 
Reoperation after closure of sternotomy for the purpose of controlling bleeding   
Transfusion of ≥5 U whole blood or packed red blood cells within a 48-h period† 
Chest tube output ≥2L within a 24-h period 

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Type 5: fatal bleeding 
Type 5a: 
Probable fatal bleeding; no autopsy or imaging confirmation but clinically suspicious 
Type 5b: 
Definite fatal bleeding; overt bleeding or autopsy or imaging confirmation 
 
Note:  CABG indicates coronary artery bypass graft. Platelet transfusions should be recorded and reported but are 
not included in these definitions until further information is obtained about the relationship to outcomes. If a 
CABG-related bleed is not adjudicated as at least a type 3 severity event, it will be classified as not a bleeding 
event. If a bleeding event occurs with a clear temporal relationship to CABG (ie, within a 48-h time frame) but does 
not meet type 4 severity criteria, it will be classified as not a bleeding event. 
*Corrected for transfusion (1 U packed red blood cells or 1 U whole blood=1 g/dL hemoglobin). 
†Cell saver products are not counted. 
 
Abbreviations:  CNS, central nervous system; CT, computed tomography; cTn, cardiac troponin; ECG, 
electrocardiogram; g/dL, grams/deciliter; h, hour; MI, myocardial infarction; MRI, magnetic resonance imaging; U, 
units; URL, upper reference limit. 
 
 
 
 
 

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INVESTIGATOR AGREEMENT 
 
I have read this protocol and agree that it contains all necessary details for carrying out this study. I will 
conduct the study as outlined herein and will complete the study within the time designated. 
I will provide copies of the protocol and all pertinent information to all individuals responsible to me who 
assist in the conduct of this study. I will discuss this material with them to ensure that they are fully informed 
regarding the study intervention, the conduct of the study, and the obligations of confidentiality. 
 
Principal (Site) Investigator: 
 
Name (typed or printed): 
 
Institution and Address: 
 
 
 
 
 
 
 
Telephone Number: 
 
Signature: 
 
Date: 
 
 
 
 
(Day Month Year)