Clinical trial NCT04484259
Conditions: Diabetes Mellitus, Type 2 Coronary Artery Disease
Keywords: diabetes mellitus ticagrelor clopidogrel percutaneous coronary intervention
Sponsor: University of Florida
Start date: 2021-03-31; Completion date: 2024-06-15
Enrollment: 105 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Recent studies have shown that withdrawing aspirin and maintaining P2Y12 inhibitor monotherapy for up to 12 months post-PCI, after a brief period of DAPT, reduces bleeding without increasing ischemic harm. Such effects have shown to of particular benefit in patients with diabetes mellitus (DM). However, if an aspirin-free approach can be considered after this time frame is a matter of debate. The aim of this study is to assess the PD effects of ticagrelor 60 mg with and without aspirin therapy in CAD patients and to compare this with a standard DAPT regimen of aspirin plus clopidogrel.

Detailed description:
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care for the prevention of thrombotic complications in patients with coronary artery disease (CAD) undergoing percutaneous coronary interventions (PCI). However, such ischemic benefit occurs at the expense of enhanced bleeding, the risk of which increases in a graded fashion with prolonged exposure to DAPT. Recent studies have shown that withdrawing aspirin and maintaining P2Y12 inhibitor monotherapy for up to 12 months post-PCI, after a brief period of DAPT, reduces bleeding without increasing ischemic harm. Such effects have shown to of particular benefit in patients with diabetes mellitus (DM). However, if an aspirin-free approach can be considered after this time frame is a matter of debate. In fact, current guidelines recommend maintaining P2Y12 inhibiting therapy for high risk patients but which all imply background use of aspirin. P2Y12 inhibitors for long-term (beyond 12 months) secondary prevention mainly include clopidogrel and ticagrelor. In particular, the dosing regimen for clopidogrel remains the standard 75 mg qd, whereas ticagrelor dosing is recommended to be reduced from 90 mg bid to 60 mg bid. However, of these regimens the pharmacodynamics (PD) effects of ticagrelor 60 mg in the absence of aspirin has not yet been tested. Because DM patients are likely to continue with long-term P2Y12 inhibitor therapy, defining the optimal antithrombotic approach for these patients is of critical importance. In light of the above made observations, patients with DM represent an ideal population to define the antiplatelet effects of a ticagrelor 60 mg monotherapy regimen. The aim of this study is to assess the PD effects of ticagrelor 60 mg with and without aspirin therapy in CAD patients and to compare this with a standard DAPT regimen of aspirin plus clopidogrel.

Arms: arm 1: ticagrelor 60 mg bid monotherapy arm 2: aspirin 81 mg qd plus clopidogrel 75 mg qd arm 3: aspirin 81 mg qd plus ticagrelor 60 mg bid
Interventions: intervention 1: Ticagrelor monotherapy intervention 2: Ticagrelor plus aspirin intervention 3: Clopidogrel with aspirin
Intervention descriptions: intervention 1: Eligible patients will enter a 7-10 day run-in phase with aspirin 81 mg/ qd plus ticagrelor 90 mg bid after which they will discontinue aspirin and maintain ticagrelor 90 mg bid monotherapy for 10±3 days. After this period, patients will be randomized using a randomly generated computer sequence in a 1:1:1 fashion to either: a) ticagrelor 60 mg bid monotherapy; b) aspirin 81 mg qd plus ticagrelor 60 mg bid; c) aspirin 81 mg qd plus clopidogrel 75 mg qd. Randomized treatment will be maintained for 10±3 days. intervention 2: Eligible patients will enter a 7-10 day run-in phase with aspirin 81 mg/ qd plus ticagrelor 90 mg bid after which they will discontinue aspirin and maintain ticagrelor 90 mg bid monotherapy for 10±3 days. After this period, patients will be randomized using a randomly generated computer sequence in a 1:1:1 fashion to either: a) ticagrelor 60 mg bid monotherapy; b) aspirin 81 mg qd plus ticagrelor 60 mg bid; c) aspirin 81 mg qd plus clopidogrel 75 mg qd. Randomized treatment will be maintained for 10±3 days. intervention 3: Eligible patients will enter a 7-10 day run-in phase with aspirin 81 mg/ qd plus ticagrelor 90 mg bid after which they will discontinue aspirin and maintain ticagrelor 90 mg bid monotherapy for 10±3 days. After this period, patients will be randomized using a randomly generated computer sequence in a 1:1:1 fashion to either: a) ticagrelor 60 mg bid monotherapy; b) aspirin 81 mg qd plus ticagrelor 60 mg bid; c) aspirin 81 mg qd plus clopidogrel 75 mg qd. Randomized treatment will be maintained for 10±3 days.

Protocol documents:
Prot_SAP_000.pdf: 
 
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Project Title: Pharmacodynamic Effects of Different Ticagrelor Maintenance Dosing 
Regimens With and Without Aspirin in Patients with Diabetes Mellitus: The OPTIMUS 
(Optimizing Antiplatelet Therapy in Diabetes Mellitus)-7 Study 
 
1. Investigators: Dominick J Angiolillo, MD, PhD, Francesco Franchi, MD, Fabiana Rollini, 
MD, J. Hope Dover, RN, Latonya Been, AAS 
 
2. Abstract: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the 
standard of care for the prevention of thrombotic complications in patients with coronary 
artery disease (CAD) undergoing percutaneous coronary interventions (PCI). However, such 
ischemic benefit occurs at the expense of enhanced bleeding, the risk of which increases in a 
graded fashion with prolonged exposure to DAPT. Recent studies have shown that 
withdrawing aspirin and maintaining P2Y12 inhibitor monotherapy for up to 12 months post-
PCI, after a brief period of DAPT, reduces bleeding without increasing ischemic harm. Such 
effects have shown to of particular benefit in patients with diabetes mellitus (DM). However, 
if an aspirin-free approach can be considered after this time frame is a matter of debate. In 
fact, current guidelines recommend maintaining P2Y12 inhibiting therapy for high risk 
patients but which all imply background use of aspirin. P2Y12 inhibitors for long-term 
(beyond 12 months) secondary prevention mainly include clopidogrel and ticagrelor. In 
particular, the dosing regimen for clopidogrel remains the standard 75 mg qd, whereas 
ticagrelor dosing is recommended to be reduced from 90 mg bid to 60 mg bid. However, of 
these regimens the pharmacodynamics (PD) effects of ticagrelor 60 mg in the absence of 
aspirin has not yet been tested. Because DM patients are likely to continue with long-term 


 
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P2Y12 inhibitor therapy, defining the optimal antithrombotic approach for these patients is of 
critical importance. In light of the above made observations, patients with DM represent an 
ideal population to define the antiplatelet effects of a ticagrelor 60 mg monotherapy regimen. 
The aim of this study is to assess the PD effects of ticagrelor 60 mg with and without aspirin 
therapy in CAD patients and to compare this with a standard DAPT regimen of aspirin plus 
clopidogrel. Data will be collected and then entered into a secure database. For the scope of 
this study, the REDCap system will be used to store study related data, and all patients will 
be identified using a subject identifier. Telephone numbers, street addresses and email 
addresses may be used to contact the patient, however this information will not be stored in 
REDCap. 
 
3. Background and Significance:  
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care 
for the prevention of thrombotic complications in patients with coronary artery disease 
(CAD) undergoing percutaneous coronary interventions (PCI) [1]. However, such ischemic 
benefit occurs at the expense of enhanced bleeding, the risk of which increases in a graded 
fashion with prolonged exposure to DAPT [1,2]. In light of the adverse prognosis associated 
with bleeding, there has been much attention toward identifying antithrombotic regimens that 
can reduce the risk of bleeding while maintaining efficacy post-PCI [3,4]. Among these, 
maintaining P2Y12 inhibitor monotherapy, after a brief period of DAPT, has emerged as a 
promising bleeding reduction strategy in a number of investigations [5]. Such aspirin-free 
approach has been postulated based on pharmacodynamic investigations demonstrating that, 
on background of potent P2Y12 inhibiting therapy, including ticagrelor, aspirin offers limited 


 
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antiplatelet effect and may therefore mainly contribute to bleeding potential [5]. Recently, the 
Ticagrelor With Aspirin or Alone in High-Risk Patients after Coronary Intervention 
(TWILIGHT) trial showed that among high-risk PCI patients, after 3 months of DAPT, 
P2Y12 inhibitor monotherapy with ticagrelor 90 mg bid (without aspirin) reduced bleeding 
without increasing ischemic harm after 12 months of therapy compared with ticagrelor 90 mg 
bid used in adjunct to aspirin [6].  
Although the TWILIGHT trial provides important insights on the benefits of an aspirin-free 
approach within the first year after undergoing PCI, it does not address how to manage 
patients after this time frame. Current guidelines recommend maintaining P2Y12 inhibiting 
therapy for high risk patients but which all imply background use of aspirin [1]. P2Y12 
inhibitors for long-term (beyond 12 months) secondary prevention mainly include 
clopidogrel and ticagrelor [1]. In particular, the dosing regimen for clopidogrel remains the 
standard 75 mg qd, whereas ticagrelor dosing is recommended to be reduced from 90 mg bid 
to 60 mg bid [1]. In light of the improved outcomes associated with a ticagrelor 90 mg bid 
regimen without aspirin during the first year after PCI demonstrated in the TWILIGHT trial, 
understanding the differential effects of different antiplatelet combinations, in particular the 
effects of long-term ticagrelor at a 60 mg bid regimen without aspirin, is of utmost clinical 
interest. Importantly, pharmacodynamic (PD) studies have shown that the 90 and 60 mg 
ticagrelor regimens provide similar platelet inhibitory effects [7-9]. However, the 60 mg 
regimen has been associated with an overall more favorable safety profile which is the 
rationale for it being recommended for long-term secondary prevention in patients with 
CAD, irrespective of whether they underwent PCI [10]. However, the PD effects of ticagrelor 
60 mg in the absence of aspirin have not yet been tested. 


 
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Patients with diabetes mellitus (DM) are known to be at high-risk for both ischemic and 
bleeding complications post-PCI [11,12]. A number of factors which commonly affect 
patients with DM contribute to these observations, including the complexity of coronary 
interventions, endothelial dysfunction, concomitant comorbidities, and dysregulation of 
hemostatic and thrombotic processes [11,12]. Importantly, the prevalence of DM (mostly 
type 2) in the past decade has increased by 30% globally, an observation also reflected in PCI 
trials wherein DM is a more frequently encountered risk factor, and is projected to markedly 
increase in the upcoming decades [13]. These observations highlight the importance of 
defining optimal post-PCI pharmacotherapy in patients with DM. Of note, a pre-defined 
subgroup analysis of the TWILIGHT trial showed that among patients with DM patients 
undergoing PCI, ticagrelor monotherapy significantly reduced clinically relevant bleeding 
compared with ticagrelor plus aspirin, without increasing the risk of ischemic events [14]. In 
particular, the reduction in net adverse cardiac events in DM patients treated with a ticagrelor 
monotherapy strategy was markedly greater than that observed in non-DM patients [14]. 
While the potent level of P2Y12 blockade achieved with ticagrelor limits the adjunctive 
benefits associated with aspirin therapy, the synergism on platelet inhibitory effects with the 
use aspirin in the presence of more modest levels of P2Y12 blockade induced by clopidogrel 
may be more relevant particularly in patients with DM [15]. Because DM patients are likely 
to continue with more potent antithrombotic treatment regimens for long-term secondary 
prevention beyond 12 months [1,16], defining the optimal antithrombotic approach for these 
patients is of critical importance. In light of the above made observations, patients with DM 
represent an ideal population to define the antiplatelet effects of a ticagrelor 60 mg 
monotherapy regimen. 


 
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4. Specific Aims:  
The aim of this study is to assess the PD effects of ticagrelor 60 mg with and without aspirin 
therapy in CAD patients and to compare this with a standard DAPT regimen of aspirin plus 
clopidogrel. We hypothesize that withdrawal of aspirin therapy among ticagrelor treated 
patients will not result in significant changes in ADP-induced platelet reactivity and will 
provide more effective platelet inhibition compared with aspirin plus clopidogrel. The results 
of the study will allow defining the best antiplatelet strategy when transitioning patients to 
long-term antiplatelet treatment. 
  
5. Research Plan: 
Research Design  
This will be a prospective, randomized, open-label study conducted in patients with CAD 
and diagnosis of DM. Patients can be on any background antiplatelet therapy, including aspirin 
or any P2Y12 inhibitor (clopidogrel, ticagrelor or prasugrel). The study will be performed at the 
Division of Cardiology of University of Florida Health, Jacksonville, Florida and patients will be 
recruited within the Cardiovascular services of our Institution. Patients will be screened by 
Cardiology Research staff, who will verify that all candidates meet inclusion and exclusion 
criteria. Results from blood tests performed within the last 90 days will be considered valid for 
screening purposes. If these are not available, a blood sample will be collected for the screening 
phase after the patient has signed informed consent. 
Eligible patients will enter a 7-10 day run-in phase with aspirin 81 mg/ qd plus ticagrelor 
90 mg bid after which they will discontinue aspirin and maintain ticagrelor 90 mg bid 


 
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monotherapy for 10±3 days. After this period, patients will be randomized using a randomly 
generated computer sequence in a 1:1:1 fashion to one of three treatment groups: a) ticagrelor 60 
mg bid monotherapy; b) aspirin 81 mg qd plus ticagrelor 60 mg bid; c) aspirin 81 mg qd plus 
clopidogrel 75 mg qd. Randomized treatment will be maintained for 10±3 days. The approach of 
having a run-in phase with aspirin plus ticagrelor 90 mg followed by ticagrelor 90 mg 
monotherapy is in line with the TWILIGHT trial to assess for tolerability and compliance with 
ticagrelor therapy [6, 17]. The approach of having an aspirin plus ticagrelor 60 mg regimen as 
well as an aspirin plus clopidogrel regimen is reflective of guideline recommendations for long-
term secondary prevention [1,16]. The current investigation will test the hypothesis that the 
experimental strategy of ticagrelor 60 mg monotherapy will not result in significant changes in 
P2Y12 inhibitory effects compared with aspirin plus ticagrelor 60 mg and will provide more 
effective platelet inhibition compared with aspirin plus clopidogrel. The study design is 
illustrated in Figure 1 and a further breakdown of what will occur during the course of the study: 
 
 
 
 


 
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Figure 1. OPTIMUS-7 study design.   
 
• Potential subjects will first be screened by research personnel to see if they are 
eligible for the study. Results from blood tests performed within the last 90 days 
which they would have performed as part of their standard of care will be 
considered valid for screening purposes.  
• If the potential subject is a woman of childbearing potential, a pregnancy test will 
be done. If subject is found to be pregnant, the participation in this study will end. 
• If subject is eligible for the study based on the screening results, the subject will 
start the study procedures as outlined below: 
▪ Every participant will start a so called run-in phase during and will be 
treated with aspirin 81mg once a day, and Ticagrelor 90mg twice a day for 
7-10 days. After that, the participant will stop taking the aspirin and only 
take the Ticagrelor 90mg for 10±3 days. This run-in phase is to make sure 
that subjects are able to take the medication without side effects.  
 


 
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▪ After completing the run-in part of the study, subjects will be randomized to 
one of three medication groups and take study medication for 10 ± 3 days: 
a) Ticagrelor 60mg twice daily (without aspirin) 
b) Ticagrelor 60mg twice daily, plus aspirin 81mg once daily 
c) Clopidogrel 75mg once daily, plus aspirin 81mg once daily 
 
 
Blood sampling for PD testing will be performed at 4 time points: a) after completing 1-
week aspirin plus ticagrelor 90 mg run-in phase; b) after completing 10±3 days of treatment with 
ticagrelor 90 mg monotherapy; c) after completing 10±3 days of randomized treatment. At each 
time point PD assessments will be performed 12 ± 2 hours after last ticagrelor dose and 24 hours 
after last clopidogrel dose in order to define trough levels of platelet inhibition. At the last time 
point (after 10±3 days of randomized treatment) blood samples will also be collected 2 hours 
after administration of the antiplatelet regimen in order to assess for peak levels of platelet 
inhibition. The Ticagrelor (Brilinta) tablets are being provided by AstraZeneca. The Clopidogrel 
and aspirin will be provided by the Cardiovascular Research Department. All medications will 
dispensed by the Cardiovascular Research Department and will be packaged using supplies and 
guidelines provided by UF Health Research Pharmacy.  
 
Study Population 
Inclusion criteria: 
For inclusion in the study patients should fulfill the following criteria: 
1. 
Provision of informed consent prior to any study specific procedures 
2. 
Men or women ≥18 years of age 


 
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3. 
Diagnosed with type 2 DM defined by ongoing glucose lowering therapy (oral 
medications and/or insulin) treatment for at least 1 month 
4. 
Known angiographically defined CAD (including a history of previous PCI, CABG, or 
>50% stenosis in a major epicardial vessel) on standard of care antiplatelet therapy* 
*Patients can be treated with any background antiplatelet treatment regimen as part of their 
standard of care, including aspirin and/or any P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel). 
  
Exclusion criteria: 
 
1. PCI < 6 months prior 
2. Recent (< 6 months) type I myocardial infarction 
3. Anticipated concomitant oral or intravenous therapy with strong cytochrome P450 3A4 
(CYP3A4) inhibitors or CYP3A4 substrates with narrow therapeutic indices that cannot 
be stopped for the course of the study: 
− Strong inhibitors: ketoconazole, itraconazole, voriconazole, telithromycin, 
clarithromycin (but not erythromycin or azithromycin), nefazadone, ritonavir, 
saquinavir, nelfinavir, indinavir, atanazavir 
− CYP3A4 substrates with narrow therapeutic index: quinidine, simvastatin at doses 
>40 mg daily or lovastatin at doses >40 mg daily 
4. Anticipated concomitant oral or intravenous therapry of strong CYP3A inducers 
(phenytoin, rifampin, phenobarb, carbamazepine) 
5. Need for chronic oral anticoagulant therapy or chronic low-molecular-weight heparin (at 
venous thrombosis treatment not prophylaxis doses) 
6. Patients with known bleeding diathesis or coagulation disorder 


 
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7. History of previous intracerebral bleed at any time, gastrointestinal (GI) bleed within the 
past 6 months prior to randomization, or major surgery within 30 days prior to 
randomization 
8. Active pathological bleeding 
9. Hypersensitivity to aspirin, ticagrelor or clopidogrel 
10. Increased risk of bradycardic events (eg, known sick sinus syndrome, second or third 
degree AV block or previous documented syncope suspected to be due to bradycardia) 
unless treated with a pacemaker 
11. Known severe liver disease  
12. Renal failure requiring dialysis 
13. Known platelet count <80x106/mL 
14. Known hemoglobin <9 g/dL 
15. Pregnant or breastfeeding women.  
*Women of childbearing age must use reliable birth control (i.e. oral contraceptives) while 
participating in the study. 
 
Laboratory assessments 
Laboratory assessments will be the same for all time points and will include: 
1. VerifyNow PRU assay 
2. Whole blood vasodilator-stimulated phosphoprotein (VASP) 
3. Light transmittance aggregometry (LTA) 
4. Serum thromboxane B2 
5. Total Thrombus-Formation Analysis System (T-TAS) 


 
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Blood sampling: Peripheral venous blood samples (10 mL) will be drawn through a short venous 
catheter inserted into a forearm vein and collected in anticoagulated and serum tubes at each 
study time point for all PD assessments. The first 2-4 mL of blood will be discarded to avoid 
spontaneous platelet activation.  
 
Description of laboratory assays 
1) VerifyNow PRU assay: The VerifyNow System is a turbidimetric based optical detection 
system which measures platelet induced aggregation as an increase in light transmittance 
(Accriva, San Diego, CA) and will be utilized according to manufacturer’s instructions [15]. The 
assay is based on microbead agglutination and uses specific reagents for the pathways of interest. 
The instrument measures this change in optical signal and reports results in P2Y12 Reaction Units 
(PRU). 
2) Whole blood vasodilator-stimulated phosphoprotein (VASP):  VASP phosphorylation (VASP-
P) is a marker of P2Y12 receptor signaling. VASP will be assessed the ELISA VASP-P kit 
(Biocytex Inc., Marseille, France) as previously described [15]. After a first step of parallel 
whole blood sample activation with PGE1 and PGE1+ADP, platelets from the sample are lysed, 
allowing released VASP to be captured by an anti-human VASP antibody, which is coated in the 
microtiter plate. Then, a peroxidase-coupled anti-human VASP-P antibody binds to 
phosphorylated serine 239 antigenic determinant of VASP. The bound enzyme peroxidase is 
then revealed by its activity on TMB substrate over a predetermined time. After stopping the 
reaction, absorbance at 450 nm is directly related to the concentration of VASP-P contained in 
the sample.PGE1 increases VASP-P levels by stimulation of adenylate cyclase. Binding of ADP 


 
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to P2Y12 leads to Gi-coupled inhibition of adenylate cyclase. Therefore, the addition of ADP to 
PGE1-stimulated platelets reduces PGE1-induced VASP-P levels. If P2Y12 receptors are 
successfully inhibited, addition of ADP will not reduce the PGE1-stimulated VASP-P levels. The 
platelet reactivity index (PRI) will be calculated after measuring VASP-P levels.  
3) Light transmittance aggregometry (LTA): Platelet aggregation will be performed using LTA 
according to standard protocols. Blood will be collected in citrated (3.8%) tubes. LTA will be 
assessed using platelet rich plasma (PRP) by the turbidimetric method in a 2-channel 
aggregometer (Chrono-Log 490 Model, Chrono-Log Corp., Havertown) as previously described 
[15]. Platelet agonists will include ADP (20 µM), arachidonic acid (1 mM), collagen (3µg/ml), 
TRAP (15 μM), and a combination of 2 µg/ml collagen-related peptide + 5 µM ADP + 15 µM 
TRAP (CAT). The reagent cocktail CAT will allow to assess the overall platelet response to a 
combination of agonists that leads to activation of multiple platelet pathways (platelet-mediated 
global thrombogenicity). PRP will be obtained as a supernatant after centrifugation of citrated 
blood at 1000 rpm for 10 minutes. The isolated PRP will be kept at 37° C before use. Platelet 
poor plasma (PPP) will be obtained by a second centrifugation of the blood fraction at 2800 rpm 
for 10 minutes. Light transmission will be adjusted to 0% with the PRP and to 100% for the PPP 
for each measurement. Curves will be recorded for 6 minutes and platelet aggregation will be 
determined as the maximal percent change (MPA%) in light transmittance from baseline using 
PPP as a reference. 
4) Serum thromboxane B2: The concentration of serum thromboxane B2 (TXB2) will be 
measured by using the TXB2 EIA kit (Cayman Chemical Company, Ann Arbor, MI), as 
previously described [15]. Briefly, samples will be diluted with EIA buffer to bring their 
concentrations within the range of the standard curve. A standard curve will be established by 


 
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serial dilution of TXB2 between 1000 pg/mL and 7.8 pg/mL using EIA buffer as the matrix. The 
concentration of TXB2 in the samples will be calculated from a logistic 4-parameter fit of the 
standard concentrations versus percentage bound/maximum bound. 
5) T-TAS: T-TAS is an automated microchip flow chamber system for the quantitative analysis 
of the thrombus formation process under blood flow conditions. T-TAS allows measurement of 
thrombus formation using the PL-chip (Diapharma, West Chester Township, OH) [18]. The PL-
chip contains 25 capillary channels (width 40 μm, depth 40 μm) coated with type I collagen and 
is specifically designed for quantitative analysis of platelet thrombus formation, including 
platelet adhesion and aggregation, granule secretion, and thrombus growth in the absence of 
coagulation and fibrinolysis systems. In measurements using the PL-chip, a blood sample 
collected in a hirudin containing blood sampling tube. The platelet aggregates gradually increase 
in size and, in the process, occlude the capillary, resulting in an increase in flow pressure. In the 
present study, total platelet-derived thrombogenicity is expressed as the area under the flow 
pressure curve for the first 10 min for the PL-chip tested at a flow rate of 18 μL/min (PL18-
AUC10). Low PL18-AUC10 reflect reduced thrombus growth and rapid breakdown of the 
thrombus. 
 
Study endpoints, sample size calculation and statistical analysis  
The primary end-point of the study is the comparison of the PRU determined by 
VerifyNow PRU between between aspirin plus ticagrelor 60 mg and ticagrelor 60 mg 
monotherapy at 10 ± 3 days (trough effect). We hypothesize that ticagrelor monotherapy will be 
non-inferior to aspirin plus ticagrelor. Under the assumption of 0 difference in mean PRU 
between the 2 groups and a common standard deviation of 55 PRU, a sample size of 25 patients 


 
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per group will allow for the 95% confidence interval (CI) to stay within 45 PRU with a 80% 
power and alpha=0.025. Considering ~15% of invalid samples due to haemolysis, technical 
issues or drop out, and the 3 arms of treatment a total of 87 patients will need to be included. 
Non-inferiority will be assessed using a 95% CI of the difference in mean PRU between the 2 
strategies. The sample size has been calculated according to data previously published [19]. A 
PRU of 45 was arbitrarily chosen for the noninferiority margin for the upper 95% CI limit of the 
difference in line with prior similar investigations [20-22]. Secondary end points will include 1) 
the comparisons of platelet reactivity, measured by the different assays and agonists (see 
Description of laboratory assays for details) between the different randomized treatments; 2) the 
comparisons between ticagrelor 90 mg monotherapy and the randomized treatments; 3) the 
comparisons between groups of rates of high on-treatment platelet reactivity, defined according 
to consensus definitions [23]. Continuous variables will be expressed as a mean ± SD or median 
[IQR]. Categorical variables will be expressed as frequencies and percentages. An analysis of 
variance method with a general linear model, with treatment as the main effect will be used to 
evaluate the primary non-inferiority endpoint as well as all superiority between-group 
comparisons at each time point. Least squares mean (LSM) differences in PRU between groups 
and the corresponding 2-sided 95% CI for the difference will be obtained based on the analysis 
of variance model and used to assess non-inferiority.  Chi-square test and McNemar test will be 
used to compare categorical variables between groups. Statistical analysis will be performed 
using a SPSSv24.0 software (SPSS Inc. Chicago, IL). 
The PD population will include all patients with PD data and without a major protocol 
deviation thought to affect significantly the PD of ticagrelor or clopidogrel. The PD population 
will be used for analysis of all primary and secondary PD variables. Erroneously treated patients 


 
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(eg, those randomized to one treatment but actually given the other) will be accounted for based 
on the actual treatment received. 
All patients who will receive at least 1 dose of study drug will be included in the safety 
population. Safety will be evaluated by assessment of adverse events (including bleeding and 
ischemic). Adverse events will collected up to completion of the study. Bleeding events will be 
classified according to BARC (Bleeding Academic Research Consortium) criteria [24]. Stent 
thrombosis will be classified according to ARC (Academic Research Consortium) definitions 
[25]. MI, including peri-procedural MI, will be defined according to the universal definition [26]. 
Ischemic stroke will be defined as an ischemic cerebral infarction caused by an embolic or 
thrombotic occlusion of a major intracranial artery. Death will be considered cardiac in origin 
unless obvious non-cardiac causes can be identified.   
 
6. Possible Discomforts and Risk: 
In clinical trials, the most important adverse effect associated with the use of ticagrelor 
was bleeding. The risk of major bleeding with ticagrelor 90 and 60 mg was 2.8% and 2.3%, 
respectively; the combined risk of intracranial hemorrhage or fatal bleeding was <1% [7,27]. 
However, such bleeding prevalence occurred in the setting of long-term trial (median follow-up 
of 9 and 33 months in PLATO and PEGASUS) with bleeding events that accrued over time, 
while our study is limited to only 30 ± 3 days of therapy. Ticagrelor will be compared with 
clopidogrel, which is also associated with an increased risk of bleeding compared with placebo 
[28]. We do not anticipate that ticagrelor will significantly increase the risk of bleeding 
compared with clopidogrel. Dyspnea has been reported as the main non-bleeding side effect with 


 
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ticagrelor and occurs in up to 15.8% of patients [7,27]. Below is a complete lists of potential 
medication risks: 
• Bleeding 
• Dyspnea (shortness of breath) 
• Headache 
• Cough 
• Mild to moderate diarrhea 
• Nausea 
• Hypotension (low blood pressure) 
• Hypertension 
• Dizziness 
• Non-cardiac chest pain 
• Back Pain 
• Fatigue 
• Cardiac (heart) chest pain 
 Patients who discontinue ticagrelor therapy will be switched back to their standard of 
care treatment regimen.  
All clinical events described above, if they were to occur, as well as death, myocardial 
infarction, stroke, and urgent revascularization procedure with PCI or coronary artery bypass 
grafting will be recorded.  All serious adverse events will be submitted to the AstraZeneca 
Product Safety mailbox. Bleeding data will be collected using BARC definitions [24]. The study 
will have a DSMB, comprised of 2 faculty members (2 cardiologists), not directly involved in 


 
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the research. In the event of a report of a serious adverse event the local committee will meet and 
antiplatelet treatment management will be managed according to physician recommendation. 
 
7. Possible benefits: 
The present investigation is aimed to evaluate the PD effects of ticagrelor 60 mg bid with 
and without aspirin compared with a standard dosing regimen of aspirin and clopidogrel. This 
study is not designed to evaluate differences in clinical benefit. However, differences in 
antiplatelet profiles may potentially prompt further investigations of the clinical implication of 
this difference by means of a larger scale clinical study. 
 
8. Conflict of Interest: 
Dr. Angiolillo is a consultant for Bristol Myers Squibb/Sanofi-Aventis, the makers of clopidogrel 
(Plavix) and Astra Zeneca, the makers of ticagrelor (Brilinta). 
Dr. Franchi is a consultant for Sanofi-Aventis, the makers of clopidogrel (Plavix) and Astra 
Zeneca, the makers of ticagrelor (Brilinta). 
 
9. Publication Strategy/Additional Information: 
Study subjects will be identified first (months 1-21): we expect to enroll approximately 3 
subjects monthly and complete enrollment in 21 months (total: 87 subjects enrolled). Months 22-
24 will be implied for completion of follow-up, statistical analysis and abstract or manuscript 
preparation. We intend to present data at a major scientific meeting at completion of the study. 
We anticipate no major problems with the described protocol since the approach is a 
straightforward prospective study and is based on well-established methods. 


 
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10. Potential Financial Risks or Benefits  
None 
 
 
 
 


 
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Abbreviation List (alphabetical order) 
AA: arachidonic acid 
CAD: coronary artery disease  
DAPT: dual antiplatelet therapy 
LTA: light transmittance aggregometry 
MPA: maximal percent change  
PCI: percutaneous coronary intervention  
PD: pharmacodynamics  
PGE1: Prostaglandin E1 
PRU: P2Y12 Reaction Units 
TMB: 3,3',5,5'-tetramethylbenzidine 
TRAP: thrombin receptor activating peptide  
VASP: vasodilator-stimulated phosphoprotein 
VN: VerifyNow