Clinical trial NCT04483583
Conditions: Coronary Artery Disease
Keywords: percutaneous coronary intervention dual antiplatelet therapy oral anticoagulant
Sponsor: University of Florida
Start date: 2020-12-08; Completion date: 2025-01-07
Enrollment: 81 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Clopidogrel is the P2Y12 inhibitor of choice in PCI patients requiring OAC. However, concerns have been raised based on the notion that a considerable number of patients may have inadequate response to clopidogrel. Although practice recommendations indicate that the use of potent P2Y12 inhibitors (i.e., ticagrelor) may be considered in patients at increased thrombotic risk, they do not recommend routine testing to identify patients with poor response to clopidogrel. The aim of this study is to assess the pharmacodynamic effects of different P2Y12 inhibiting therapy (clopidogrel vs ticagrelor) in patients at high risk for high platelet reactivity identified according to the ABCD-GENE score in PCI treated patients also requiring OAC. Up to a total of up to 63 patients are planned to be prospectively enrolled in this investigation which will entail a series of comprehensive pharmacodynamic assessments to reach the study aim.

Detailed description:
The combination of aspirin plus a P2Y12 receptor inhibitor, also known as dual antiplatelet therapy (DAPT), is the cornerstone of treatment for patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). However, a considerable number of patients undergoing PCI also have an indication to be on treatment with an oral anticoagulant (OAC). It is estimated that 10-15% of PCI patients also have an indication to be on OAC, raising concerns on their optimal antithrombotic treatment regimen. Studies have consistently shown dropping aspirin and maintaining a P2Y12 inhibitor and OAC to be associated with reduces bleeding without any significant increase in ischemic events. Accordingly, current practice recommendations is to limit the use of aspirin to the peri-PCI period and maintain dual therapy with a P2Y12 inhibitor and an OAC. Clopidogrel is the P2Y12 inhibitor of choice in PCI patients requiring OAC. However, concerns have been raised based on the notion that a considerable number of patients may have inadequate response to clopidogrel, also known as high platelet reactivity (HPR) status, and thus be at risk for thrombotic complications. Although practice recommendations indicate that the use of potent P2Y12 inhibitors (i.e., ticagrelor) may be considered in patients at increased thrombotic risk, they do not recommend routine testing to identify patients with HPR status. Nevertheless, consensus recommendations do indicate that the selective use of tests to define HPR status is a reasonable option in selected cases such as PCI patients requiring OAC. The aim of this study is to assess the pharmacodynamic effects of different P2Y12 inhibiting therapy (clopidogrel vs ticagrelor) in patients at high risk for HPR identified according to the ABCD-GENE score in PCI treated patients also requiring OAC. Up to a total of up to 63 patients are planned to be prospectively enrolled in this investigation which will entail a series of comprehensive pharmacodynamic assessments to reach the study aim.

Arms: arm 1: Patients with an ABCD-GENE\>10 score will be randomized in a 1:1 fashion to ticagrelor (60 mg/bid) or clopidogrel (75 mg/qd). Treatment will be maintained for 30 days. arm 2: Patients with an ABCD-GENE\>10 score will be randomized in a 1:1 fashion to ticagrelor (60 mg/bid) or clopidogrel (75 mg/qd). Treatment will be maintained for 30 days. arm 3: Patients with an ABCD-GENE\<10 will be treated with clopidogrel (75 mg/qd) for 30 days.
Interventions: intervention 1: Ticagrelor 60mg intervention 2: Clopidogrel
Intervention descriptions: intervention 1: Patients will be administered a 180 mg loading dose followed by a 60 mg bid for the duration of the study. intervention 2: Patients will be administered a 600 mg loading dose followed by a 75 mg daily for the duration of the study.

Protocol documents:
Prot_SAP_001.pdf: 
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1. Project Title: Tailoring P2Y12 Inhibiting Therapy in Patients requiring Oral 
Anticoagulation after undergoing Percutaneous Coronary Intervention: The Switching 
Anti-Platelet and Anti-Coagulant Therapy (SWAP-AC) – 2 Study 
 
2. Investigators: Dominick J Angiolillo, MD, PhD, Francesco Franchi, MD, Fabiana 
Rollini, MD, Andrea Goosen, RN, Latonya Been, AAS 
 
3. Abstract: The combination of aspirin plus a P2Y12 receptor inhibitor, also known as dual 
antiplatelet therapy (DAPT), is the cornerstone of treatment for patients with coronary 
artery disease (CAD) undergoing percutaneous coronary intervention (PCI). However, a 
considerable number of patients undergoing PCI also have an indication to be on 
treatment with an oral anticoagulant (OAC). It is estimated that 10-15% of PCI patients 
also have an indication to be on OAC, raising concerns on their optimal antithrombotic 
treatment regimen. Studies have consistently shown dropping aspirin and maintaining a 
P2Y12 inhibitor and OAC to be associated with reduces bleeding without any significant 
increase in ischemic events. Accordingly, current practice recommendations is to limit 
the use of aspirin to the peri-PCI period and maintain dual therapy with a P2Y12 inhibitor 
and an OAC. Clopidogrel is the P2Y12 inhibitor of choice in PCI patients requiring OAC. 
However, concerns have been raised based on the notion that a considerable number of 
patients may have inadequate response to clopidogrel, also known as high platelet 
reactivity (HPR) status, and thus be at risk for thrombotic complications. Although 
practice recommendations indicate that the use of potent P2Y12 inhibitors (i.e., ticagrelor) 
may be considered in patients at increased thrombotic risk, they do not recommend 


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routine testing to identify patients with HPR status. Nevertheless, consensus 
recommendations do indicate that the selective use of tests to define HPR status is a 
reasonable option in selected cases such as PCI patients requiring OAC. The aim of this 
study is to assess the pharmacodynamic effects of different P2Y12 inhibiting therapy 
(clopdiogrel vs ticagrelor) in patients at high risk for HPR identified according to the 
ABCD-GENE score in PCI treated patients also requiring OAC.  Up to a total of up to 84 
patients are planned to be prospectively enrolled in this investigation which will entail a 
series of comprehensive pharmacodynamic assessments to reach the study aim. 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.  
 
4. Background: The combination of aspirin plus a P2Y12 receptor inhibitor, also known as 
dual antiplatelet therapy (DAPT), is the cornerstone of treatment for patients with 
coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) [1]. 
However, a considerable number of patients undergoing PCI also have an indication to be 
on treatment with an oral anticoagulant (OAC) [2-5]. Most of these patients have atrial 
fibrillation (AF) [2-5]. Importantly, CAD and AF share common risk factors which 
explains why up to 40% of AF patients also have CAD [2-5]. Other indication to be on 
OAC include a history of deep venous thrombosis (DVT)/pulmonary embolism (PE), 
mechanical valves, and left ventricular thrombus [2-5]. It is estimated that 10-15% of PCI 
patients also have an indication to be on OAC, raising concerns on their optimal 
antithrombotic treatment regimen [2-5]. In fact, while PCI treated patients require DAPT 


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for the prevention of arterial thrombotic complications, they must also maintain OAC for 
cardioembolic protection [2-5].  However, the use of triple antithrombotic therapy 
(DAPT+OAC) significantly enhances the risk of bleeding complications [2-5]. 
Importantly, increased bleeding in PCI patients is associated with adverse prognosis, 
including mortality [6-7]. These observations have set the foundations for a number of 
studies in PCI patients also requiring OAC assessing antithrombotic treatment regimens 
associated with reduced bleeding while preserving efficacy [2-5]. Aspirin has been 
identified as a key contributor to bleeding complications, mostly gastrointestinal [8]. On 
this background a number of studies have tested withdrawal of aspirin therapy and 
maintaining alternative antithrombotic agents as a strategy to reduce bleeding [8]. Studies 
have consistently shown dropping aspirin and maintaining a P2Y12 inhibitor and OAC to 
be associated with reduces bleeding without any significant increase in ischemic events 
[9-13]. Accordingly, current practice recommendations is to limit the use of aspirin to the 
peri-PCI period and maintain dual therapy with a P2Y12 inhibitor and an OAC [14,15]. 
Clopidogrel is currently the P2Y12 inhibitor of choice in patients undergoing PCI 
requiring OAC [14,15]. However, concerns have been raised based on the notion that a 
considerable number of patients may have inadequate response to clopidogrel, also 
known as high platelet reactivity (HPR) status, and thus be at potential risk for 
thrombotic complications [16,17]. Although practice recommendations indicate that the 
use of more potent P2Y12 inhibitors (i.e., ticagrelor) may be considered in patients at 
increased thrombotic risk, they do not recommend routine testing to identify patients with 
HPR status [14,15]. Nevertheless, consensus recommendations do indicate that the 
selective use of tests to define HPR status is a reasonable option in selected cases such as 


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PCI patients requiring OAC [17]. Most recently a scoring system called ABCD-GENE 
has been developed which allows to readily identify patients with HPR status with high 
accuracy [18]. In particular, this scoring system integrates clinical (age, body mass index, 
chronic kidney disease, and diabetes mellitus) and genetic (CYP2C19 alleles) variables. 
Patients with a high ABCD-GENE score (≥10) have an increased risk of HPR and 
adverse ischemic events [18]. However, data on the impact on platelet inhibitory effects 
associated with tailored selection of P2Y12 inhibiting agents in this setting remains 
unexplored.  
 
5. Specific Aims: The aim of the Switching Anti-Platelet and Anti-Coagulant Therapy 
(SWAP-AC) – 2 Study is to assess the pharmacodynamic effects of different P2Y12 
inhibiting therapy (clopdiogrel vs ticagrelor) according to the ABCD-GENE score in PCI 
treated patients also requiring OAC.   
 
6. Research Plan: 
Study design 
This will be a prospective study conducted in any patients with CAD, including 
those with Acute Coronary Syndrome (ACS) undergoing PCI who have an indication to 
be treated with an OAC. Patients undergoing PCI treated with DAPT during the peri-PCI 
period and also require OAC as part of their standard of care will be identified. The study 
will be performed at the Division of Cardiology of University of Florida Health, 
Jacksonville, Florida (site PI: Dominick Angiolillo, MD, PhD) and at St. Antonius 
Hospital in Nieuwegein, The Netherlands (site PI: Jurrien M. ten Berg, MD, PhD).  


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Patients will be recruited within the Cardiovascular services of each Institution. Patients 
will be screened by Cardiology Research staff, who will verify that all candidates meet 
inclusion and exclusion criteria. After providing written informed consent, patients will 
be stratified according to their ABCD-GENE score (using a cut-off of 10) into two 
cohorts: ABCD-GENE10 and ABCD-GENE< 10. The ABCD-GENE scoring system is 
described in Figure 1.  
 
Figure 1. ABCD-GENE score 
 
Patients will be screened during hospital stay after undergoing successful PCI. 
Results from blood tests performed within the last 30 days will be considered valid for 
screening. Patients will undergo genetic testing to identify CYP2C19 genetic status using 
the Spartan assay or central lab. Randomization will occur once genetic testing results 
become available, ideally prior to hospital discharge. However, for patients discharged 


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before having results available or over the weekend they will be allowed to return for 
their randomization within 3 days from test results. Patients with an ABCD-GENE10 
score will be randomized in a 1:1 fashion to ticagrelor (60 mg/bid) or clopidogrel (75 
mg/qd). Patients with an ABCD-GENE<10 will be treated with clopidogrel (75 mg/qd).  
Since the choice of P2Y12 inhibitor during the PCI procedure may vary 
(commercially available agents include clopidogrel, ticagrelor and prasugrel), the 
following recommendations will be made based on the agent chosen and the treatment 
assignment: a) patients assigned to clopidogrel and also treated with clopidogrel during 
PCI will continue with a 75 mg/qd maintenance dose for the duration of the study; b) 
patients assigned to clopidogrel but treated with ticagrelor or prasugrel during PCI will 
receive a 600 mg loading dose clopidogrel followed by a 75 mg/qd maintenance dose for 
the duration of the study; c) patients assigned to ticagrelor and also treated with ticagrelor 
during PCI will continue with ticagrelor 60 mg bid maintenance dose for the duration of 
the study; d) patients assigned to ticagrelor but treated with clopidogrel or prasugrel 
during PCI will be administered a 180 mg loading dose followed by a 60 mg bid for the 
duration of the study. Administration of randomized treatment will occur prior to hospital 
discharge as would occur per standard of care for administration of the next dose of 
P2Y12 inhibiting therapy. The use of a loading dose when switching agent is in line with 
consensus recommendations for switching P2Y12 inhibiting therapy [19]. The clopidogrel 
600mg loading dose and 75 mg/qd maintenance dose regimen is in line with practice 
recommendations [1]. The ticagrelor 180 mg loading dose regimen is in line with practice 
guidelines; the 60 mg bid maintenance dose regimen was chosen in light of recent data 
that this dose provides platelet inhibitory effects not dissimilar from the 90 mg bid dosing 


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regimen but with less side effects and more efficacious platelet inhibitory effects than 
clopidogrel, including after PCI [1,20]. All patients will maintain aspirin 81 mg /qd at 
least for the duration of hospital stay. Aspirin therapy will be discontinued at time of 
hospital discharge or at 7 days after PCI at the discretion of the treating physician in 
patients deemed to be at high ischemic risk, as per standard of care for patients requiring 
concomitant treatment with a P2Y12 inhibitor and an OAC [14,15].  
Assigned treatment will be maintained for 30±5 days. PD assessments will be 
conducted at 3 time points: i) baseline (while on standard of care DAPT therapy): day 
after PCI, ideally before the administration of the morning dose of P2Y12 inhibiting 
therapy and OAC (trough levels of platelet reactivity); however, since patients may get 
discharged the same day of the PCI or may have already taken their daily dosing regimen, 
blood sampling will be allowed as this does not interfere with the study hypothesis; 
patients will continue to take their morning dose of aspirin and all other standard of care 
therapies; ii) 30±5 days after randomization: before (trough levels of platelet reactivity) 
and 2 hours after (trough levels of platelet reactivity) the administration of the morning 
doses of P2Y12 inhibiting therapy and OAC (trough levels of platelet reactivity); patients 
will take all other standard of care therapies. Figure 2 illustrates the overall study design 
and a further breakdown of what will occur during the course of the study:  
 
 
 
 
 


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Figure 2. SWAP-AC-2 study design 
 
• Patients will first be screened by research personnel to see if they are eligible for the 
study. Results from blood tests performed within the last 30 days which patients 
would have performed because of their stent procedure will be considered valid for 
screening purposes.  
• If it is a woman of childbearing potential, a pregnancy test will be done. If the 
subject is found to be pregnant, their participation in this study will end. 
• If they are eligible for the study based on the screening results, they will start the 
study procedures as outlined below: 
▪ Genetic test buccal swab. This swab is being done to determine CYP2C19 
genetic status. 
▪ The physician will determine the ABCD-GENE score as described in Figure 
1. This score is calculated by looking at the subject’s CYP2C19 genetic 


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status and clinical information, including age, BMI, renal function, and 
diabetic status.   
Patients with an ABCD-GENE<10 will be treated with clopidogrel (75 
mg/qd). Patients with an ABCD-GENE10 score will be randomized in a 
1:1 fashion to ticagrelor (60 mg/bid) or clopidogrel (75 mg/qd). Assigned 
treatment will be maintained for 30 +/- 5 days.  
▪ Blood will be collected at two visits by inserting a needle into a vein or from 
a catheter in a vein. The first visit will be after the PCI ideally before the 
subject has taken their antithrombotic medications (baseline); however, 
since patients may get discharged the same day of the PCI or may have 
already taken their daily dosing regimen, blood sampling will be allowed as 
this does not interfere with the study hypothesis. The second visit will be 30 
+/- 5 days later. At this visit there will be two blood draws: the first before 
the subject has taken their antithrombotic medication (trough) and second 2 
hours after the subject has taken their antithrombotic medication (peak).  
 
PD measures will include a multitude of assays aimed to assess various measures 
of platelet reactivity, including purinergic and non-purinergic signaling pathways, and 
thrombin generation, as described below. Although the study will have an open-label 
design, laboratory personnel will be blinded to treatment assignments. Compliance with 
antithrombotic therapies will be assessed by interview and pill counting. During study 
treatment, major adverse cardiac events (death, myocardial infarction, stroke, and urgent 
revascularization procedures), serious adverse events (bleeding and other adverse events), 


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as well as non-serious adverse events will be collected. After completing the study, 
patients will resume an antithrombotic treatment regimen at the discretion of the treating 
physician.    
 
Study population 
A total of 84 CAD patients will be recruited In particular, 42 patients with an 
ABCD-GENE10 will be included and randomized to ticagrelor (n=20) or clopidogrel 
(n=20), while 42 patients will be in the ABCD-GENE<10 cohort. Patients will need to 
meet the following study entry criteria: 
Inclusion criteria: 
• Age ≥ 18 years 
• Willing and able to provide written informed consent 
• Undergone successful PCI and treated with DAPT (aspirin plus a P2Y12 
inhibitor) per standard of care 
• On treatment with a novel oral anticoagulant (apixaban, dabigatran, edoxaban, or 
rivaroxaban) for any indication (dosing regimen will be according to standard of 
care and at the discretion of the treating physician) 
 
Exclusion criteria: 
• 
Any active bleeding or history of major bleeding 
• 
Ischemic Stroke within 1 month  
• 
Any history of hemorrhagic stroke, or intracranial hemorrhage 
• 
Known non-cardiovascular disease that is associated with poor prognosis (e.g., 
metastatic cancer) or that increases the risk of an adverse reaction to study 
interventions. 
• 
End-stage renal disease on hemodialysis 


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• 
Known severe liver dysfunction or any known hepatic disease associated with 
coagulopathy 
• 
History of hypersensitivity or known contraindication to clopidogrel or 
ticagrelor. 
• 
Systemic treatment with strong inhibitors of both CYP 3A4 and p-glycoprotein 
(e.g., systemic azole antimycotics, such as ketoconazole, and human 
immunodeficiency virus [HIV]-protease inhibitors, such as ritonavir), or strong 
inducers of CYP 3A4, i.e. rifampicin, rifabutin, phenobarbital, phenytoin, and 
carbamazepine 
• 
Subjects who are pregnant, breastfeeding, or are of childbearing potential, and 
sexually active and not practicing an effective method of birth control (e.g. 
surgically sterile, prescription oral contraceptives, contraceptive injections, 
intrauterine device, double barrier method, contraceptive patch, male partner 
sterilization) 
• 
Concomitant participation in another study with investigational drug 
• 
Hemoglobin ≤9 mg/dL 
• 
Platelet count <80x106/mL 
 
Genetic Testing 
Spartan RX point-of-care rapid genotyping: Spartan RX (Spartan Bioscience Inc., 
Ontario, Canada) is a point-of-care determining the CYP2C19 (*1,*2,*3,*17) allele status 
within 1 hour [21,22]. This test consists of four separate steps intended to be done in less 
than 8 minutes: acquisition of a buccal swab; insertion of the swab into the cartridge; 
insertion of the reaction solution into the device; and analysis of CYP2C19 genotype 
triggered by a button on the device. Patients are classified as having or not having a loss of 
function (LOF) allele status. In particular, patients may be carriers of one (heterozygotes) 
or two (homozygotes) LOF alleles (*2 or *3) which can be summarized as follows: 
heterozygotes (*1/*2, *1/*3, *2/*17, *3/*17) or homozygotes (*2/*2, *3/*3 or *2/*3). 


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Patients without a *2 or *3 LOF (*1/*1, *1/*17 or *17/*17) are defined as non-carriers of 
LOF alleles [21,22]. 
Laboratory assessments 
Peripheral venous blood samples will be drawn through a short venous catheter 
inserted into a forearm vein and collected in citrate, EDTA, and serum tubes as 
appropriate for assessments. The first 2-4 mL of blood will be discarded to avoid 
spontaneous platelet activation. Blood sampling for PD will be performed at 3 time points 
as described above and shown in the study design section. The following tests will be 
performed to explore the pharmacodynamic effects of the tested strategies. 
1. VerifyNow PRU 
2. Light Transmittance Aggregometry (LTA)  
3. Whole blood vasodilator-stimulated phosphoprotein (VASP) 
4. Thrombus Formation Assay (Turbidimetric assay) 
5. Total Thrombus-Formation Analysis System (T-TAS) 
Laboratory assessments including VerifyNow PRU and LTA will be performed 
within 2 hours of sample collection. VASP and thrombus generation assessments will be 
performed on stored samples as final batch analysis. Samples will be stored under 
required refrigerated conditions at the Cardiovascular Research Center of the University 
of Florida-Jacksonville. Only laboratory staff will have access to the samples. Subject 
identity will be protected. In particular, samples will be de-identified and data coded. 
This information will be stored in locked filing cabinets or in computers with security 
passwords. All laboratory assessments with the exception of thrombin generation 
measures will be performed at the Cardiovascular Research Center of the University of 


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Florida-Jacksonville. Thrombus generation assessments will be performed at central core 
lab (Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 
Leeds, UK).   
 
Description of laboratory assays 
1) VerifyNow (VN) PRU: The VN 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 [23-25]. The assay is based on microbead agglutination and uses specific 
reagents for the pathways of interest. The VN-PRU assay, by combining ADP+PGE1, 
measures changes in platelet function specific to P2Y12 receptor inhibitors. The assay is 
based upon the ability of activated platelets to bind fibrinogen. Fibrinogen-coated 
microparticles aggregate in proportion to the number of GP IIb/IIIa receptors expressed. 
Light transmittance increases as activated platelets bind and aggregate fibrinogen-coated 
beads. The instrument measures this change in optical signal and reports results in P2Y12 
Reaction Units (PRU). HPR is defined by PRU >208 [17]. 
2) Light transmittance aggregometry (LTA): Platelet aggregation will be 
performed using LTA according to standard protocols. Blood will be collected in citrated 
(3.2%) 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) [23-25]. Platelet agonists will include arachidonic acid (AA; 1 mM), 
collagen (3µg/ml), thrombin receptor activating peptide (TRAP;15 μM) and ADP (20 
µM). LTA following 2 µg/ml collagen-related peptide + 5 µM ADP + 15 µM TRAP 


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(CAT) will also be used as agonist to assess the overall platelet-mediated 
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 min. 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. HPR will be defined as MPA 
with 20 μM ADP > 59% [17]. 
3) 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 [25]. 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 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 


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will not reduce the PGE1-stimulated VASP-P levels. The platelet reactivity index (PRI) 
will be calculated after measuring VASP-P levels. HPR is defined by a PRI >50 [17]. 
4) Thrombus Formation Assay: A validated turbidimetric assay will be used to 
study fibrin clot formation, structure and lysis, as previously described [26]. Clot 
formation will be activated with thrombin (0.03u/ml) or tissue factor (10pM) after 
recalcification of citrated samples and the following parameters evaluated: 1) lag phase 
(seconds): time from start of reaction to beginning of clot formation, 2) clot formation 
time (seconds), representing the period from start of reaction to full clot formation, 3) clot 
final turbidity (maximum absorbance, measured in absorbance units), which is a measure 
of fibrin network density and 4) clot lysis time (seconds), assessed as time from full clot 
formation to 50% lysis, which is used to evaluate fibrinolysis potential [26]. 
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/AR-chips (Diapharma, 
West Chester Township, OH) [17-18]. The PL/AR-chips 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/AR-chips, a blood sample collected 
in a hirudin and sodium citrate 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/AR-


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chips 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 our study will be levels of platelet reactivity, measured 
as PRU using the VN system, of ticagrelor versus clopidogrel at 30 days after 
randomization in patients with an ABCD-Gene score ≥10. We hypothesize that ticagrelor 
60 mg bid will lead to lower PRU compared with clopidogrel 75 mg qd. Based on 
previous studies [20], assuming a standard deviation of 55 and 80 PRU for ticagrelor and 
clopidogrel, respectively, a sample size of 17 patients per treatment group with valid 
primary end point data will be required to detect an absolute difference of 90 PRU 
between ticagrelor and clopidogrel with a 90% power and a 2-tailed alpha value of 0.05. 
Assuming a potential 25% in data attrition due to patient drop-out (e.g., due to side 
effects, unplanned use of parenteral antiplatelet therapies after randomization or 
withdrawal of consent) or invalid PD samples (e.g., due to hemolysis or technical 
reasons), a sample size of up to 21 patients per randomized group; 42 total will be 
randomized and an additional 42 in the control group. Thus, considering the 3 treatment 
arms, a total of up to 84 patients are expected to be enrolled to reach the sample size of 
patients with valid primary end point data required for the primary end point. 
Additional exploratory end points will include the comparisons between 
clopidogrel-treated patients with ABCD-Gene score<10 and the other 2 arms, as well as 
comparisons between groups of rates of HPR. For baseline characteristics, categorical 
variables will be expressed as frequencies and percentages; continuous variables will be 


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presented as mean ± SD or median [IQR]. Continuous variables will be analyzed for 
normal distribution with the Kolmogorov-Smirnov test. Comparisons for the primary end 
point as well as for other intergroup comparisons of continuous variables will be 
performed with an analysis of covariance with a general linear model with baseline value 
of the corresponding platelet function test as a covariate. Intragroup comparisons will be 
performed using a mixed linear model.  Comparisons for categorical variables, including 
rates of HPR will be performed with the Chi square test or Fisher exact test. A p-value < 
0.05 will be considered statistically significant. Statistical analysis will be performed with 
SPSS version 25 software (SPSS Inc.). Data analysis will be performed at the University 
of Florida. Data transfer will occur in a HIPAA de-identified manner. Data from The 
Netherlands will arrive coded so that source of data can be easily known.” 
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 (eg, those randomized to one treatment but actually given the 
other) will be accounted for based on the actual treatment received. 
All patients who received 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 be collected up to completion of the study. 
Bleeding events will be classified according to BARC (Bleeding Academic Research 
Consortium) criteria [27]. Stent thrombosis will be classified according to ARC 
(Academic Research Consortium) definitions [28]. MI, including peri-procedural MI, will 
be defined according to the universal definition [29]. Ischemic stroke will be defined as 


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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.   
 
7. Possible Discomforts and Risks 
In clinical trials, the most important adverse effect associated with the use of 
ticagrelor 60 mg was bleeding. The risk of major bleeding with ticagrelor 60 mg was 
2.3%; the combined risk of intracranial hemorrhage or fatal bleeding was 0.7% [30]. 
However, such bleeding prevalence occurred in the setting of long-term trial (median 
follow-up of 33 months) with bleeding events that accrued over time, while our study is 
limited to only 30 ± 3 days of therapy. Moreover, these bleeding rates occurred versus 
placebo, while in our investigation which is being conducted in patients undergoing PCI 
which mandates the use of a P2Y12 inhibitor per standard of care. Ticagrelor will be 
compared with clopidogrel, which is also associated with an increased risk of bleeding 
compared with placebo [31]. However, the rates of bleeding are lower with clopidogrel 
than with ticagrelor [32]. Dyspnea has been reported as the main non-bleeding side effect 
with ticagrelor and occurs in up to 15.8% of patients [30]. Dyspnea has been associated 
with drug discontinuation in 4.6% of patients [30]. Below is a complete lists of potential 
medication risks: 
• Bleeding 
• Dyspnea (shortness of breath) 
• Headache 
• Cough 


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• Atrial fibrillation 
• 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 to clopidogrel. 
Ultimately, although a 60 mg dosing regimen has not been specifically tested in patients 
undergoing PCI treated with an OAC, this dosing regimen has shown to be associated 
with more potent antiplatelet effects than clopidogrel and has not been associated with 
any increase in thrombotic complications in elective PCI patients conducted in an 
unselected cohort of subjects [20]. Overall, these considerations limit any safety concerns 
associated with the conduct of this study.  
The risks of the blood draw may include faintness, inflammation of the vein, pain, 
bruising or bleeding at the site of the puncture.There is also a slight risk of infection from 
the blood draw. 
All clinical events described above, if they were to occur, as well as death, 
myocardial infarction, stroke, and urgent revascularization procedure with PCI or 


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coronary artery bypass grafting will be recorded. Clinical events will be evaluated by a 
local data safety monitoring board (DSMB) committee, comprised of 2 faculty members 
(2 cardiologists), not directly involved in the research. In the event of a report of a serious 
adverse event (as defined below) the DSMB will meet and antiplatelet treatment 
management will be managed, including stopping if of clinical concern, according to 
physician recommendation. 
 
8. Possible benefits 
The present investigation is aimed to evaluate the PD effects of ticagrelor 60 mg 
bid compared with a standard dosing regimen of clopidogrel in PCI patients requiring 
OAC presenting with an ABCD-GENE score ≥10. 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. 
 
9. Conflict of Interest 
Dr. Angiolillo is a consultant for Sanofi, the maker of clopidogrel (Plavix) and 
Astra Zeneca, the makers of ticagrelor (Brilinta). Dr. Franchi is a consultant for Sanofi, 
the maker of clopidogrel (Plavix) and Astra Zeneca, the maker of ticagrelor (Brilinta). 
 
10. Publication Strategy/Additional Information  
Study subjects will be identified first (months 1-21): we expect to enroll 
approximately 4 subjects monthly and complete enrollment in 21 months (total: 84 


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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. 
 
11. Potential Financial Risks or Benefits 
 
None 
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Abbreviation List (alphabetical order) 
AA: arachidonic acid 
ADP: adenosine diphosphate 
BARC: Bleeding Academic Research Consortium  
CAD: coronary artery disease  
CAT: Collagen, Adenosine Diphosphate, Thrombin receptor activator for peptide 6  
DAPT: dual antiplatelet therapy 
HPR: high platelet reactivity  
LOF: loss of function  
LTA: light transmittance aggregometry 
MPA: maximal percent change  
PCI: percutaneous coronary intervention  
PD: pharmacodynamics  
PGE1: Prostaglandin E1 
PPP: platelet-poor plasma 
PRU: P2Y12 Reaction Units 
TMB: 3,3',5,5'-tetramethylbenzidine 
TRAP: thrombin receptor activating peptide  
VASP: vasodilator-stimulated phosphoprotein 
VN: VerifyNow