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M. Valgimigli, MD, PhD On behalf of 3T/2R Investigators

T ailoring T reatment with T irofiban in patients showing R esistance to aspirin and/or R esistance to clopidogrel. M. Valgimigli, MD, PhD On behalf of 3T/2R Investigators. Background i. Current treatment strategies for patients with coronary artery disease ignore the individual

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M. Valgimigli, MD, PhD On behalf of 3T/2R Investigators

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  1. Tailoring Treatment with Tirofiban in patients showing Resistance to aspirin and/or Resistance to clopidogrel M. Valgimigli, MD, PhD On behalf of 3T/2R Investigators

  2. Background i Current treatment strategies for patients with coronary artery disease ignore the individual response to antiplatelet agent(s) This largely contrasts with the existing practice surrounding many cardiovascular medications including anti-hypertensive and lipid-lowering agents where response to therapy, or lack thereof, drives subsequent treatment decisions

  3. Background ii Inhibition of platelet aggregation following aspirin or clopidogrel intake varies greatly among patients Previous studies, using a variety of definitions, have shown that poor response to Aspirin or Clopidogrel increases up to 10-fold the risk of thrombotic events, particularly after PCI Whether this reflects suboptimal platelet inhibition per se which might benefit from alternative/ more potent antiplatelet agents, is unknown

  4. Patients selection Screening Patients scheduled to undergo elective CAG/PCI for silent ischemia, stable angina or low risk NSTEACS Eligibility -Undergoing PCI -CK, CK-MB and Tp I/T persistently –ve -No controindications to Gp IIb/IIIa blockers -Aspirin and/or Clopidogrel poor response as assessed by VerifyNow™ Aspirin and P2Y12 assays (Accumetrics, USA)

  5. Response evaluation Aspirin Poor Response • Aspirin reaction units (ARU) >550 • ASA orally ≥80 mg for at least 5 days • i.v. 500 mg ASA 15 mins or more before And/Or Clopidogrel Poor Response • < 40% platelet inhibition •  600 mg clopidogrel LD at least 2 hours before • 300 mg clopidgrel LD at least 6 hours before • 75 mg clopidogrel MD for at least 7 days Or Or Valgimigli et al. Cardiovasc Drugs Ther. 2008 Aug;22(4):313-20

  6. Trial Design Aspirin + Clopidogrel UFH or Bivalirudin 1:1 Double Blind Tirofiban* Placebo Bail-out Placebo Bail-out Tirofiban Blood sampling: Hb, PLT, Tp; CK-MB mass @ 6, 12, 18 or 24 hrs Clinical F-UP: 30-d, 4, 8 and 12 months *: 25 g/kg in 3 mins, followed by an 14-24 hour infusion at 0.15 g/kg/min

  7. Study Endpoints Primary Troponin I/T elevation > 3 times ULN in one or more blood sample(s) within 48 hours after PCI Ho= 45% in placebo vs. 25% in Tirofiban arm; =90% =5% Target sample size: 240 pts Secondary CK-MB mass elevation >1; 3 or 5 times ULN Major adverse cardiovascular events Stent thrombosis based on ARC classification Valgimigli et al. Cardiovasc Drugs Ther. 2008 Aug;22(4):313-20

  8. Study Organization Sponsor:University of Ferrara, Italy Data Management:Medical Trial Analysis, Switzerland Site and data monitoring:Medical Trial Analysis, Italy Clinical Events Committee:S. Curello (Chair), Brescia, Italy ECG core lab:MTA, C. Arcozzi (Chair) Angiographic core lab: MTA, P. Malagutti (Chair) DSMB:G Fucà, (Chair), Italy

  9. 3T/2R P.I. and Sites G Campo Ferrara M Sabatè Barcelona G Percoco Lagosanto M Hamon Caen N de Cesare Zingonia Brugaletta Barcelona Meliga/Marra Torino A Repetto Pavia P Vranckx Hasselt P Agostoni Antwerp A Furgieri Cotignola C Tumscitz Piacenza

  10. 1277 Patients Assessed for Eligibility 916 screened for Aspirin response 283 were also screened for Clopidogrel response 361 screened for Clopidogrel response 240 Clopidogrel Screening failure 754 Aspirin Screening Failure 204 Clopidogrel Screening Failure 754 53 Clopidogrel Poor Responders 204 162 Aspirin Poor Responders 26 were also Clopidogrel Poor Responders 15% 174 Clopidogrel Poor Responders Overall 73 pts excluded: 36 Medical Tx 18 CABG 13 Troponin/CK-MB +ve 5 Refused to participate 1 sudden drop of haemoglobin 27% 9% 10% 23% 8% 116 Randomised 52 Allocated to Placebo 10 Received bailout tirofiban 64 Allocated toTirofiban 2 Calls for bailout tirofiban 116 Completed 30-d F-UP 147 Randomised 79 Allocated to Placebo 5 Received bailout tirofiban 68 Allocated to Tirofiban 1 Call for bailout tirofiban 147 Completed 30-d F-UP

  11. Baseline Characteristics TirofibanPlaceboP-Value (n=132)(n=131) Age (yr) 69(62-75) 69(61-75) 0.84 Male Sex (%) 74.2 72.5 0.78 BMI (kg/m2) 28(25-30) 27(25-29) 0.27 Diabetes (%) 24 28 0.57 Hypertension(%) 67 76 0.10 CrCl (ml/min) 75.6 74.5 0.77 Prior MI (%) 47.7 38.2 0.13 Prior PCI (%) 38.9 38.9 0.99 Prior CABG (%) 6.8 6.1 0.99 LVEF (%) 56.5 58 0.98 Stable CAD (%) 65 69 0.78 Unstable CAD (%) 35 31 0.51 1-Vessel Disease (%) 27 28 0.78 Multi-Vessel Disease (%) 73 72 0.99 ASA Steady State (%) 100 100 0.99 Clopid. Steady State (%) 100 100 0.99

  12. Procedural Results TirofibanPlaceboP-Value (n=132)(n=131) No treated lesions 1.5±0.6 1.5±0.70.96 Multivessel PCI (%) 24 19 0.37 No Stents implanted 1.6±0.9 1.6±1.00.96 Stent Lenght (mm) 27 27 0.59 Use of UFH (%) 98 98 0.99 Use of Bivalirudin (%) 2 2 0.99 Location of lesion (%) LMCA 2.6 1.6 0.72 LAD 40.9 34.0 0.17 CFX 21.8 25.0 0.47 RCA 65 69 0.78 Venous Graft 2.1 0.5 0.37 B2 or C type lesion (%) 58 56 0.86 Thrombus present (%) 5.7 4.3 0.64 Bifurcation (%) 25 18 0.13 Stenting (%) 92 94 0.82

  13. Primary EndpointTp >3ULN w/in 48 hs Tirofiban Placebo P=0.053 P=0.009 for superiority 8.4 50 RRR: 42% 95%CI: 61-12 45 40 35.1% % 35 2.3 30 20.4% 25 20 Bail-out Tirofiban 15 10 5 0

  14. 1° Endpoint: Subgroup Analysis PRIMARY END POINT P-VALUE LOG RISK RATIO (95% CI) TirofibanPlacebo (%) 20.4 35.1 Overall < 70 yr 21.4 38.5 0.68 20.3 30.6 ≥ 70 yr 21.4 40.0 Male 0.38 17.6 22.2 Female 22.1 39.3 No Diabetes 0.51 Diabetes 16.2 21.8 21.9 40.4 Aspirin Poor Responders 0.78 16.5 30.8 Clopidogrel Poor Responders % Inhibition ≥21 17.1 25.5 0.35 15.9 37.5 % Inhibition <21 0 25.0 Poor Responders to Both 22.1 34.1 Stable Angina 0.47 Unstable Angina 18.3 37.5 1 Treated lesion 15.2 26.7 0.87 > 1 Treated Lesion 28.3 51.1 A/B1 Treated Lesion(s) 8.1 20.3 0.69 B2/C Treated Lesion(s) 27.7 45.4 0.1 1 10 Placebo Better Tirofiban Better

  15. Secondary Endpoints Relative Risk Reduction 62% 50% 70%

  16. 48 hour OutcomesEfficacy Endpoints (CEC adjudicated) Tirofiban Placebo 40% P=0.009 P=0.009 25% 10% Definite ST uTVR MACE Death MI

  17. 48 hour/30-day OutcomesEfficacy Endpoints (CEC adjudicated) Tirofiban Placebo 40% 1 Type 4a* 1 Type 4b* 1 Type 4a* Pulmonary embolism 25% 10% 2 1 1 1 1 Definite ST uTVR MACE Death MI *: according to universal definition of myocardial infarction

  18. 30-Day OutcomesEfficacy Endpoints (CEC adjudicated) Tirofiban Placebo P=0.006 P=0.006 40% 37% 25% 21% 10% Definite ST uTVR MACE Death MI

  19. 30-Day OutcomesSafety Endpoints (DSMB adjudicated) 8% Tirofiban Placebo 6% 4% P=0.99 P=0.99 2% 0% Major Minor RBC Tranfusion Mild  PLT TIMI-Bleeding

  20. Summary The tailored intensification of platelet inhibition through the infusion of tirofiban in poor responders to aspirin and/or clopidogrel decreased the rate of myocardial infarction after elective PCI and resulted in a lower rate of major adverse cardiovascular events at 30 days Our study provides proof of concept for a new treatment strategy in patients with coronary artery disease which, by assessing response to standard anti-platelet agents by a point-of-care assay, modulates intensity of treatment accordingly

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