This is a prospective, single-center, randomized trial including 1500 subjects requiring PCI. Subjects with ischemic heart disease due to stenotic lesions in either native coronary arteries or coronary artery bypass undergoing PCI with stent placement and no contraindication to prolonged dual antiplatelet therapy (≥1 year) are eligible to be in the study. Subjects will be randomized to either guided antiplatelet therapy arm (n=750) or standard therapy arm (n=750) and undergo laboratory testing, antiplatelet adjustment, and clinical follow-up for 1 year. Patients (non-emergent) presenting for PCI will receive standard pre-procedural PCI care as outlined by the current ACC/AHA guidelines. Subjects will be consented peri- PCI (prior to or within 24 hours of PCI) and then randomized (1:1 ratio) to guide or standard non-guided (control) antiplatelet therapy. Physicians will be blinded to genotyping and platelet function results for subjects randomized to the standard therapy group for the duration of the study or if endpoint is met. Subjects on chronic clopidogrel or prasugrel therapy (≥ 2 weeks) will be guided by VerifyNow P2Y12 assay, whereas clopidogrel naïve subjects will be guided by Verigene CYP2C19 genotyping assay. Patients on clopidogrel maintenance and/or in the control group will also be genotyped; conversely, clopidogrel naïve subjects will have VerifyNow testing prior to discharge for additional study analysis. Patients in the guided therapy group that have a measurement of ≥ 230 PRU will be reloaded with 60mg prasugrel and receive standard maintenance dosing. Similarly, clopidogrel naïve subjects that are considered CYP2C19\*2 carriers will also be reloaded with 60mg prasugrel and receive standard maintenance dosing (see flow schematic). Patients randomized to the control arm will remain on 75mg clopidogrel arm throughout the study. All patients will remain on 325mg ASA for one month and 81-162 mg daily ASA thereafter. Clinical follow-up (office visit) and post-PCI VerifyNow maintenance testing will occur at 2 weeks, 3 months, and 6 months for patients in the guided therapy group. VerifyNow testing, adverse event occurrence and drug compliance will be performed as part of follow-up. Patients having a measurement of ≥ 230 PRU at 2 weeks or the 3 month visit will be reloaded with 60 mg prasugrel and receive standard maintenance dosing thereafter until the 6-month visit. Patients in guided and control study arms will return at 6 months for clinical follow-up and VerifyNow testing. After completing 6 months of the study treatment period, further antiplatelet therapy will be at the physician's discretion. At 1 year, study subjects will be contacted via phone for clinical assessment and antiplatelet compliance. Physicians adjudicating events will be blinded to the therapy assignment.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
7
Subjects on chronic clopidogrel will be guided by VerifyNow P2Y12 assay, whereas clopidogrel naïve subjects will be guided by Verigene CYP2C19 genotyping assay. Patients on clopidogrel maintenance and/or in the control group will also be genotyped; conversely, clopidogrel naïve subjects will have VerifyNow testing prior to discharge for additional study analysis. Patients in the guided therapy group that have a measurement of ≥ 230 PRU will be reloaded with 60mg prasugrel and receive standard maintenance dosing. Similarly, clopidogrel naïve subjects that are considered CYP2C19\*2 carriers will also be reloaded with 60mg prasugrel and receive standard maintenance dosing (see flow schematic).
Sinai Center for Thrombosis Research
Baltimore, Maryland, United States
MACE
To demonstrate a 30% relative risk reduction in post-PCI ischemic event occurrence (composite of cardiovascular death, ischemic stroke, non-fatal myocardial infarction, urgent target vessel revascularization) with personalized guided antiplatelet treatment as compared to standard post-intervention treatment
Time frame: 6 months
Major, Minor, and Nuisance Bleeding
To demonstrate no significant differences in major, minor, and nuisance bleeding with guided therapy as compared to conventional therapy.
Time frame: 6 months
MACE
To compare CYP2C19 guided therapy with VerifyNow P2Y12 guided approach in relation to MACE.
Time frame: 6 months
Predicting MACE
To determine if a combined (genetic and platelet) approach for guiding therapy is superior to a single approach (genetic or platelet) for predicting MACE.
Time frame: 6 months
Overcoming HPR
To demonstrate efficacy of prasugrel in overcoming high platelet reactivity as compared to clopidogrel maintenance therapy.
Time frame: 6 months
Platelet Reactivity, Verify Now
To determine the stability of platelet reactivity over time as measured by VerifyNow.
Time frame: 6 months
VerifyNow and Bleeding
To determine a relation between VerifyNow P2Y12 results and bleeding events (medically relevant major, minor, and nuisance).
Time frame: 6 months
Verify Now and Ischemic Event
To determine a relation between VerifyNow P2Y12 results and ischemic event occurrence.
Time frame: 6 months
CYP2C19, ischemia and bleeding
To determine the relation of CYP2C19 variants to ischemia and bleeding.
Time frame: 6 months
HPR in prasugrel treatment
To determine the incidence of HPR (as define by PRU ≥230) in prasugrel treated subjects.
Time frame: 6 months
Genotype guided therapy
To demonstrate feasibility of genotype guided therapy with the Verigene System by evaluation of test turnaround time, ease of use and reliability in a point of care setting.
Time frame: 6 months
Algorithm
To develop an optimal or "recommended" algorithm for guided antiplatelet therapy integrating genotyping and platelet function testing.
Time frame: 6 months
Utilizing Patient Questionnaire
To assess the utility of the personalized antiplatelet approach in clinical practice (utilizing a physician questionnaire)
Time frame: 6 months
Cutpoints for Plateletworks
To determine cutpoints for ischemic and bleeding risk using the Plateletworks Assay.
Time frame: 6 months
Platelet Mapping
To determine a relation between platelet mapping results and bleeding.
Time frame: 6 months
Platelet Mapping and Ischemic Event
To determine a relation between platelet mapping results and ischemic event occurrence.
Time frame: 6 months
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.