BMJ
Confidential: For Review Only Ticagrelor with Aspirin for Platelet Reactivity in Minor Stroke or Transient Ischemic Attack Patients: A Randomized, Open-label, Blinded-endpoint Trial
Journal: BMJ
Manuscript ID BMJ-2018-047607
Article Type: Research
BMJ Journal: BMJ
Date Submitted by the 22-Oct-2018 Author:
Complete List of Authors: WANG, YILONG; Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China, Chen, Weiqi; Beijing Tiantan Hospital, Capital Medical University Lin, Yi; Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University Meng, Xia; Beijing Tiantan Hospital Capital Medical University, Department of Neurology Chen, Guohua; Department of Neurology, Wuhan No.1 Hospital Wang, zhimin; Department of Neurology, Taizhou First People's Hospital, Huangyan Hospital of Wenzhou Medical University Wu, Jialing; Department of Neurology, Tianjin Huanhu Hospital Wang, Dali; Department of Neurology, North China University of Science and Technology Affiliated Hospital, Li, Jianhua; Department of Neurology, the First Hospital of Fangshan District Cao, Yibin; Department of Neurology, Tangshan Gongren Hospital Xu, Yu-ming ; The First Affiliated Hospital of Zhengzhou University, Department of Neurology Zhang, Guohua; Department of Neurology, the Second Hospital of Hebei Medical University, Li, Xiaobo; Department of Neurology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University PAN, YUESONG; Beijing Tiantan Hospital, Capital Medical University, Department of Neurology LI, HAO; Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China, Zhao, Xingquan; Beijing Tiantan Hospital Capital Medical University, Department of Neurology Liu, Liping; Beijing Tiantan Hospital Capital Medical University, Department of Neurology Lin, Jinxi; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Dong, Kehui; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Jing, Jing; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University,
https://mc.manuscriptcentral.com/bmj Page 1 of 32 BMJ
1 2 3 Johnston, S Claiborne; University of Texas, Austin, Neurology 4 Wang, David; INI Stroke Network, OSF Healthcare System, University of 5 Illinois College of Medicine, 6 Wang, Yongjun; Department of Neurology, Beijing Tiantan Hospital, 7 Capital Medical University, 8 9 Keywords: Platetlet Reactivity, Ticagrelor, Stroke, TIA, CYP2C19 10 11 Confidential: For Review Only 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 32
Wang Page 1 1 2 3 Ticagrelor with Aspirin for Platelet Reactivity in Minor Stroke or Transient 4 5 6 Ischemic Attack Patients: A Randomized, Open-label, Blinded-endpoint Trial 7 Yilong Wang, MD, PhD1,2,3,4*, Weiqi Chen, MD, PhD1,2,3,4*, Yi Lin, MD, PhD5, Xia Meng, MD, 8 PhD1,2,3,4, Guohua Chen, MD6, Zhimin Wang, MD7, Jialing Wu, MD8, Dali Wang, MD9, Jianhua 9 10 11 12 13 14 10 Li, MD , Yibin Cao , MD, Yuming Xu , MD, Guohua Zhang , MD, Xiaobo Li , MD, 1,2,3,4 1,2,3,4 1,2,3,4 11 YuesongConfidential: Pan, PhD , Hao Li, PhD ,For Xingquan Review Zhao, MD, PhD Only, Liping Liu, MD, 12 PhD1,2,3,4, Jinxi Lin, MD, PhD1,2,3,4, Kehui Dong, MD1,2,3,4, Jing Jing, MD, PhD1,2,3,4, S. 13 Claiborne Johnston, MD, PhD15, David Wang, DO, FAHA, FAAN16, Yongjun Wang, MD1,2,3,4; 14 On Behalf of the PRINCE Protocol Steering Group 15 16 17 Yilong Wang and Weiqi Chen contributed equally to the manuscript. 18 19 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China 20 2 China National Clinical Research Center for Neurological Diseases, Beijing, China 21 3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China 22 4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China 23 5 Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical 24 25 University, Fuzhou, China 6 26 Department of Neurology, Wuhan No.1 Hospital, Wuhan, China 27 7 Department of Neurology, Taizhou First People's Hospital, Huangyan Hospital of Wenzhou 28 Medical University, Taizhou, China 29 8 Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China 30 9 Department of Neurology, North China University of Science and Technology Affiliated 31 Hospital, Tangshan, China 32 10 33 Department of Neurology, the First Hospital of Fangshan District, Beijing, China 11 34 Department of Neurology, Tangshan Gongren Hospital, Tangshan, China 35 12 Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 36 China 37 13 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang, 38 China 39 14 40 Department of Neurology, Northern Jiangsu People's Hospital, Clinical Medical School, 41 Yangzhou University, Yangzhou, China 42 15 Dell Medical School, University of Texas at Austin, USA 43 16 INI Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, 44 Peoria, USA 45 46 Corresponding author: Yongjun Wang and Yilong Wang 47 48 E-mail address: [email protected] and [email protected] 49 Address: No.6 Tiantanxili, Dongcheng District, Beijing, China, 100050 50 Business telephone: 0086-010-67098350 51 Fax numbers: 0086-010-67013383 52 Tables: 3; Figures: 4; Word count: 3846 (not including title page, figure legends, references, 53 tables and figures) 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 3 of 32 BMJ
Wang Page 2 1 2 3 ABSTRACT 4 5 6 OBJECTIVE 7 8 To test the hypothesis that ticagrelor plus aspirin is safe and superior to clopidogrel plus aspirin 9 10 for reducing the 90-day high platelet reactivity and stroke recurrence in patients with minor 11 Confidential: For Review Only 12 stroke or transient ischemic attack (TIA), particularly in carriers of the CYP2C19 loss-of- 13 14 15 function allele and patients with large-artery atherosclerosis. 16 17 DESIGN 18 19 Randomized, open-label, controlled, blinded-endpoint trial. 20 21 22 SETTING 23 24 Prospective studies conducted at 26 centres in China. 25 26 PARTICIPANTS 27 28 29 A total of 675 acute minor stroke or TIA patients. 30 31 INTERVENTION 32 33 Ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300 mg loading 34 35 dose, 75 mg daily thereafter) on a background of aspirin (100 mg daily for the first 21 days) 36 37 38 within 24 h of symptom onset. 39 40 MAIN OUTCOME MEASURES 41 42 The primary outcome of the trial was the proportion of patients with high platelet reactivity at 90 43 44 45 days. High platelet reactivity was defined as a P2Y12 reaction unit of >208 measured using the 46 47 VerifyNow P2Y12 assay. The secondary outcomes included high platelet reactivity at 90±7 days 48 49 in patients carrying genetic variants that would affect clopidogrel metabolism and any stroke 50 51 52 (ischemic or haemorrhagic) recurrence at 90±7 days, 6 months, and 1 year. 53 54 RESULTS 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 32
Wang Page 3 1 2 3 At 90 days, high platelet reactivity occurred in 35 of 280 patients (12.5%) in the 4 5 6 ticagrelor/aspirin group and 86 of 290 patients (29.7%) in the clopidogrel/aspirin group (odds 7 8 ratio [OR], 0.34; 95% confidence interval [CI], 0.22-0.52; P<0.001), and 10.8% versus 35.4% 9 10 (OR, 0.22, 95% CI, 0.12-0.40; P<0.001) of patients carrying CYP2C19 loss-of-function alleles 11 Confidential: For Review Only 12 (P=0.04 for interaction). Stroke occurred in 21 of 336 patients (6.3%) in the ticagrelor/aspirin 13 14 15 group and 30 of 339 patients (8.8%) in the clopidogrel/aspirin group (hazard ratio, 0.70; 95% CI, 16 17 0.40-1.22; P=0.20). Patients with large-artery atherosclerosis in the ticagrelor/aspirin group had 18 19 lower stroke recurrence at 90 days (6.0%) than did those in the clopidogrel/aspirin group (13.1%, 20 21 22 hazard ratio, 0.45; 95% CI, 0.20-0.98; P=0.04). No difference was observed in the rates of major 23 24 or minor haemorrhagic events between the ticagrelor and clopidogrel groups (4.8% and 3.5%, 25 26 respectively; P=0.42). 27 28 29 CONCLUSION 30 31 Minor stroke or TIA patients who were treated with ticagrelor had a lower rate of high platelet 32 33 reactivity than did those who were treated with clopidogrel, particularly those who were carriers 34 35 of the CYP2C19 loss-of-function allele and lower recurrent stroke in patients with large-artery 36 37 38 atherosclerosis. 39 40 TRIAL REGISTRATION 41 42 Clinicaltrials.gov NCT02506140 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 5 of 32 BMJ
Wang Page 4 1 2 3 Introduction 4 5 6 Acute minor ischemic stroke and transient ischemic attack (TIA) patients are at high risk of 7 8 recurrent stroke and cardiovascular events.1 The Clopidogrel in High-risk patients with Acute 9 10 Non-disabling Cerebrovascular Events (CHANCE) trial indicated that combined clopidogrel and 11 Confidential: For Review Only 12 aspirin treatment is superior to aspirin alone in reducing the risk of stroke,2 but may increase the 13 14 15 risk of non-intracranial haemorrhage.1, 3 The CHANCE genetic sub-study demonstrated that 16 17 patients who were carriers of the cytochrome P450 (CYP) 2C19*2 and *3 loss-of-function 18 19 alleles benefitted more from using aspirin alone than from using dual antiplatelet therapy.4 20 21 22 Additionally, a previous study found that Asian stroke patients had a higher risk of intracranial 23 24 large-artery atherosclerosis (LAA), and there was a higher rate of recurrent stroke in patients 25 26 with intracranial arterial stenosis with minor stroke or a high risk of TIA than in those without.5 27 28 6 29 Ticagrelor is primarily metabolized via the CYP3A4 enzyme. A genetic sub-study of the 30 31 Platelet Inhibition and Patient Outcomes (PLATO) trial indicated that ticagrelor is more 32 33 efficacious for acute coronary syndromes than clopidogrel regardless of CYP2C19 genotype, but 34 35 was associated with an increased risk of haemorrhage in patients with a history of stroke.7 The 36 37 38 Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient 39 40 Outcomes (SOCRATES) Trial revealed a trend towards better efficacy in reducing the risk of 41 42 vascular events in the ticagrelor treated group than in the aspirin group in an Asian 43 44 45 subpopulation. However, limited data are available on the safety and efficacy of ticagrelor for the 46 47 treatment of stroke as compared to those for clopidogrel on a background of aspirin in acute 48 49 stroke patients.4, 8, 9 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 6 of 32
Wang Page 5 1 2 3 High platelet reactivity is defined as resistance or non-responsiveness to antiplatelet agents.10, 4 5 11 6 High platelet reactivity is associated with poor cerebrovascular outcomes, and might be of 7 8 clinical value as a surrogate marker in the evaluation of the effects of antiplatelet agents.12, 13 9 10 We conducted this Platelet Reactivity in Acute Stroke or Transient Ischemic Attack (PRINCE) 11 Confidential: For Review Only 12 trial to test the hypothesis that ticagrelor plus aspirin is safe and superior to clopidogrel plus 13 14 15 aspirin in reducing the 90 day high platelet reactivity and stroke recurrence in minor stroke or 16 17 TIA patients, particularly in carriers of the CYP2C19 loss-of-function allele and patients with 18 19 LAA.14 20 21 22 Methods 23 24 The PRINCE study protocol and data collection were approved by the ethics committee of 25 26 Beijing Tiantan Hospital and all of the study centres. An interim analysis was pre-planned in the 27 28 14 29 published protocol. All participants or their representatives provided written consent before 30 31 being enrolled in the study. The design of the trial was published previously.14 The trial was 32 33 conducted in accordance with the Declaration of Helsinki. 34 35 Study design and participants 36 37 38 The trial was a prospective, multicentre, randomized, open-label, active-controlled, blinded- 39 40 endpoint trial. Patients were recruited at 26 study centres from August 2015 to March 2017. The 41 42 trial included six visits: randomization (baseline), 7+2 days, 21±2 days, 90±7 days, 6 months±14 43 44 45 days, and 1 year±14 days. Additional visits at 2 and 24 h after the first dose was administered 46 47 were optional. All visits involved face-to-face interviews, with the exception of the 6-month 48 49 follow-up, which was conducted by telephone, with data collected on electronic case report 50 51 52 forms. The general schedule of the trial and the collection times for blood and urine samples are 53 54 listed in the appendix. 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 7 of 32 BMJ
Wang Page 6 1 2 3 The PRINCE trial enrolled patients aged 40-80 years who had experienced an acute minor 4 5 6 ischemic stroke (National Institutes of Health Stroke Scale score of ≤3 at the time of 7 8 randomization) or those with a moderate to high risk of TIA (ABCD2 stroke risk score of >4 at 9 10 the time of randomization or >50% stenosis of cervical or intracranial vessels that could account 11 Confidential: For Review Only 12 13 for the presentation) who could be treated with the study drug within 24 h of symptom onset. 14 15 Patients were excluded from the trial if they were diagnosed with intracranial haemorrhage, 16 17 acute coronary syndrome, or other pathology that could account for the neurological symptoms; 18 19 20 had a modified Rankin scale score of >2 at randomization; or had a contraindication to ticagrelor, 21 22 clopidogrel, or aspirin. Details of the full inclusion and exclusion criteria are provided in the 23 24 appendix. 25 26 Randomization and masking 27 28 29 Immediately after signing the written informed consent form, eligible patients were randomized 30 31 in a 1:1 ratio to the ticagrelor and aspirin (intervention) or clopidogrel and aspirin (control) group 32 33 via a block randomization process by investigators at the clinical centres. The block 34 35 36 randomization sequence was provided by an independent statistician using computer-generated 37 38 random numbers with a block size of four. The block size was not listed in the Chinese version 39 40 of the protocol (which was provided to the investigators) in order to prevent the investigators 41 42 43 from speculating about the group assignment. 44 45 VerifyNow testing was conducted in each study centre by qualified personnel who were 46 47 blinded to the treatment allocation. Each reported composite clinical vascular event and safety 48 49 outcome was independently adjudicated by two members (Drs Kehui Dong and Jimei Li) of the 50 51 52 data and safety monitoring board (DSMB) who were blinded to the treatment group assignments. 53 54 All discrepancies were reviewed by all five members of the DSMB and resolved by consensus. 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 8 of 32
Wang Page 7 1 2 3 Procedures 4 5 6 The enrolled patients were randomly assigned to receive either ticagrelor (a loading dose of 180 7 8 mg administered as two 90 mg tablets on day 1, followed by 90 mg twice daily until day 90) 9 10 combined with aspirin (a loading dose of 100-300 mg administered as 1-3 100 mg tablets on day 11 Confidential: For Review Only 12 13 1, followed by 100 mg once daily until day 21) or clopidogrel (a loading dose of 300 mg 14 15 administered as four 75 mg tablets on day 1, followed by 75 mg once daily until day 90) 16 17 combined with aspirin (a loading dose of 100-300 mg administered as 1-3 100 mg tablets on day 18 19 20 1, followed by 100 mg once daily until day 21). Both the investigators and the patients were 21 22 aware of the study drug assignment, but were blinded to the platelet reactivity data until the end 23 24 of the trial. The study drugs were required to be administered within 1 h of randomization. The 25 26 27 loading dose and maintenance doses of ticagrelor were administered as in the SOCRATES and 28 29 PLATO studies.9, 15 30 31 Outcomes 32 33 The primary outcome of the PRINCE trial was the proportion of patients with high platelet 34 35 36 reactivity at 90 days. High platelet reactivity was defined as a P2Y12 reaction unit (PRU) 37 38 of >208 measured using the VerifyNow P2Y12 assay. The PRUs were measured in each study 39 40 centre by specially trained and qualified personnel according to a standardized procedure 41 42 43 manual. Pre-specified secondary outcomes included high platelet reactivity at 90±7 days in 44 45 patients carrying genetic variants that would affect clopidogrel metabolism; any stroke (ischemic 46 47 or haemorrhagic); and composite clinical vascular events (ischemic/haemorrhagic stroke, TIA, 48 49 50 myocardial infarction, or vascular death) at 90±7 days, 6 months, and 1 year. 51 52 The primary safety outcome was major bleeding, which was defined as that in the PLATO 53 54 study classification of haemorrhagic events; fatal/life-threatening bleed, major bleed, and other 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 9 of 32 BMJ
Wang Page 8 1 2 3 (appendix). Secondary safety outcomes included the incidence of intracranial bleeding; dyspnoea 4 5 6 events; and mortality at 90±7 days, 6 months, and 1 year. Complete information on pre-specified 7 8 outcomes is available in the study protocol.14 9 10 Genotyping 11 Confidential: For Review Only 12 While several genetic variants affect clopidogrel metabolism, we designed the present study to 13 14 15 focus on the CYP2C19 (National Center for Biotechnology Information (NCBI) Genome build 16 17 37.1, NG_008384). The pre-specified analysis included the single-nucleotide polymorphisms 18 19 (SNPs) CYP2C19*2 (681G>A, rs4244285), CYP2C19*3 (636G>A, rs4986893), and 20 21 22 CYP2C19*17 (-806C>T, rs12248560), which were genotyped in all participants with adequate 23 24 blood samples. Most genotyping of the three SNPs was performed using the Sequenom 25 26 MassARRAY iPLEX platform (Sequenom, San Diego, CA). Sanger sequencing (ABI 3500 27 28 29 Genetic Analyzer [Applied Biosystems]) was used when the results were otherwise inconclusive. 30 31 We used star allele nomenclature to categorize patients by the CYP2C19 metabolizer status 32 33 based on *2, *3, and *17 genotypes.16 Patients with at least one gain-of-function allele (*17) 34 35 were classified as "gain-of-function allele carriers", and those with at least one loss-of-function 36 37 38 allele (*2 or *3) were classified as "loss-of-function allele carriers".17 Patients who carried at 39 40 least one *17 allele (*1/*17 or *17/*17) were classified as "ultra-metabolizers", those without 41 42 any *2, *3, or *17 allele (*1/*1) were classified as "extensive metabolizers", those with one *2 43 44 45 or *3 allele (*1/*2 or *1/*3) were classified as "intermediate metabolizers", and those with at 46 47 least two *2 or *3 alleles (*2/*2, *2/*3, or *3/*3) were classified as "poor metabolizers".17 48 49 Patients with one *17 and a loss-of-function allele (*2/*17 or *3/*17) were classified as 50 51 18, 19 52 "unknown metabolizers”, since the clinical effect of these alleles is uncertain. 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 10 of 32
Wang Page 9 1 2 3 Based on our pre-planned aims, we compared the recurrence of stroke in patients whose stroke 4 5 6 subtype was LAA with those whose stroke subtype was non-LAA based on the SSS-TOAST 7 8 stroke subtype. Non-LAA included cardioaortic embolism, small-artery occlusion, other causes, 9 10 and undetermined causes. 11 Confidential: For Review Only 12 Statistical analysis 13 14 15 We calculated that a total of 952 patients (estimated 10% dropout rate) would be required to 16 17 achieve 90% power with a two-sided α=0.05 to detect a relative reduction of 24% in the rate of 18 19 the primary outcome in the ticagrelor/aspirin group compared to that in the clopidogrel/aspirin 20 21 22 group. The DSMB opted to terminate the study after the interim analysis based on 476 patients 23 24 (50% of the projected necessary sample size) who completed 90 days of follow-up based on 25 26 achieving a pre-specified threshold for efficacy (P<0.005). At the time of this decision, an 27 28 29 additional 199 patients had already been recruited and randomized into the trial, and these 30 31 patients were also followed-up to study completion. Therefore, a total of 675 patients were 32 33 included in the intention-to-treat analyses. 34 35 We compared the baseline characteristics of patients between the two treatment groups. 36 37 38 Proportions were used for categorical variables and medians with interquartile ranges were used 39 40 for continuous variables. The non-parametric Kruskal-Wallis test was used to compare group 41 42 differences for nominal variables, and the χ2 test or Fisher’s exact test was used for dichotomous 43 44 45 variables. The rates of high platelet reactivity at the 90-day follow-up (the primary outcome) 46 47 were compared between the two groups using logistic regression analysis adjusted by the 48 49 baseline high platelet reactivity status, reported as an odds ratio (OR) with 95% confidence 50 51 52 intervals (CIs). The differences in the rates of stroke, composite outcome, death, and bleeding 53 54 events during the 90-day follow-up period were assessed using Cox proportional-hazards 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 11 of 32 BMJ
Wang Page 10 1 2 3 regression and hazard ratios (HRs) with 95% CIs. Whether the treatment effect differed in 4 5 6 certain genotype categories was assessed by testing the treatment-by-genotype interaction effect 7 8 using a logistic model for the primary outcome and Cox models for other outcomes, as described 9 10 earlier. 11 Confidential: For Review Only 12 All statistical analyses were two-sided, and differences with a P-value of <0.05 were 13 14 15 considered to be statistically significant. Analyses were performed using SAS software, version 16 17 9.4 (SAS Institute, Cary, NC). Data are presented as means ± standard deviation. This study is 18 19 registered with ClinicalTrials.gov, number NCT02506140. 20 21 22 Results 23 24 Between August 2015 and March 2017, a total of 5,644 stroke or TIA patients were screened at 25 26 26 hospitals, and 675 patients (mean age, 61.1±8.5 years) were enrolled before the DSMB opted 27 28 29 to terminate the trial after reviewing the results of the interim analysis. Thus, 336 patients were 30 31 randomly assigned to the ticagrelor/aspirin group and 339 patients were assigned to the 32 33 clopidogrel/aspirin group (figure 1 and table 1). The average age was 60.8±8.7 years, and 26.8% 34 35 of the patients were women. At 90 days, 12 patients were lost to follow-up owing to clinical 36 37 38 events, and the VerifyNow P2Y12 assay data were not obtained from 105 patients. 39 40 Among the 675 patients enrolled, 650 (mean age, 60.8±8.7 years) had complete genotype data 41 42 for all three SNPs, of whom 321 were randomly assigned to the ticagrelor/aspirin group and 329 43 44 45 were assigned to the clopidogrel/aspirin group (see the appendix for details of the baseline 46 47 characteristics of patients enrolled in the genetic sub-study). Of the 650 participants, 374 (57.5%) 48 49 were classified as CYP2C19 loss-of-function carriers. 50 51 52 We obtained valid measurements in 627 (92.9%) and 570 (84.4%) patients for the VerifyNow 53 54 P2Y12 assay at the 7-day and 90-day follow-up periods, respectively. The PRUs before 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 12 of 32
Wang Page 11 1 2 3 receiving the study drugs were similar in the ticagrelor/aspirin group (256.4±61.3) and the 4 5 6 clopidogrel/aspirin group (246.9±53·7, P=0.13). The PRU in the ticagrelor/aspirin group 7 8 (69.3±87.0) was significantly lower than that in the clopidogrel/aspirin group (173.5±67.6; 9 10 P<0.001) at the 90-day follow-up (figure 2A). The primary outcome (high platelet reactivity) 11 Confidential: For Review Only 12 was observed in 35 of the 280 patients (12.5%) in the ticagrelor/aspirin group, and in 86 of the 13 14 15 290 patients (29.7%) in the clopidogrel/aspirin group at 90 days (OR, 0.34; 95% CI, 0.22-0.52; 16 17 P<0.001) (figure 2B and table 2). 18 19 Stroke, the main secondary outcome, occurred in 21 (6.3%) of the 336 patients in the 20 21 22 ticagrelor/aspirin group and 30 (8.8%) of the 339 patients in the clopidogrel/aspirin group (HR, 23 24 0.70; 95% CI, 0.40-1.22; P=0.20). Composite clinical vascular events occurred in 22 patients 25 26 (6.5%) in the ticagrelor/aspirin group and 32 patients (9.4%) in the clopidogrel/aspirin group 27 28 29 (HR, 0.68; 95% CI, 0.40-1.18; P=0.17) (table 2). 30 31 Among the CYP2C19 loss-of-function carriers, high platelet reactivity at 90 days was 32 33 markedly less frequent in the ticagrelor/aspirin group than in the clopidogrel/aspirin group 34 35 (10.8% in ticagrelor/aspirin group versus 35.4% in the clopidogrel/aspirin group; OR, 0.22; 95% 36 37 38 CI, 0.12-0.40; P<0.001) (appendix). The event rates of stroke, composite events, and 39 40 haemorrhagic events varied by treatment assignment and phenotype (figure 3). Other primary 41 42 and secondary outcomes in patients with available genotype data are listed in the appendix. 43 44 45 Among the patients with LAA, stroke recurrence at 90 days was markedly lower in the 46 47 ticagrelor/aspirin group than in the clopidogrel/aspirin group (6.0% in ticagrelor/aspirin group 48 49 versus 13.1% in clopidogrel/aspirin group; HR, 0.45; 95% CI, 0.20-0.98; P=0.04) (table 3 and 50 51 52 figure 4). However, among the patients with non-LAA, the risk of stroke recurrence was similar 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 13 of 32 BMJ
Wang Page 12 1 2 3 in the two groups (8.1% in ticagrelor/aspirin group versus 7.4% in the clopidogrel/aspirin group; 4 5 6 HR, 1.1; 95% CI, 0.46-2.63; P=0.84) (table 3 and figure 4). 7 8 The primary safety outcome (PLATO major haemorrhagic event) occurred in five patients 9 10 (1.5%) in the ticagrelor/aspirin group and four patients (1.2%) in the clopidogrel/aspirin group 11 Confidential: For Review Only 12 (HR, 1.27; 95% CI, 0.34-4.72) (table 2). Three patients (0.9%) in the ticagrelor/aspirin group and 13 14 15 two patients (0.6%) in the clopidogrel/aspirin group experienced intracranial haemorrhage. 16 17 However, the rate of any haemorrhagic events occurring was higher in the ticagrelor/aspirin 18 19 group (22.3%) than in the clopidogrel/aspirin group (14.2%; HR, 1.65; 95% CI, 1.15-2.37) (table 20 21 22 2). 23 24 The rate of major bleeding did not significantly vary in the ticagrelor/aspirin and 25 26 clopidogrel/aspirin groups between the carriers (rate of 0.0% in the ticagrelor/aspirin group 27 28 29 versus 1.6% in the clopidogrel/aspirin group; HR, 0.40; 95% CI, 0.04-3.85; P=0.43) and non- 30 31 carriers (rate of 0.0% in the ticagrelor/aspirin group versus 0.7% in the clopidogrel/aspirin 32 33 group) (appendix). 34 35 Dyspnoea was more common in the ticagrelor/aspirin group (16.1%) than in the 36 37 38 clopidogrel/aspirin group (3.2%) (appendix). A total of 69 (20.5%) patients in the 39 40 ticagrelor/aspirin group and 47 (13.9%) patients in the clopidogrel/aspirin group stopped 41 42 receiving the study drug before 90 days (figure 1). Two of the most common reasons were 43 44 45 dyspnoea and epistaxis. The rate of permanent discontinuation caused by dyspnoea was 4.2% in 46 47 the ticagrelor/aspirin group and 0.0% in the clopidogrel/aspirin group, and the rate of permanent 48 49 discontinuation caused by epistaxis was 1.8% in the ticagrelor/aspirin group and 0.0% in the 50 51 52 clopidogrel/aspirin group. Serious adverse events and adverse events leading to permanent drug 53 54 discontinuation within 90 days are listed in the appendix. 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 14 of 32
Wang Page 13 1 2 3 Discussion 4 5 6 This PRINCE trial indicated that the rate of high platelet reactivity at 90 days was significantly 7 8 reduced with ticagrelor plus aspirin treatment compared to that with clopidogrel plus aspirin 9 10 treatment in acute minor stroke patients and those at moderate to high risk of TIA, while it was 11 Confidential: For Review Only 12 not powered to study clinical events. There were numerically fewer strokes and composite 13 14 15 outcomes at 90 days in patients treated with ticagrelor plus aspirin than in those treated with 16 17 clopidogrel plus aspirin. 18 19 There are limited data addressing the safety of dual anti-platelet therapy with ticagrelor and 20 21 22 aspirin in stroke patients. In this study, we found that the risk of major, minor, or intracranial 23 24 haemorrhage in patients who were treated within 24 h of the onset of minor stroke or TIA did not 25 26 increase with treatment with a combination of ticagrelor compared to the risk in those who were 27 28 29 treated with clopidogrel plus aspirin, but a higher rate of dyspnoea and minimal haemorrhagic 30 31 events was observed in the ticagrelor/aspirin group than in the clopidogrel/aspirin group. 32 33 Compared to that in the PLATO study, the major haemorrhage rate in our study was markedly 34 35 lower (ticagrelor/aspirin group, 11.6% in PLATO versus 1.5% in PRINCE; clopidogrel/aspirin 36 37 38 group, 11.2% in PLATO versus 1.2% in PRINCE).15 This could be partially due to the short- 39 40 term use of dual anti-platelet therapy in our study (277 days in PLATO versus 21 days in 41 42 PRINCE). Compared to that in the Asian subgroup in the SOCRATES trial, which used 43 44 45 monotherapy, our study found a slightly higher major haemorrhagic rate (0.6% in the ticagrelor 46 47 group in SOCRATES versus 1.5% in the ticagrelor/aspirin group in PRINCE).4 This may be 48 49 related to the combined use of two drugs in our study. Similar to that reported in the PLATO and 50 51 52 SOCRATES trials, dyspnoea occurred more commonly with ticagrelor than with clopidogrel 53 54 treatment.9, 15 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 15 of 32 BMJ
Wang Page 14 1 2 3 The premature discontinuation of the study drug was more frequent in the ticagrelor/aspirin 4 5 6 group than in the clopidogrel/aspirin group, although the rate of serious adverse events did not 7 8 differ between the two groups. One potential explanation is that our study was of an open-label 9 10 design, considering that ticagrelor had not yet been approved for treatment of acute stroke 11 Confidential: For Review Only 12 patients at the time of the study. Once an adverse event occurred in a patient receiving ticagrelor, 13 14 15 the treating physician or patient had the option of temporarily or permanently discontinuing the 16 17 drug and may have taken this opportunity more frequently when using an unapproved drug. 18 19 Furthermore, early discontinuation and non-adherence likely contributed to the increase in 20 21 22 platelet reactivity observed at 90 days compared to that observed at 7 days in patients 23 24 randomized to the ticagrelor/aspirin treatment groups. 25 26 In this trial, we tested the clinical efficacy of ticagrelor plus aspirin compared to that of 27 28 29 clopidogrel plus aspirin, but the trial was not powered to find an association. There were 30 31 numerically fewer recurrent stroke and composite events in patients treated with ticagrelor plus 32 33 aspirin than in those treated with clopidogrel plus aspirin, but the difference was not statistically 34 35 significant. Given the testing power of 90% and the significance level of 5% (two-sided), a total 36 37 38 of 4,690 patients would be required to detect the relative risk difference between the 39 40 ticagrelor/aspirin and clopidogrel/aspirin groups based on the event rates in our study. The 41 42 current study provided 25.5% power to detect a 30% relative risk difference with a two-sided test 43 44 45 at a 5% significance level. A previous study demonstrated that patients with LAA had a higher 46 47 risk of stroke recurrence even after using clopidogrel and aspirin.5 In our study, we found that 48 49 minor stroke or TIA with LAA patients might benefit more from ticagrelor plus aspirin than 50 51 52 from clopidogrel and aspirin therapy. 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 16 of 32
Wang Page 15 1 2 3 Understanding the relationship between CYP2C19 variants and the impact of clopidogrel on 4 5 6 platelet function is critically important, and prompted the genetic analysis in the present study. 7 8 Among patients randomized to clopidogrel, there was a dose-response relationship between the 9 10 number of CYP2C19 loss-of-function alleles and the proportion of high platelet reactivity, with 11 Confidential: For Review Only 12 patients carrying more loss-of-function alleles having higher rates of platelet aggregation. The 13 14 15 relationship between CYP2C19 and the response to ticagrelor was less clear, and a larger relative 16 17 benefit of ticagrelor was observed in those carrying more loss-of-function alleles. While a similar 18 19 trend was observed in clinical outcomes among those randomized to clopidogrel, the numbers 20 21 22 were small, and the patients randomized to ticagrelor also had numerically higher rates of 23 24 clinical events among those carrying a greater number of loss-of-function alleles. Thus, the 25 26 relative clinical benefit of ticagrelor on platelet inhibition among those with a greater number of 27 28 29 CYP2C19 loss-of-function alleles was not confirmed in this trial. 30 31 This study had several limitations. First, the primary outcome was a surrogate endpoint, which 32 33 was not completely consistent with the clinical outcome of a 90 day stroke recurrence. Further 34 35 study is needed to evaluate the clinical efficacy as the primary endpoint. Second, the surrogate 36 37 38 endpoint (high platelet reactivity) was susceptible to missing data, which could have introduced 39 40 bias. Third, the open-label design could have led to a placebo effect,20 which could have caused 41 42 potential bias in adverse events assessment, drug continuation, and even the physicians’ or 43 44 45 patients’ decisions. 46 47 Conclusion 48 49 In minor ischemic stroke or TIA patients, combined treatment with ticagrelor and aspirin, as 50 51 52 compared to clopidogrel and aspirin, significantly reduced the rate of high platelet reactivity, 53 54 particularly carriers of CYP2C19 loss-of-function alleles. With regard to the stroke recurrence 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 17 of 32 BMJ
Wang Page 16 1 2 3 risk at 90 days, patients with LAA might benefit more from ticagrelor and aspirin than from 4 5 6 clopidogrel and aspirin. Larger clinical trials are required to evaluate the clinical efficacy of 7 8 ticagrelor with aspirin in this setting. 9 10 11 Confidential: For Review Only 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 18 of 32
Wang Page 17 1 2 3 We thank all patients and their families for providing blood, and the participating researchers at 4 5 6 all study centres. 7 8 Contributors: YW, WC, XM, and YL contributed to the study design, drafting, and revision of 9 10 the manuscript. YP and HL contributed to study design, implementation of the statistical 11 Confidential: For Review Only 12 analysis, and revision of manuscript. KD contributed to study design and the review of the 13 14 15 clinical events that occurred in all patients. YW, YL, XZ, LL, SJ, and DW were members of the 16 17 PRINCE Trial Steering Committee. JJ coordinated the central MRI analyses. JL coordinated the 18 19 central blood sample and genetic sequencing. GC, ZW, JW, DW, JL, YC, YX, GZ, and XL 20 21 22 contributed to the study design, revision of the manuscript, and approval of the report. 23 24 Funding: The study was supported by grants from National Key Technology Research and 25 26 Development Program of the Ministry of Science and Technology of The People’s Republic of 27 28 29 China (2013BAI09B14, 2015BAI12B04, and 2015BAI12B02), the Advanced Innovation Centre 30 31 for Human Brain Protection (117212), Beijing Municipal Science and Technology Commission 32 33 (D15110700200000/D151100002015001/D151100002015002/D151100002015003), Beijing 34 35 Municipal Commission of Health and Family Planning, and AstraZeneca provided the study 36 37 38 drugs and with no role in design and analysis of this trial. 39 40 Competing interests: Yilong Wang reports grants from the Beijing Municipal Science and 41 42 Technology Commission and the Beijing Municipal Commission of Health and Family Planning. 43 44 45 Yongjun Wang reports grants from the National Key Technology Research and Development 46 47 Program of the Ministry of Science and Technology of The People’s Republic of China. 48 49 Ethical approval: The trial was conducted in accordance with the guiding principles of the 50 51 52 Declaration of Helsinki and was approved by the local ethics committees. 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 19 of 32 BMJ
Wang Page 18 1 2 3 Data sharing: The technical appendix and dataset are available from the corresponding author 4 5 6 ([email protected]). 7 8 Transparency statement: The lead author (the manuscript’s guarantor) affirms that this 9 10 manuscript is an honest, accurate, and transparent account of the study being reported; that no 11 Confidential: For Review Only 12 important aspects of the study have been omitted; and that any discrepancies from the study as 13 14 15 planned (and, if relevant, registered) have been explained. 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 20 of 32
Wang Page 19 1 2 3 References 4 5 6 1 Amarenco P, Lavallee PC, Labreuche J, et al. One-year risk of stroke after transient 7 8 ischemic attack or minor stroke. N Engl J Med 2016; 374: 1533-42. doi: 9 10 10.1056/NEJMoa1412981 11 Confidential: For Review Only 12 2 Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or 13 14 15 transient ischemic attack. N Engl J Med 2013; 369: 11-9. doi: 10.1056/NEJMoa1215340 16 17 3 Wang D, Gui L, Dong Y, et al. Dual antiplatelet therapy may increase the risk of non- 18 19 intracranial haemorrhage in patients with minor strokes: a subgroup analysis of the 20 21 22 CHANCE trial. Stroke Vasc Neurol 2016; 1: 29-36. doi: 10.1136/svn-2016-000008. 23 24 4 Wang Y, Minematsu K, Wong KS, et al. Ticagrelor in acute stroke or transient ischemic 25 26 attack in Asian patients: from the SOCRATES Trial (acute stroke or transient ischemic 27 28 29 attack treated with aspirin or ticagrelor and patient outcomes). Stroke 2017; 48: 167-73. 30 31 doi: 10.1161/STROKEAHA.116.014891 32 33 5 Liu L, Wong KS, Leng X, et al. Dual antiplatelet therapy in stroke and ICAS: Subgroup 34 35 analysis of CHANCE. Neurology 2015; 85: 1154–1162. doi: 36 37 38 10.1212/WNL.0000000000001972 39 40 6 Brilakis ES, Patel VG, Banerjee S. Medical management after coronary stent 41 42 implantation: a review. JAMA 2013; 310: 189-98. doi: 10.1001/jama.2013.7086 43 44 45 7 Wallentin L, James S, Storey RF, et al. Effect of cyp2c19 and abcb1 single nucleotide 46 47 polymorphisms on outcomes of treatment with ticagrelor versus clopidogrel for acute 48 49 coronary syndromes: a genetic substudy of the PLATO trial. Lancet 2010; 376: 1320-8. 50 51 52 doi: 10.1016/S0140-6736(10)61274-3 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 21 of 32 BMJ
Wang Page 20 1 2 3 8 Amarenco P, Albers GW, Denison H, et al. Efficacy and safety of ticagrelor versus 4 5 6 aspirin in acute stroke or transient ischaemic attack of atherosclerotic origin: a subgroup 7 8 analysis of SOCRATES, a randomised, double-blind, controlled trial. Lancet Neurol 9 10 2017; 16: 301-10. doi: 10.1016/s1474-4422(17)30038-8 11 Confidential: For Review Only 12 9 Johnston SC, Amarenco P, Albers GW, et al. Ticagrelor versus aspirin in acute stroke or 13 14 15 transient ischemic attack. N Engl J Med 2016; 375: 35-43. doi: 10.1056/NEJMoa1603060 16 17 10 Ait-Mokhtar O, Bonello L, Benamara S, Paganelli F. High on treatment platelet 18 19 reactivity. Heart Lung Circ 2012; 21: 12-21. doi: 10.1016/j.hlc.2011.08.069 20 21 22 11 Aradi D, Komocsi A, Vorobcsuk A, et al. Prognostic significance of high on-clopidogrel 23 24 platelet reactivity after percutaneous coronary intervention: systematic review and meta- 25 26 analysis. Am Heart J 2010; 160: 543-51. doi: 10.1016/j.ahj.2010.06.004 27 28 29 12 Stone GW, Witzenbichler B, Weisz G, et al. Platelet reactivity and clinical outcomes after 30 31 coronary artery implantation of drug-eluting stents (ADAPT-DES): a prospective 32 33 multicentre registry study. Lancet 2013; 382: 614-23. doi: 10.1016/S0140- 34 35 6736(13)61170-8 36 37 38 13 Braunwald E, Angiolillo D, Bates E, et al. Assessing the current role of platelet function 39 40 testing. Clin Cardiol 2008; 31: I10-6. doi: 10.1002/clc.20361 41 42 14 Wang Y, Lin Y, Meng X, et al. Effect of ticagrelor with clopidogrel on high on-treatment 43 44 45 platelet reactivity in acute stroke or transient ischemic attack (PRINCE) trial: rationale 46 47 and design. Int J Stroke 2017; 12: 321-5. doi: 10.1177/1747493017694390 48 49 15 Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with 50 51 52 acute coronary syndromes. N Engl J Med 2009; 361: 1045-57. doi: 53 54 10.1056/NEJMoa0904327 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 22 of 32
Wang Page 21 1 2 3 16 Scott SA, Sangkuhl K, Stein CM, et al. Clinical pharmacogenetics implementation 4 5 6 consortium guidelines for CYP2C19 genotype and clopidogrel therapy: 2013 update. Clin 7 8 Pharmacol Ther 2013; 94: 317-23. doi: 10.1038/clpt.2013.105 9 10 17 Wang Y, Zhao X, Lin J, et al. Association between CYP2C19 loss-of-function allele 11 Confidential: For Review Only 12 status and efficacy of clopidogrel for risk reduction among patients with minor stroke or 13 14 15 transient ischemic attack. JAMA 2016; 316: 70-8. doi: 10.1001/jama.2016.8662 16 17 18 Pare G, Mehta SR, Yusuf S, et al. Effects of CYP2C19 genotype on outcomes of 18 19 clopidogrel treatment. N Engl J Med 2010; 363: 1704-14. doi: 10.1056/NEJMoa1008410 20 21 22 19 Scott SA, Sangkuhl K, Gardner EE, et al. Clinical pharmacogenetics implementation 23 24 consortium guidelines for cytochrome P450-2C19 (CYP2C19) genotype and clopidogrel 25 26 therapy. Clin Pharmacol Ther 2011; 90: 328-32. doi: 10.1038/clpt.2011.132 27 28 29 20 Gupta A, Thompson D, Whitehouse A, et al. Adverse events associated with unblinded, 30 31 but not with blinded, statin therapy in the Anglo-Scandinavian cardiac outcomes trial— 32 33 lipid-lowering arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial 34 35 and its non-randomised non-blind extension phase. Lancet 2017; 389: 2473-81. doi: 36 37 38 10.1016/s0140-6736(17)31075-9 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 23 of 32 BMJ
Wang Page 22 1 2 3 Figure legends 4 5 6 Figure 1. Trial profile 7 8 9 10 11 Confidential: For Review Only 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 24 of 32
Wang Page 23 1 2 3 Figure 2. Platelet reactivity at different visits over 90 days 4 5 6 (a) P2Y12 reaction units; (b) proportion of patients with high platelet reactivity. 7 8 9 A total of 333, 306, and 280 patients in the ticagrelor/aspirin group and 336, 321, and 290 10 11 Confidential: For Review Only 12 patients in the clopidogrel/aspirin group were included in the 0 day, 7 days, and 90 days 13 14 analyses, respectively. High platelet reactivity was defined as a P2Y12 reaction unit (PRU) 15 16 of >208 as measured using the VerifyNow P2Y12 assay. 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 25 of 32 BMJ
Wang Page 24 1 2 3 Figure 3. Effect of ticagrelor/aspirin compared to that of clopidogrel/aspirin on the 90 day 4 5 6 high platelet reactivity and clinical outcome stratified by metabolizer status 7 8 9 Patients with two *2 or *3 alleles (i.e., *2/*2, *2/*3, or *3/*3) were classified as having a poor- 10 11 metabolizerConfidential: phenotype, those with one *2 Foror *3 allele Review (i.e., *1/*2 or *1/*3) Only were classified as 12 13 having an intermediate-metabolizer phenotype, those without a *2, *3, or *17 allele (i.e., *1/*1) 14 15 were classified as having an extensive-metabolizer phenotype, and those with a single *17 allele 16 17 18 (i.e., *1/*17) and *17 homozygotes were classified as having an ultra-metabolizer phenotype. A 19 20 composite event was defined as a new clinical vascular event, including stroke, transient 21 22 ischemic attack, myocardial infarction, or death from cardiovascular causes. A total of 321 23 24 25 patients in the ticagrelor/aspirin group and 329 patients in the clopidogrel/aspirin group were 26 27 included in the genetic analysis. NA = not applicable, CI = confidence interval, OR = odds ratio, 28 29 HR = hazard ratio. 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 26 of 32
Wang Page 25 1 2 3 4 5 6 7 8 9 10 11 Confidential: For Review Only 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 27 of 32 BMJ
Wang Page 26 1 2 3 Figure 4. Stroke recurrence risk with ticagrelor/aspirin compared to that with 4 5 6 clopidogrel/aspirin at 90 days based on stroke aetiology 7 8 9 LAA = large-artery atherosclerosis, Non- LAA = non-large-artery atherosclerosis (including 10 11 cardioaorticConfidential: embolism, small-artery occlusion, For other Review causes, and undetermined Only causes). 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 28 of 32
Wang Page 27 1 2 3 TABLES 4 5 6 Table 1. Baseline characteristics of the patients in the PRINCE trial 7 8 Characteristic Ticagrelor/Aspirin Clopidogrel/Aspirin 9 10 (n=336) (n=339) 11 Confidential: For Review Only 12 13 Age years (mean+/-SD) 61.1±8·5 60.5±9·0 14 15 Median 62.0 61.0 16 17 Interquartile range 55.0-67.0 54.0-67.0 18 19 20 Female sex n (%) 91 (27.1) 90 (26.5) 21 22 Systolic blood pressure (mmHg) 152.3±22.5 154.9±21.2 23 24 Median 150.0 154.0 25 26 Interquartile range 137.5-168.0 140.0-170.0 27 28 29 Diastolic blood pressure (mmHg) 87.7±13.0 89.4±12.8 30 31 Median 87.5 88.0 32 33 Interquartile range 80.0-96.0 80.0-97.0 34 35 2 36 Body mass index (kg/m ) * 25.0±3.8 25.0±3.8 37 38 Median 24.6 24.8 39 40 Interquartile range 22.6-27.0 22.7-27.3 41 42 43 Pulse rate (bpm) 75.1±10.1 76.3±11.5 44 45 Medical history n (%) 46 47 Hypertension 203 (60.4) 208 (61.4) 48 49 Dyslipidaemia 20 (6.0) 21 (6.2) 50 51 52 Diabetes mellitus 79 (23.5) 85 (25.1) 53 54 Ischemic stroke 59 (17.6) 62 (18.3) 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 29 of 32 BMJ
Wang Page 28 1 2 3 TIA 8 (2.4) 10 (2.9) 4 5 6 Coronary artery disease 26 (7.7) 25 (7.4) 7 8 Known atrial fibrillation 0 (0.0) 4 (1.2) 9 10 Flutter valvular heart disease 1 (0.3) 0 (0.0) 11 Confidential: For Review Only 12 13 Pulmonary embolism 0 (0.0) 0 (0.0) 14 15 Smoking status n (%) 16 17 Non-smoker 150 (44.6) 155 (45.7) 18 19 Current smoker 160 (47.6) 159 (46.9) 20 21 22 Ex-smoker 26 (7.7) 25 (7.4) 23 24 Drug use before randomisation n (%) 25 26 Proton-pump inhibitor 2 (0.6) 3 (0.9) 27 28 29 Statin 36 (10.7) 30 (8.8) 30 31 Aspirin 77 (22.9) 69 (20.4) 32 33 Clopidogrel 5 (1.5) 10 (2.9) 34 35 36 Ticagrelor 0 (0.0) 0 (0.0) 37 38 Mean time to randomization after onset of symptoms h 14.0 (8.3-20.6) 13.8 (8.0-20.8) 39 40 (range) 41 42 Time to randomization after onset of symptoms n (%) 43 44 45 <12 h 139 (41.4) 144 (42.5) 46 47 ≥12 h 197 (58.6) 195 (57.5) 48 49 Qualifying event n (%) 50 51 52 Minor stroke 275 (81.8) 289 (85.3) 53 54 TIA † 61 (18.2) 50 (14.7) 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 30 of 32
Wang Page 29 1 2 3 Baseline ABCD2 score among patients with TIA as the 4 5 6 qualifying event ‡ 7 8 Median 5.0 4.5 9 10 Interquartile range 4.0-5.0 4.0-5.0 11 Confidential: For Review Only 12 13 SSS-TOAST stroke subtype n (%)§ 14 15 Large-artery atherosclerosis 151 (54.9) 153 (52.9) 16 17 Cardioaortic embolism 8 (2.9) 5 (1.7) 18 19 Small-artery occlusion 104 (37.8) 109 (37.7) 20 21 22 Other causes 7 (2.5) 9 (3.1) 23 24 Undetermined causes 5 (1.8) 13 (4.5) 25 26 Unknown 2 (0.7) 7 (2.4) 27 28 29 Unclassified 3 (1.1) 6 (2.1) 30 31 * Body-mass index is the weight in kilograms divided by the square of the height in meters. 32 33 34 † TIA = transient ischemic attack. 35 36 2 37 ‡ ABCD stroke risk scores range from 0 to 7, with higher scores indicating higher risk; data 38 39 provided in the table are only for the group of 111 patients whose qualifying event was TIA for 40 41 inclusion in the trial. 42 43 44 § SSS-TOAST stroke subtype = Stop Stroke Study Trial of Org 10172 in Acute Stroke 45 46 Treatment stroke aetiology classification (appendix); data provided in the table are only for the 47 48 49 group of 564 patients whose qualifying event was minor stroke for inclusion in the trial. 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 31 of 32 BMJ
Wang Page 30 1 2 3 Table 2. Effect of ticagrelor/aspirin compared to that of clopidogrel/aspirin on the efficacy 4 5 6 and safety outcomes 7 8 Outcomes Ticagrelor/As Clopidogrel/A Hazard ratio/ P-value 9 10 pirin n/N. (%) spirin n/N. Odds ratio 11 Confidential: For Review Only 12 13 (%) (95% CI)* 14 15 Primary efficacy outcome † 16 17 Baseline 268/333 (80.5) 260/336 (77.4) 1.21 (0.83-1.75) 0.33 18 19 20 7+2 days 12/306 (3.9) 89/321 (27.7) 0.11 (0.06-0.20) <0.001 21 22 90±7 days 35/280 (12.5) 86/290 (29.7) 0.34 (0.22-0.52) <0.001 23 24 25 Secondary efficacy outcome 26 27 Stroke 21/336 (6.3) 30/339 (8.8) 0.70 (0.40-1.22) 0.20 28 29 Composite events ‡ 22/336 (6.5) 32/339 (9.4) 0.68 (0.40-1.18) 0.17 30 31 32 Ischemic stroke 18/336 (5.4) 28/339 (8.3) 0.64 (0.35-1.16) 0.14 33 34 Haemorrhagic stroke 3/336 (0.9) 2/339 (0.6) 1.52 (0.25-9.08) 0·65 35 36 37 Myocardial infarction 0/336 (0.0) 1/339 (0.3) - - 38 39 Death from cardiovascular causes 1/336 (0.3) 2/339 (0.6) 0.50 (0.05-5.55) 0.58 40 41 Death from any cause 3/336 (0.9) 2/339 (0.6) 1.50 (0.25-9.00) 0.65 42 43 44 Transient ischemic attack 1/336 (0.3) 2/339 (0.6) 0.50 (0.05-5.53) 0.57 45 46 Primary safety outcomes § 47 48 Major bleeding 5/336 (1.5) 4/339 (1.2) 0.72 49 1.27 (0.34-4.72) 50 51 Major, fatal/life-threatening 4/336 (1.2) 3/339 (0.9) 1.35 (0.30-6.03) 0.69 52 53 Fatal bleeding 1/336 (0.3) 1/339 (0.3) 1.01 (0.06-16.13) 1.00 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 32 of 32
Wang Page 31 1 2 3 Intracranial haemorrhage 3/336 (0.9) 2/339 (0.6) 1.27 (0.34-4.72) 0.72 4 5 6 Major, other 1/336 (0.3) 1/339 (0.3) 1.01 (0.06-16.18) 0.99 7 8 Minor bleeding 11/336 (3.3) 8/339 (2.4) 1.40 (0.56-3.47) 0.47 9 10 11 Major or minorConfidential: bleeding 16/336 For (4.8) Review12/339 (3.5) Only1.36 (0.64-2.88) 0.42 12 13 Minimal bleeding 64/336 (19.0) 36/339 (10.6) 1.86 (1.24-2.80) 0.003 14 15 16 Any bleeding 75/336 (22.3) 48/339 (14.2) 1.65 (1.15-2.37) 0.007 17 18 Other safety outcomes 19 20 Respiratory, thoracic, and mediastinal 22/336 (6.5) 0/339 (0.0) - <0.0001 21 22 23 disorders 24 25 Dyspnoea 14/336 (4.2) 0/339 (0.0) - 0.0001 26 27 Epistaxis 6/336 (1.8) 0/339 (0.0) - 0.04 28 29 * CI = confidence interval. 30 31 32 † Primary outcome indicates high platelet reactivity, which was defined as a P2Y12 reaction unit 33 34 of >208 as measured by the VerifyNow P2Y12 assay. 35 36 ‡ A composite event was defined as a new clinical vascular event, including stroke, transient 37 38 39 ischemic attack, myocardial infarction, or death from cardiovascular causes. 40 41 § Primary safety outcomes were defined according to the PLATO criteria (appendix). All 675 42 43 patients were included in the analysis of safety outcomes. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 33 of 32 BMJ
Wang Page 32 1 2 3 Table 3. Stroke recurrence at 90 days by stroke aetiology 4 5 6 Stroke aetiology* Ticagrelor/As Clopidogrel/As Hazard ratio/ P- P-value for 7 8 pirin n/N. (%) pirin n/N. (%) Odds ratio value the 9 10 (336) (339) (95% CI)* interaction 11 Confidential: For Review Only 12 13 Large-artery atherosclerosis 9/151 (6.0%) 20/153 (13.1%) 0.45 (0.20-0.98) 0.04 0.13 14 15 Non-large-artery atherosclerosis 10/124 (8.1%) 10/136 (7.4%) 1.10 (0.46-2.63) 0.84 16 17 18 * Stroke aetiology was classified by the SSS-TOAST stroke subtype. 19 20 SSS-TOAST = Stop Stroke Study Trial of Org 10172 in Acute Stroke Treatment stroke aetiology 21 22 classification (appendix). 23 24 25 Non-large-artery atherosclerosis included patients with cardioaortic embolism, small-artery 26 27 occlusion, other causes, and undetermined causes. 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj