trials of antiplatelet and oral anticoagulant drugs.

1. VARIOUS TRIALS ON
ANTIPLATELET AND
ORAL ANTICOAGULANT
DRUGS.
Dr SUMEDH RAMTEKE

2. ANTIPLATELET DRUGS- TRIALS

3. ASPIRIN
TRIALS

4. ISIS-2
(second international study of infarct survival)
ISIS-2 was the first trial to demonstrate the clinical efficacy of the
antiplatelet agent aspirin in reducing vascular mortality in acute MI.
17,187 patients with acute MI ( published in Lancet- Aug 1988)
4 groups- ASP/SK/ASP +SK/Placebo with ASP &/or SK showing
significant reduction in CV mortality in 5 weeks thus proving
combination better than either agent alone.

5. CURRENT OASIS-7
(Double dose versus standard dose clopidogrel and high dose
versus low dose aspirin in individuals undergoing PCI for
ACS.)
25086 patients with ACS undergoing PCI (aspirin 300 to 325 vs 75 to
100 mg)
conclusion- 75 mg as effective as 300 mg for primary outcome with
less frequency of minor bleeding in lower dose and hence establishing
lower dose of aspirin.

6. TICLOPIDINE
TRIALS

7. ISAR (1996)
Intracoronary stenting and Antithrombotic
regimen trial
257 patients were given antiplatelet (ticlopidine + aspirin)
and 260 to receive anticoagulant( IV heparin,
phenprocouman & aspirin)
As compared with conventional anticoagulant therapy, combined
antiplatelet therapy after the placement of coronary artery stents
reduces the incidence of both cardiac events and hemorrhagic and
vascular complications.

8. STAR (1998)
A clinical trial comparing three antithrombotic drug
regimens after coronary artery stenting.
As compared with aspirin alone and a combination
of aspirin and warfarin, treatment with aspirin and
ticlopidine resulted in a lower rate of stent
thrombosis, although there were more
hemorrhagic complications than with aspirin alone.

9. MATTIS (1998)
Multicentre aspirin and ticlopidine trial after
intracoronary stenting
In high risk patients undergoing coronary artery stent
implantation, DAPT with aspirin and ticlopidine is
superior to combination of aspirin and oral
anticoagulation.

10. FANTASTIC (1998)
Full anticoagulation versus aspirin and ticlopidine
study.
DAPT with ticlopidine and aspirin has been shown
to be as effective as or more effective than conventional
anticoagulation in patients with an optimal result after
implantation of intracoronary metallic stents.

11. CLOPIDOGRE
L TRIALS

12. CURE(2001)
Clopidogrel in unstable angina to prevent recurrent
events.
12562 patients with ACS (UA/NSTEMI) assessed
clopidogrel + aspirin vs placebo + aspirin with primary end
point as composite of death, nonfatal MI or stroke. The study
proved benefit of clopidogrel added to aspirin in NSTEMI.

13. Long-term administration of clopidogrel to patients with
atherosclerotic vascular disease is more effective than
aspirin in reducing the combined risk of ischaemic stroke,
myocardial infarction, or vascular death.
The overall safety profile of clopidogrel is at least as good as
that of medium-dose aspirin.
CAPRIE 2003
Clopidogrel versus aspirin in patients at risk of
ischaemic events -

14. COMMIT(2005)
Clopidogrel and Metoprolol in myocardial
infarction.
45852 patients of STEMI, NSTEMI, UA with primary EP-
composite of death, reinfarction and cardiac arrest at 28
days concluded that addition of clopidogrel to aspirin
caused significant reduction in event rate( including
thrombolysis patients)

15. CHARISMA (2006)
Clopidogrel and aspirin versus aspirin alone for
the prevention of atheroembolic events.
Dual antiplatelet therapy may not be beneficial in all patients
at risk for CV disease, but that in patients with established
CV disease, dual therapy may be effective in reducing
subsequent events. Several other large trials, including
CLARITY-TIMI 28 and COMMIT, have established the
efficacy of dual antiplatelet therapy in acute coronary
syndromes as well as in the setting of percutaneous coronary
intervention.

16. CLARITY TIMI 28
Clopidogrel as adjunctive reperfusion therapy –
Thrombolysis in myocardial infarction 28.
Trial for proved benefit of clopidogrel over aspirin
in thrombolysis patients.

17. PCI-CURE
Clopidogrel in unstable angina to prevent recurrent
events in PCI subgroup.
2658 patients with NSTE-ACS undergoing PCI
assessed for clopidogrel loading dose (clopidogrel
300 mg loading dose f/b 75 mg clopidogrel+ aspirin
Vs clopidogrel 75 mg for 28 days+ aspirin) and
looked at primary EP- CV death, MI, Stroke at 1 yr. It
proved benefit of clopidogrel loading dose in NSTE-
ACS patients undergoing PCI.

18. CREDO(2002)
The clopidogrel for the reduction of events during
observation.
2116 patients with stable CAD and unstable angina
undergoing PCI for clopidogrel 300mg f/b 75 mg + aspirin
Vs clopidogrel 75 mg+aspirin.
Primary EP was CV death, MI, Stroke at 1 yr. The study
established Clopidogrel LD 300 mg f/b 75 mg + aspirin
better than clopidogrel 75mg+ aspirin in PCI.

19. CURRENT OASIS 7(2010)
(Double dose versus standard dose clopidogrel and
high dose versus low dose aspirin in individuals
undergoing PCI for ACS.)
25086 patients with STEMI & NSTEMI with intended PCI.
Evaluated clopidogrel 600 mg LD vs 300 mg LD f/b 75mg
clopidogrel + aspirin.
The study concluded overall cohort showed no significant
benefit of 600 mg LD. However, for PCI only cohort 600
mg LD better than 300 mg LD.

20. GRAVITA(2011)
(Gauging responsiveness with a verify nowassay-
impact on thrombosis and safety)
2214 patients with high on treatment reactivity to standard
clopidogrel 12 to 24 hrs after PCI.
For clopidogrel 600 mg loading dose f/b 150 mg + aspirin vs
clopidogrel 75 mg + aspirin.
The study showed no benefit of clopidogrel 150 mg vs 75 mg in
patients with high on treatment reactivity.

21. PRASUGREL
TRIALS

22. TRITON TIMI 38
( trial to assess improvement in therapeutic
outcomes by optimizing platelet inhibition with
prasugrel- thrombolysis in MI.)
13608 patients with NSTE ACS & STEMI with planned PCI assessed for
primary EP of CV death, MI or stroke at 450 days between prasugrel 60mg
LD f/b 10 mg per day + aspirin vs clopidogrel 300 mg f/b 75mg/day +
aspirin.
The study showed prasugrel better than clopidogrel in ACS patients for
PCI. Prasugrel arm showed decreased primary EP , TVR, stent thrombosis
but with increased bleeding including fatal bleeding. Net clinical benefit
was not seen ( or not harm seen) in patients with prior history of stroke?
TIA, > 75 yr age, < 60 kg weight.

23. TRIOLOGY- ACS
( Targeted platelet inhibition to clarify the optimal
strategy to medically manage acute coronary
syndrome)
9326 patients with NSTE ACS treated om medical
management ( NO PCI) assessed EP composite of CV
death or nonfatal stroke or nonfatal MI at 17.1
months.
Conclusion- No improvement in mortality for prasugrel
compared to clopidogrel in UA/NSTEMI if no PCI.

24. ACCOAST (2013)
(pretreatment with prasugrel in Non-ST segment
Elevation acute coronary syndromes.)
4003 patients with NSTE ACS planned for CAG
randomized to either prasugrel 30 mg (at CAG) f/b 30 mg
another ( if PCI performed) vs placebo and assessed primary EP
of CV death, stroke, MI, urgent revascularization.
It showed administrating 30 mg prasugrel
prior to CAG in NSTE ACS patients offers no benefit in
delaying therapy until a lesson for PCI is identified on CAG.

25. TICAGRELOR
TRIALS

26. PLATO (2015)
(platelet inhibition and outcomes)
18624 patients with NSTEMI and STEMI with intended
invasive management ( PCI in 77%) randomized to either
Ticagrelor 180 mg LD f/b 90 mg BD vs clopidogrel 300-
600 mg LD f/b 75 mg BD and assessed primary EP of CV
death, stroke, urgent revascularization or GPIIb/IIIa bailout
at 7 days and showed ticagrelor was superior to
clopidogrel.

27. ATLANTIC(2018)
(thrombus aspiration and prehospital ticagrelor
administration in ST elevation MI.)
1862 patients with STEMI received ticagrelor180 mg in
ambulance f/b 90 mg BD + aspirin vs 180 mg LD in cathlab
( placebo in ambulance)+ aspirin and clopidogrel 600 mg
post PCI/ pre PCI + aspirin. The results showed no benefit of
ambulance ticagrelor ( early) in relation to cathlab ticagrelor
in STEMI patients with PCI.

28. PEGASUS – TIMI 54 (2015)
(prevention of cardiovascular events in patients with prior
heart attack using ticagrelor compared to placebo on a
background of aspirin- thrombolysis in myocardial
infarction-54)
90 mg and 60 mg BD of ticagrelor resulted in similar
degree of efficacy and safety (bleeding).
Ticagrelor 60 mg BD was associated with a reduction in
stroke(ischaemic) compared with placebo.

29. THEMIS TRIAL(2019)
(effect of ticagrelor on health outcomes in diabetes
mellitus patients intervention study)
The phase III THEMIS trial met its primary end point and
demonstrated that Ticagrelor, taken in conjuction with
aspirin, showed a statistically significant reduction in a
composite of major adverse cardiovascular events (MACE)
compared to aspirin alone.

30. TRIALS ON OAC’S
IN PCI

31. PIONEER AF-PCI(2016)
(Rivaroxaban plus P2Y12 inhibitor or DAPT in post
PCI Afib patients.)
The results of the trial show that those who received either
low dose rivaroxaban plus a P2Y12 inhibitor for 12 months
or very low dose rivaroxaban plus DAPT for one, six or 12
months had lower rates of significant bleeding compared
with the standard therapy group.
The three groups had similar rates of death from
cardiovascular events, myocardial infarction, or stroke.

32. RE-DUAL -2017
( Dual therapy Vs Triple therapy in AF patients undergoing PCI)
The risk of bleeding was significantly lower among
patients with AF undergoing PCI who received dual
therapy with Dabigatran and a P2Y12 inhibitor,
compared to those who received triple therapy with
warfarin, a P2Y12 inhibitor and aspirin.
Dual therapy was noninferior to triple therapy with
respect to risk of thromboembolic events.

33. COMPASS (2018)
(cardiovascular outcomes for people using anticoagulation
strategies.)
Among patients with stable atherosclerotic vascular
disease, those assigned to rivaroxaban (2.5 mg BD )
plus aspirin had better cardiovascular outcomes and
more major bleeding events than those assigned to
aspirin alone.
Rivaroxaban (5 mg BD) alone did not result in better
cardiovascular events than aspirin alone and resulted in
more major bleeding events.

34. AUGUSTUS-2019
(Antithrombotic therapy after acute coronary
syndrome or PCI in AF.)
Among patients with AF with recent ACS or PCI, adding
Apixaban to a P2Y12 inhibitor resulted in lower bleeding
compared with VKA with a lower rate of death or
rehospitalization.

35. SECURITY TRIAL-2014
(SECOND GENERATION DRUG ELUTING STENT
IMPLANTATION FOLLOWED BY 6 VERSUS 12
MONTH DAPT.)
The results of the SECURITY trial indicate that a 6 month
duration of DAPT may be noninferior for ishaemic and
bleeding outcomes to a 12 month duration in low risk
patients undergoing PCI with a second generation DES.

36. STOPDAPT – 2 ACS (2019)
( Short and Optimal duration of Dual Antiplatelet
Therapy-2 study for the patients with ACS.)
Among the patients undergoing PCI for stable and unstable
cardiovascular disease, 1 month DAPT followed by
clopidogrel monotherapy was superior to 12 month DAPT
followed by aspirin monotherapy at preventing net adverse
clinical events.