A Mechanistic Link Between High Platelet Reactivity,

Inflammation Marker Release and Myonecrosis in

Patients Undergoing Stenting:
CLEAR PLATELETS Ib Study

Paul Gurbel, Kevin Bliden, Tania Gesheff,

Yvonne Kreutz, Udaya Tantry

Sinai Center for Thrombosis Research

Sinai Hospital of Baltimore
Baltimore, Maryland, U.S.A.
 Disclosures
This study was supported by Millennium and Schering

Research Grants Honoraria

- Schering - Schering
- Millennium - Millennium
- Astra Zeneca - Astra Zeneca
- Bayer - Bayer
- NIH
- Haemoscope
- Medtronic
- Boston Scientific
 Background
• Thrombosis and inflammation influence the development of
ischemic events following PCI.
• Recent trials established the effectiveness of GPIIb/IIIa
inhibitors with clopidogrel and aspirin in reducing
thrombotic events following PCI.
• However, controversy remains regarding the optimal
antiplatelet strategy for elective stenting.
• Response variability to clopidogrel has been demonstrated
in patients undergoing elective stenting.1,2

1. Gurbel et al. J Am Coll Cardiol 2005;45:1392-6

2. Gurbel et al. Circulation. 2003;107: 2908-2913
 Background

• In the CLEAR PLATELETS Study a loading dose of

clopidogrel with a GPIIb/IIIa inhibitor (eptifibatide) produced:

- superior platelet inhibition

- lower myocardial necrosis
compared to 300 mg or 600 mg clopidogrel loading alone. 1

• Potential anti-inflammatory effects of clopidogrel and

GPIIb/IIIa inhibitors have been recently reported.2

• The comparative anti-inflammatory effects of clopidogrel ±

GPIIb/IIIa blockade during stenting are unknown.
1. Gurbel PA. et al Circulation 2005; 111:1153-9 2. Nannizzi-Alaimo L et al. Circulation 2003; 107:1123-1128
 Objectives

• The primary objective of the current investigation (CLEAR PLATELETS -1b):

Compare the effects of the antiplatelet regimens employed in the

CLEAR PLATELETS study on early inflammation and cardiac marker release

after PCI.

• The secondary objective:

Study relation between platelet inhibition and inflammation

Study Design of CLEAR PLATELETS-1b

CLEAR PLATELETS 1b

N = 60 N = 60 N = 60

CLEAR PLATELETS
 Study Design of CLEAR PLATELETS-1b

2 X 2 Factorial Elective Stent Study

Clopidogrel 300 mg in lab Clopidogrel 600 mg in lab
(n = 60) (n = 60)

- Eptifibatide + Eptifibatide - Eptifibatide + Eptifibatide

(n = 30) (n = 30) (n = 30) (n = 30)
Heparin per ESPIRIT dosing , Clopidogrel 75 mg qd, ASA 325 mg qd

Laboratory Measurements - Before and 18-24 hours Post-Stenting

Platelet Aggregation Inflammation Markers

Light transmittance - C-reactive protein
( 5 and 20 M ADP) Platelet Activation Markers - Tumor necrosis factor -
ADP-stimulated: by ELISA
Necrosis Markers - active GPIIb/IIIa
- Creatinine Kinase MB - P-selectin Biomarker Profile
- Troponin I by flow cytometry by Luminex®
- Myoglobin
 Results - Patient Demographics
Clopidogrel Clopidogrel + p-value
(n=60) Eptifibatide (n=60)

Age (years) 63+/-14 65+/-12 ns

Race (Caucasian) (%) 70 70 ns
Gender (Male) (%) 63 70 ns
BMI 29+/-5 30+/-6 ns
Risk Factors (%)
Smoking 45 38 ns
Family history of CAD 38 36 ns
Hypertension 60 73 ns
Hyperlipidemia 80 87 ns
Diabetes 50 53 ns
Prior Myocardial Infarction 25 35 ns
Prior CABG 25 20 ns
Prior PTCA 35 55 0.03

Baseline Medications (%)

Beta blockers 87 97 ns
ACE Inhibitors 62 75 ns
Calcium blockers 20 27 ns
Lipid lowering agents
CYP3A4 metabolized 62 57 ns
Non -CYP 3A4 metabolized 20 20 ns
 Results - Procedural Characteristics
Clopidogrel Clopidogrel + p-value
(n=60) Eptifibatide
(n=60)
Length of procedure (min.) 60+/-21 60+/-22 ns
Ejection Fraction (%) 54+/-8 52+/-9 ns
Number of vessels treated 1.2+/-0.5 1.4+/-0.6 ns
Lesion Morphology
Denovo (%) 93 87 ns
Lesion Location (%)
LAD 32 33 ns
CX 23 28 ns
RCA 40 32 ns
SVG 5 7
Stent Types (%)
Drug eluting 70 67 ns
Bare metal 23 27 ns
PTCA only 7 4 ns
Reference vessel diameter 3.1+/-0.5 3+/-0.4 ns
(mm)
Total lesion length (mm) 20.2+/-12.0 21+/-13.0 ns
Pre-stenosis (%) 85+/-7 84+/-7 ns
Post-stenosis (%) 3+/-1 4+/-2 ns
 Relative Change in Platelet Aggregation,
P-Selectin and Active GPIIb/IIIa Expression:
Four Treatment Groups

300 C 600 C 300 C+E 600 C+E

LTA LTA Stimulated Stimulated

5 uM ADP 20 uM ADP GPIIb/IIIa P-selectin
0

-20
Relative Change (%)

-40

-60

-80 p=0.04 p=0.004 p=ns p<0.01 p<0.001

-100
p=ns p=ns p=ns

-120
 Relative Change in Plasma TNF- and CRP:
Four Treatment Groups

300 C 600 C 300 C+E 600 C+E

50 TNF-  CRP
p = ns
40
30
Relative Change (%)

20
10
0
-10
-20
-30 p<0.001 p = ns
-40
-50 p = 0.009
 Myocardial Necrosis Markers:
Clopidogrel vs. Clopidogrel + Eptifibatide

Clopidogrel Clopidogrel + Eptifibatide

20
16
Number of Patients

16

12 11
9
8
5
4
4 3 3

0
0
CKMB CKMB Tn - I Myoglobin
(>1-3xULN) (>3xULN) (>ULN) (>2xULN)
Relative Change in Aggregation, P-Selectin, Active GPIIb/IIIa, TNF-, CRP:
Clopidogrel vs. Clopidogrel + Eptifibatide

Clopidogrel Clopidogrel + Eptifibatide

60

40 LTA- LTA- Stimulated Stimulated TNF-Alpha CRP

5uM ADP 20uM ADP GPIIb/IIIa P-Selectin
20
Relative Change (%)

-20
p<0.001
-40
p<0.001
-60
p=0.095
-80

-100
p<0.001 p<0.001 p<0.001
-120
 Relation of Necrosis Marker Release to
Plasma CRP and TNF-

p<0.001
p=0.001
Post-Treatment CRP (mg/L)

p<0.001
7.5 p=0.01 p=0.09
300

6.0 240

TNF-Alpha (ng/mL)
Post-Treatment
4.5 180

3.0 120

1.5 60

0.0 0
CK-MB CK-MB CK-MB CK-MB CK-MB CK-MB
(NL) (>1-3X ULN) (>3X ULN) (NL) (>1-3X ULN) (>3X ULN)
 Absolute Change in Platelet Aggregation and
(%) Patients Treated with Eptifibatide in CRP Quartiles

p=0.003

Treated With Eptifibatide (%)

Platelet Aggregation (%)

80
80
Absolute Change in

Frequency of Patients
60
60 p=0.06

40 p=0.004
40

20 p<0.001
20

0
0
<2.1 2.2-3.6 3.7-4.6 >4.7
< 2.1 2.2-3.6 3.7-4.6 >4.7
CRP (mg/L) Quartiles
CRP (mg/L) Quartiles
 Biomarker Profile by MAP:
Clopidogrel vs. Clopidogrel + Eptifibatide
Clopidogrel Myoglobin <0.0001

Clopidogrel + Eptifibatide Fatty Acid Binding Protein <0.0001

CD40-L 0.001

VCAM-1 0.03

CRP <0.0001

TNF-Alpha 0.003
MIP-Alpha 0.03

RANTES 0.006

Fibrinogen 0.007

Tissue Factor <0.0001

vWF 0.001

MMP-9 <0.0001

-100 -50 0 50 100

Relative Change (%)

 Conclusions
• Clopidogrel + eptifibatide produces a distinctly different periprocedural
biomarker profile than clopidogrel alone in elective stenting:
significant inhibition of inflammation and myocardial necrosis
marker release.
• Inhibition of platelet aggregation and active GP IIb/IIIa expression but not
p-selectin expression was associated with inhibition of inflammation.
• The mechanistic and clinical implications of attenuated periprocedural
inflammation and myocardial necrosis with a strategy of GPIIb/IIIa
inhibition warrant further investigation.
GPIIb/IIIa Inhibition

Inflammation Necrosis