Double Randomization of a Monitoring Adjusted Antiplatelet Treatment Versus a Common Antiplatelet Treatment for DES Implantation, and Interruption Versus Continuation of Double Antiplatelet Therapy (ARCTIC)

This study has been completed.
Sponsor:
Collaborators:
Allies in Cardiovascular Trials Initiatives and Organized Networks:ACTION
Institut National de la Santé Et de la Recherche Médicale, France
Sanofi
Bristol-Myers Squibb
Medtronic
Cordis Corporation
Fondation de France
Diagnostica Stago
Boston Scientific Corporation
Information provided by (Responsible Party):
Assistance Publique - Hôpitaux de Paris
ClinicalTrials.gov Identifier:
NCT00827411
First received: January 13, 2009
Last updated: April 11, 2013
Last verified: April 2013
  Purpose

Our first hypothesis is that dose adjustment of aspirin and clopidogrel based on biological monitoring reduces the rate of severe cardiovascular complications compared to a conventional strategy in patients scheduled for drug eluting stent implantation and followed up for one year. Our second hypothesis is that interruption of clopidogrel / Prasugrel after one year of a combined therapy of clopidogrel/Prasugrel and aspirin is associated with a higher rate of severe cardiovascular complications as compared with patients in whom aspirin and clopidogrel / Prasugrel is maintained during the subsequent 6 months of follow-up.


Condition Intervention Phase
Coronary Artery Disease
Acute Coronary Syndrome
Drug: Aspirin and clopidogrel / Prasugrel
Device: VerifyNow
Drug: Aspirin
Phase 4

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: Double Randomization of a Monitoring Adjusted Antiplatelet Treatment Versus a Common Antiplatelet Treatment for DES Implantation, and a Interruption Versus Continuation of Double Antiplatelet Therapy, One Year After Stenting

Resource links provided by NLM:


Further study details as provided by Assistance Publique - Hôpitaux de Paris:

Primary Outcome Measures:
  • Composite endpoint of death, myocardial infarction, stroke, urgent coronary revascularization, stent thrombosis assessed at one year for the first hypothesis and between 6 up to 18 months of follow-up for the second hypothesis [ Time Frame: during the study (one year in both " monitoring " and " conventional " arms and during the periode from 6 up to 18 months in the "interruption" and "pursuit" arms) ] [ Designated as safety issue: No ]

Secondary Outcome Measures:
  • Stent thrombosis and urgent coronary revascularization [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Rate of individual event at one year follow-up in both " monitoring " and " conventional " arms but also during the period from one year up to 24 months in the " interruption " and " pursuit " arms. [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Time delay from treatment interruption (randomization 2) to any thrombotic event (stent thrombosis, urgent revascularization, acute myocardial infarction, cardiac death) treatment interruption(randomisation 2) [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Treatment compliance evaluated by the number of oral antiplatelet treatment in both arms and with respect to all individual events of the primary composite endpoint [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Rate of use of GP IIb/IIIa receptor antagonists in both " monitoring " and " conventional " arms before percutaneous coronary intervention and in bail out situations and in both. [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Rate of suboptimal responders as defined by ARU>550 for aspirin or by a % of inhibition <15% and or a PRU<235) and the average dosage of aspirin and clopidogrel (in mg) will evaluated before and after dose adjustment (J0) and after each dose adjustment [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Net clinical benefit (death, myocardial infarction, urgent revascularization, stent thrombosis, stroke, major bleeding) [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient

  • Medico-economic evaluations will be performed for both hypotheses. The rate of rehospitalisation and the length of stay will be used as economic indicators [ Time Frame: at month 12 and month 30 ] [ Designated as safety issue: No ]
    • at month 12 for the non-randomized patients at M12
    • at month 12 and month 30 for the randomized patient


Enrollment: 2500
Study Start Date: January 2009
Study Completion Date: January 2013
Primary Completion Date: March 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: 1: Monitoring Arm

First randomization:

Monitoring Arm: dose adjustment of both aspirin and clopidogrel in suboptimal responders identified based on a point of care assay (VerifyNow).

Drug: Aspirin and clopidogrel / Prasugrel
modification of aspirin and clopidogrel/Prasugrel maintenance doses based on a biological assay
Device: VerifyNow
point of care assay VerifyNow (ACCUMETRICS San Diego USA)
Active Comparator: 2: Conventional Arm

First randomization:

Conventional Arm: fixed dose regiment of both aspirin and clopidogrel in all patients following DES implantation according to international guidelines

Drug: Aspirin and clopidogrel / Prasugrel
aspirin and clopidogrel/ Prasugrel maintenance doses (according to international guidelines)
Experimental: 3: Pursuit Arm

Second randomization after one year of follow-up:

Pursuit Arm: Pursuit of a dual oral antiplatelet therapy (aspirin and clopidogrel) beyond one year

Drug: Aspirin and clopidogrel / Prasugrel
maintenance dose of clopidogrel / Prasugrel and aspirin
Active Comparator: 4: Interruption Arm

Second randomization after one year of follow-up:

Interruption Arm: Interruption of clopidogrel therapy.

Drug: Aspirin
Interruption of clopidogrel / Prasugrel after one year of follow-up

Detailed Description:

Participating Centers : 38 french high PCI volume (>700) centers Rationale: Clopidogrel / Prasugrel (75 mg/day), in combination with aspirin (75 mg/day), is currently the antiplatelet treatment of choice for prevention of stent thrombosis, and clinical trials have shown that, in high-risk patients, prolonged dual antiplatelet treatment is more effective than aspirin alone in preventing major cardiovascular events. However, despite the use of clopidogrel, a considerable number of patients continue to have cardiovascular events. Numerous in VITRO studies have shown that individual responsiveness to clopidogrel but also to aspirin is not uniform in all patients and is subject to inter- and intraindividual variability. The recent possibility of bedside monitoring of oral antiplatelet therapy offers the unique opportunity of tailoring antiplatelet therapy. However, the relevance of such strategy has never been evaluated in a randomized prospective adequately powered study having long term follow-up (rationale 1). Late state stent thrombosis, especially in the era of drug eluting stent and after interruption of OAT, is another important safety issue raising the questions of the modalities of interruption of dual OAT after one year according to the most recent updated recommendations. Can we switch from dual to single OAT after one year? If so, what is the ischemic hazard? (Rational 2) Our first hypothesis is that a strategy of dose adjustment of OAT based on biological monitoring reduces the rate of the combined ischemic endpoints of death, urgent revascularization, stent thrombosis and stroke as compared to a conventional strategy (local practice without monitoring) in patients scheduled for DES implantation and followed up for one year. Our second hypothesis is that interruption of clopidogrel after one year of dual OAT is associated with a higher rate of the same combined ischemic endpoints as compared with patients in whom dual OAT is maintained during the subsequent 6 months of follow-up. Objectives: 1) To demonstrate the superiority of the strategy of monitoring with dose adjustment in suboptimal responders (Monitoring Arm) as compared to a more conventional strategy (Conventional Arm) with fixed dose regimen of both oral antiplatelet agents in all patients as defined by the international guidelines to reduce the primary endpoint evaluated one year after DES implantation. 2) to demonstrate the superiority of a strategy of pursuit of a dual OAT beyond one year (Pursuit Arm) as compared to a strategy of interruption (Interruption Arm).

Duration of the participation : from 18 up to 30 months according to the time delay from study start to randomization. No participants will be excluded from the study at the exception of consent withdrawal. However, participants who have not been randomized for interruption or continuation of DAPT at the 12 month follow up visit will terminate the study

Number of patients: 2500 patients. This number was obtained for the demonstration of the superiority of the strategy of monitoring (Monitoring Arm) over the conventional strategy (Conventional Arm) to reduce the primary endpoint by 33% (relative risk reduction).

Expected results: The ARCTIC study will provide answers to two major clinical challenges. It will also give a unique opportunity to assess the prevalence and the associated risk factors of suboptimal answers to OAT, but also to improve a suboptimal biological response. Finally, the economic impact of both strategies of monitoring and of interruption will be evaluated.

  Eligibility

Ages Eligible for Study:   18 Years and older
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Patients (≥18 years) in whom elective DES stent placement is scheduled after diagnostic angiography
  • Patients not treated by GPIIb/IIIa inhibitors prior to randomization.
  • Provided written consent for participation in the trial prior to any study-specific procedures or requirements.

Exclusion Criteria:

  • Oral anticoagulation (Vitamin K Antagonists).
  • Contraindication for aspirin and/or clopidogrel/Prasugrel or GPIIb/IIIa inhibitors or to increasing dose of clopidogrel or aspirin
  • Ongoing or recent bleeding and/or recent major surgery (<3 weeks)
  • Severe liver dysfunction
  • Thrombocytopenia (Platelet count <80000/µl).
  • IIb/IIIa inhibitors within a week prior to randomization
  • STEMI presentation
  • Patient at risk of poor compliance to the study
  • Patient not affiliated to social security
  • Pregnant women, no signed inform consent
  • Any invasive or surgical planned intervention during the year after stent placement
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00827411

Locations
France
Institut de Cardiologie- Hopital la Pitié Salpétrière
Paris, France, 75013
Sponsors and Collaborators
Assistance Publique - Hôpitaux de Paris
Allies in Cardiovascular Trials Initiatives and Organized Networks:ACTION
Institut National de la Santé Et de la Recherche Médicale, France
Sanofi
Bristol-Myers Squibb
Medtronic
Cordis Corporation
Fondation de France
Diagnostica Stago
Boston Scientific Corporation
Investigators
Principal Investigator: Gilles Montalescot, PUPH Assistance Publique - Hôpitaux de Paris
Principal Investigator: Jean-Philippe Collet, PH Assistance Publique - Hôpitaux de Paris
  More Information

Publications:
Additional publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: Assistance Publique - Hôpitaux de Paris
ClinicalTrials.gov Identifier: NCT00827411     History of Changes
Other Study ID Numbers: P080403
Study First Received: January 13, 2009
Last Updated: April 11, 2013
Health Authority: France: Ministry of Health

Keywords provided by Assistance Publique - Hôpitaux de Paris:
Drug Eluting Stent
Percutaneous coronary intervention
Oral antiplatelet therapy
Clopidogrel/Aspirin
Acute Coronary Syndrome

Additional relevant MeSH terms:
Coronary Artery Disease
Myocardial Ischemia
Coronary Disease
Acute Coronary Syndrome
Heart Diseases
Cardiovascular Diseases
Arteriosclerosis
Arterial Occlusive Diseases
Vascular Diseases
Angina Pectoris
Chest Pain
Pain
Signs and Symptoms
Aspirin
Ticlopidine
Clopidogrel
Prasugrel
Anti-Inflammatory Agents, Non-Steroidal
Analgesics, Non-Narcotic
Analgesics
Sensory System Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Pharmacologic Actions
Anti-Inflammatory Agents
Therapeutic Uses
Antirheumatic Agents
Fibrinolytic Agents
Fibrin Modulating Agents
Molecular Mechanisms of Pharmacological Action

ClinicalTrials.gov processed this record on July 20, 2014