Carlo Briguori, MD, FACC, FSCAI Clinica Mediterranea, Naples, Italy NAPLES III Novel Approaches in Preventing or Limiting Event III TriaL Randomised Comparison of Bivalirudin versus Unfractionated Heparin in Patients at High Risk of Bleeding Undergoing Elective Coronary Stenting thought the Femoral Approach Carlo Briguori, MD, FACC, FSCAI Clinica Mediterranea, Naples, Italy

Disclosure Statement of Financial Interest I, Carlo Briguori DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 2

Background Major bleeding and blood transfusion after PCI have been strongly associated with increased rates of in-hospital and late mortality, myocardial infarction (MI) and repeat revascularization1-2 Unfractionated heparin (UFH) is the most commonly used anticoagulant drug during PCI in order to prevent thrombotic complications Limitations of UFH include4-5 inability to inactivate clot-bound thrombin, the indirect mechanism of thrombin inhibition via anti-thrombin-III activation, the nonspecific protein binding Non-linear pharmacokinetic, requiring a continuous monitoring of the effect in order to confirm the optimal anticoagulation regimen and, on the contrary, avoid a high bleeding risk 1 Doyle BJ et al. J Am Coll Cardiol 2009;53:2019-27 2 Rao SV. et al. Am Heart J 2008;155:369-74 3.Young E, et al. Thrombosis and Haemostasis 1992; 67:639-43. 4. Sobel M et al. J Vasc Surg 2001;33:587-94

Background Bivalirudin (The Medicine’s Co., Parsippany, NJ) is a synthetic direct thrombin inhibitor approved for patients with stable and unstable coronary syndromes undergoing PCI1. Favorable properties of bivalirudin include: its ability to inhibit both circulating and clot-bound thrombin, an inherent anti-platelet effect by inhibition of thrombin-induced platelet activation, a short half-life, which may minimize bleeding. direct binding to thrombin without co-factors and no binding to plasma proteins. linear kinetics, resulting in predictable serum concentrations2-4 1. Levine GN et al. J Am Coll Cardiol 2011;58:e44 2. Stone GW et al. JAMA 2007;298:2497 3. Stone GW, et al. N Engl J Med 2008;358:2218 4. Lincoff AM et al. JAMA 2003;298;853

Background The Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment (ISAR-REACT) 3 trial1 showed that bivalirudin led to a net clinical outcome comparable with that achieved with UFH. However: an high (140 U/Kg) single bolus dose of UFH was used Not specifically designed for high-risk bleeding patients The ISAR-REACT 3A2 showed that, in biomarker negative patients, a low dosing regimen (100 U/Kg) of UFH represents a simple and safe method of lowering the bleeding peri-procedural risk without compromise the risk of ischemic complications. However: Single-arm prospective study 1. Kastrati et al. N Engl J Med 2008;359:688-96 2. Schultz S et al. Eur Heart J 2010;31:582-7

High risk bleeding patients Score Risk of Major Bleeding 0-1 1.3% 2-6 1.8% 7-9 2.3% 10 ≥5% Age > 75 years 0 for ≤55 years Add 4 for every 10 years over 55 Female gender 3 Anemia 2 LMWH within 48 h pre-PCI eGFR <60 mlmin1.73 m2 Nikolski E et al Eur Heart J 2007; 28:1936-45

Background At present there is a lack of prospective clinical trial assessing the safety and the efficacy of bivalirudin compared with UFH in the subset of patients exposed to high risk of bleeding.

Purpose We performed a prospective, randomized, double-blind, single center, investigator-initiated study comparing the 2 different strategies in high-risk bleeding patients: Unfractionated heparin (UFH Group) Bivalirudin (Bivalirudin Group)

NAPLES III trial DESIGN: Prospective, randomized, double-blind single center, investigator-initiated clinical study Elective PCI in biomarker negative patients at high risk of bleeding (risk score ≥10) UFH group Bivalirudin group In-hospital major bleeding

Sample size Hypothesis: Sample size: Reduction in the primary endpoint from >5%1-3 in the UFH group to <3%2-3 in the Bivalirudin group Sample size: A total of 830 patients (415 each group) will be necessary to gave the study 80% power and a significance level <0.05 This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 1. Nikolski E et al. Eur Heart J 2007; 28:1936-45 2. Kastrati A et al. N Engl J Med 2008;359:688-96 3. Schultz S et al. Eur Heart J 2010;31:582-7 10

Inclusion criteria Age 18 y Bleeding risk score ≥10 Procedure planned through the femoral approach Angiographic evidence of de novo or restenotic lesions requiring revascularization Stable or unstable angina or documented silent ischemia Negative biomarkers of myocardial injury Double antiplatelet therapy Stable hemodynamic conditions

Exclusion criteria Bleeding risk score <10 Pregnancy Ongoing or recent (<48 h) episode of STEMI or NSTEMI Negative biomarkers of myocardial injury Chronic dialysis and/or history or previous dialysis Hemodynamic instability requiring inotropic support or IABP Ongoing or recent (<7 days) treatment with glycoprotein IIb/IIIa inhibitors Ongoing or recent (6 months) bleeding or bleeding diathesis. Recent (within 6 months) stroke History of heparin-induced thrombocitopenia Platelet count <100.000/mm3

NAPLES III trial UFH group Bivalirudin group 70 U/Kg i.v. prior to start the procedure Additional bolus 20 U/Kg in case ACT <250 sec Bolus of 0.75 mg/kg i.v. prior to the start of the procedure, followed by infusion of 1.75 mg/kg per hour for the duration of the procedure Additional bolus 0.3mg/Kg in case ACT <250 sec

Endpoints Primary endpoint: Rate of in-hospital major bleeding, defined according the REPLACE 2 criteria: intracranial, intraocular, retroperitoneal, access-site haemorrhage requiring intervention, clinically overt blood loss resulting in a decrease in haemoglobin by ≥3 g/dl, any decrease in haemoglobin ≥4 g/dl, transfusion of ≥2 units of packed cells or whole blood This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 14

Endpoints Secondary endpoints: Rate of in-hospital major and minor bleeding, defined according the REPLACE 2 criteria Rate of in-hospital, 30-day and 1-year major adverse cardiac events, defined as death, non-fatal myocardial infarction, repeat revascularization Rate of stent thrombosis, according to the ARC criteria Rate of major bleeding according to other criteria This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 15

Assessed for eligibility ( n= 1859) Exclusion (n = 1021) Not meeting inclusion/exclusion criteria (n = 998) Radial access (n = 275) Acute myocardial infarction (n = 219) End-stage renal disease = 238) IIbIIIa inhibitors (n = 211) Recent bleeding (n = 55) Refused to partecipate (n = 23) Enrollement Randomized (n = 837) Patients allocated in the Bivalirudin Group (n = 418) Received allocated treatment (n = 418) Did not receive the allocated treatment (n =0) Patients allocated in the UFH group (n = 419) Received allocated treatment (n = 419) Did not receive the allocated treatment (n= 0) Allocation Patients lost at follow-up (n = 0) Discontinued treatment (n = 0) Patients lost at follow-up (n = 0) Discontinued treatement (n = 0) Follow-up Analysis Patients analized ( n = 418) Patients excluded from analysis (n = 0) Patients analized ( n 419) Patients excluded from analysis (n = 0) 16

Clinical Characteristics Bivalirudin group (N= 418) UFH Group (N=419) P Age, yrs (mean  SD) 78  4 0.89 Female, % 210 (50.5%) 186 (44.5%) 0.09 BMI (kg/m2) 28 4 27  4 0.25 LVEF, % (mean  SD) 49  9 50  8 0.07 Prior MI Prior PCI Prior CABG 181 (42%) 143 (34%) 55 (13.2%) 158 (38%) 150 (36%) 57 (13.6%) 0.10 0.63 0.85 eGFR (ml/min/1.73 m2) GFR <60 66±25 179 (42.8%) 64±24 204 (48.7%) 0.20 Diabetes mellitus Insulin-treated 189 (45.2%) 88 (21%) 181 (43%) 69 (16%) 0.56 Hypertension, % 350 (84%) 349 (83%) 0.86 Symptoms Silent ischemia Stable angina Unstable angina 77 (18%) 244 (68.4%) 97 (23.2%) 76 (18%) 250 (69.6%) 93 (22.4%) 0.98

Procedural Characteristics Bivalirudin group (N= 418) UFH Group (N=419) P CASS 1-vessel 2-vessel 3-vessel 78 (18.5%) 140 (33.5%) 200 (48%) 92 (22%) 149 (35.5%) 178 (42.5%) 0.20 Target vessel (not mutually exclusive) LAD LCX RCA LM SVG 155 (37%) 118 (28%) 120 (28.5%) 20 (4.5%) 10 (2%) 156 (37% 115 (27%) 121 (29%) 18 (4%) 14 (3%) 0.63 Lesion site Ostial Proximal Middle Distal 543 60 (11%) 204 (37.5%) 228 (42%) 51 (9.5%) 544 207 (38%) 223 (41%) 54 (10%) 0.84

Procedural Characteristics Bivalirudin group (N= 418) UFH Group (N=419) P Procedure Stent DES Rotablator Direct stenting Multivessel stenting 417 (99.8%) 338 (81%) 26 (6.5%) 42 (10%) 96 (23%) 417 (99.5%) 352 (84%) 46 (11%) 100 (24%) 0.94 0.84 0.98 0.73 0.80 Complex lesions (B2/C) 247(59%) 256 (61%) 0.51 CTO 40 (9.5%) 31 (7.5%) 0.24 Bifurcation lesion 77 (18.5%) 84 (20%) 0.63 Thrombus 17 (4%) 14 (3%) 0.56 Calcified lesion 171 (41%) 0.96

Procedural Characteristics Bivalirudin group (N= 418) UFH Group (N=419) P Pre-procedural QCA RVD, mm MLD, mm DS, % Lesion length, mm 3.06  0.53 0.52  0.37 83  10 17  10 3.06  0.56 0.56  0.37 82  10 18  9 0.87 0.12 0.19 0.60 Post-procedural QCA 3.23  0.52 3.19  0.52 2  3 3.22 0.57 3.17  0.58 2  5 0.88 0.63 0.40 Stent/patient 1.3  0.8 1.3  0.9 0.57 Stent length, mm 29  18 30  18 0.24 Max inflation pressure, atm 18  5 19  5 0.44 BA ratio 1.02  0.14 1.00  0.19 0.45

Procedural Characteristics Bivalirudin group (N= 418) UFH Group (N=419) P Radial approach 2 (0.5%) 0.99 Glycoprotein IIbIIIa inhibitors 5 (1.3%) 0.22 Volume of contrast media (ml) 177  83 170  79 0.26 Peak ACT value (seconds) <250 seconds 483±187 10 (2.4%) 305±77 68 (16.2%) <0.001 0.002

Primary endpoint Odds ratio = 1.28; 95% CI= 0.58-2.86 p = 0.54 3.3% 14/418 3,5 3,0 2.6% 14/418 2,5 11/419 2,0 16/146 % 1,5 1,0 0,5 0,0 UFH group Bivalirudin group

Primary endpoint Major bleeding Bivalirudin group (N= 14/418) UFH Group (N= 11/419) P Intracranial - Intraocular Retroperitoneal Access-site requiring intervention 7 (1.7%) 2 (0.5%) 0.10 Clinically overt bleeding (Hb drop >3 gr/dL) 2 (0.2%) 6 (1.4%) 0.29 Concealed bleeding (Hb drop >4 gr/dL) 5 (1.2%) 3 (0.7%) 0.50 Transfusion >2 units 4 (0.9%) 1.00

Primary endpoint % Entry-site Non entry-site UFH group 2,5 p = 0.80 2.1% 2,0 p = 0.10 7/418 9/419 1.7% 1.7% 7/418 7/418 1,5 % 1,0 0.5% 0,5 2/419 UFH group Bivalirudin group 0,0 Entry-site Non entry-site

Secondary endpoint Major bleeding Bivalirudin group (N= 418) UFH Group BARC 17 (4.1%) 11 (2.6%) 0.24 GUSTO 3 (0.7%) 5 (1.2%) 0.72 TIMI 2 (0.5%) 0.65 CURE 7 (1.7%) 0.56 PLATO 16 (3.8%) 10 (2.4%) 0.23

All bleeding (major and minor) 10.0 Odds ratio = 0.88; 95% CI= 0.55-1.44; p = 0.63 9.1% 9.0 8.1% 38/419 8.0 34/418 % 7.0 6.0 5.0 4.0 p = 1.00 6.0 5.2% 5.2% 5.0 p = 0.56 22/419 22/418 3.8% 4.0 % 16/419 2.9% 3.0 12/418 2.0 UFH group 1.0 Bivalirudin group Entry-site Non entry-site

Peak ACT & Bleeding Event yes Event no 365±151 364±150 355±141 316±86 380 365±151 364±150 355±141 360 340 Event yes 316±86 320 Event no 300 peak ACT (seconds) 280 260 240 220 200 Major bleeding Major&Minor bleeding

Periprocedural Myocardial Infarction (TnI >5x ULN) 25 21.5 21.8 20 90/419 91/418 % 15 10 5 UFH group Bivalirudin group

Secondary endpoint 30-day MACE Bivalirudin group (N= 418) UFH Group (N=419) P Major bleeding 14 (3.3%) 11 (2.6%) 0.58 Death 10 (2.4%) 6 (1.4%) 0.31 Myocardial infarction 1 (0.2%) 0.50 Revascularization 5 (1.2%) 3 (0.7%) 0.47 Stent thrombosis 2 (0.5%) 0.99 Composite 27 (6.5%) 18 (4.3%) 0.17

Secondary endpoint 1-year MACE Bivalirudin group (N= 418) UFH Group (N=419) P Death 20 (4.8%) 21 (5.0%) 1.00 Myocardial infarction 6 (1.7%) 2 (0.5%) 0.17 Revascularization 30 (7.2%) 32 (7.6%) 0.89 Stent thrombosis 4 (1.0%) 3 (0.7%) 0.71 Composite 68 (16.3%) 62 (14.8%) 0.11

Conclusions In patients at high risk of bleeding undergoing to elective PCI through the femoral approach, the use of bivalirudin does not reduce the rate of in-hospital major bleeding compared to UFH. Entry-site bleeding still represent an important issue Radial approach should be routinely used in this subgroup of patients

NAPLES III Investigators Inteventional Cardiologists Carlo Briguori, MD, PhD Amelia Focaccio, MD Gabriella Visconti, MD Michael Donahue, MD Laboratory of Interventional Cardiology, Clinica Mediterranea, Naples, Italy Clinical Cardiologists Bruno Golia, MD Bruno Ricciardelli, MD Coronary Care Unit and Department of Cardiology, Clinica Mediterranea, Naples, Italy Vascular surgeon Lucio Selvetella, MD Vascular Surgery, Clinica Mediterranea, Naples, Italy

NAPLES III Investigators Clinical Events Commitee Flavio Airoldi, MD Davide Tavano, MD Laboratory of Interventional Cardiology, IRCCS Multimedica, Milan Italy Data Monitoring & Safety Commitee Gerolama Condorelli, MD, PhD Cristina Quintavalle, PhD Department of Pathology, Federico II University, Naples, Italy Clinical Trial & Evaluation Unit Members Chiara Viviani Anselmi, PhD Laura Lapa, PhD Deparment of Cardiology IRCCS Humanitas Hospital, Milan, Italy