1. M. Valgimigli, MD, PhD On behalf of 3T/2R Investigators Tailoring Treatment with Tirofiban in patients showing Resistance to aspirin and/or Resistance to clopidogrel Tailoring Treatment with Tirofiban in patients showing Resistance to aspirin and/or Resistance to clopidogrel

2. Current treatment strategies for patients with coronary artery disease ignore the individual response to antiplatelet agent(s) This largely contrasts with the existing practice surrounding many cardiovascular medications including anti-hypertensive and lipid-lowering agents where response to therapy, or lack thereof, drives subsequent treatment decisions Background i

3. Inhibition of platelet aggregation following aspirin or clopidogrel intake varies greatly among patients Previous studies, using a variety of definitions, have shown that poor response to Aspirin or Clopidogrel increases up to 10-fold the risk of thrombotic events, particularly after PCI Whether this reflects suboptimal platelet inhibition per se which might benefit from alternative/ more potent antiplatelet agents, is unknown Background ii

4. Patients scheduled to undergo elective CAG/PCI for silent ischemia, stable angina or low risk NSTEACS Patients selection Screening Eligibility -Undergoing PCI -CK, CK-MB and Tp I/T persistently –ve -No controindications to Gp IIb/IIIa blockers -Aspirin and/or Clopidogrel poor response as assessed by VerifyNow™ Aspirin and P2Y12 assays (Accumetrics, USA)

5. < 40% platelet inhibition  600 mg clopidogrel LD at least 2 hours before  300 mg clopidgrel LD at least 6 hours before  75 mg clopidogrel MD for at least 7 days Aspirin reaction units (ARU) >550  ASA orally ≥80 mg for at least 5 days  i.v. 500 mg ASA 15 mins or more before Response evaluation Aspirin Poor Response Clopidogrel Poor Response or

6. Aspirin + Clopidogrel UFH or Bivalirudin Aspirin + Clopidogrel UFH or Bivalirudin Tirofiban*Tirofiban*PlaceboPlacebo Trial Design 1:1 *: 25  g/kg in 3 mins, followed by an 14-24 hour infusion at 0.15  g/kg/min Blood sampling: Hb, PLT, Tp; CK-MB mass @ 6, 12, 18 or 24 hrs Clinical F-UP: 30-d, 4, 8 and 12 months Bail-out Tirofiban Double Blind

7. Study Endpoints Primary Troponin I/T elevation > 3 times ULN in one or more blood sample(s) within 48 hours after PCI Ho= 45% in placebo vs. 25% in Tirofiban arm;  =90%  =5% Target sample size: 240 pts Secondary Troponin I/T elevation > 1 or 5 times ULN CK-MB mass eevation >1; 3 or 5 times ULN Major adverse cardiovscular events Stent thrombosis based on ARC classification

8. Study Organization Sponsor: University of Ferrara, Italy Data Management: Medical Trial Analysis, Switzerland Site and data monitoring: Medical Trial Analysis, Italy Clinical Events Committee: S. Curello (Chair), Brescia, Italy ECG core lab: MTA, C. Arcozzi (Chair) Angiographic core lab: MTA, P. Malagutti (Chair) DSMB: G Fucà, (Chair), Italy

9. 3T/2R P.I. and Sites G Campo Ferrara M Sabatè Barcelona G Percoco Lagosanto M Hamon Caen N de Cesare Zingonia Brugaletta Barcelona Meliga/Marra Torino A Repetto Pavia P Vranckx Hasselt P Agostoni Antwerp A Furgieri Cotignola C Tumscitz Piacenza

10. 1277 Patients Assessed for Eligibility 633 screened for Aspirin response 283 screened for Aspirin and Clopidogrel response 361 screened for Clopidogrel response Aspirin Screening failure Clopidogrel Screening failure 501253240204 132121 4 2653 Medical Tx CABG Troponin/CK-MB +ve Refused to participate 27 Coronary Angiography PCI 4 7 7 1 1 1 Medical Tx CABG Troponin/CK-MB +ve Refused to participate At risk for bleeding 1 1 3 2 1 3 5 6 3 26 Poor Responders to both agents 23 Randomised 12 allocated to/received Placebo 0 Died 11 allocated to/received Tirofiban tirofiban 0 Died 23 completed 30-d F-UP 30 day F-UP 93 Randomised 40 allocated to/received Placebo 5 received bailout tirofiban 1 Died 53 allocated to/received Tirofiban 2 calls for bailout tirofiban 0 Died 92 completed 30-d F-UP 147 Randomised 79 allocated to/received Placebo 5 received bailout tirofiban 0 Died 68 allocated to/received Tirofiban 0 Died 1 call for bailout tirofiban 147 completed 30-d F-UP 136 Aspirin Poor Responders 174 Clopidogrel Poor Responders 15%27% 9% 10% 8%23%

11. Baseline Characteristics Tirofiban Placebo P-Value (n=132) (n=131) Age (yr) 69 (62-75) 69 (61-75) 0.84 Male Sex (%) 74.2 72.5 0.78 BMI (kg/m 2 ) 28 (25-30) 27 (25-29) 0.27 Diabetes (%) 24 280.57 Hypertension (%) 67 760.10 CrCl (ml/min) 75.6 74.50.77 Prior MI (%) 47.7 38.20.13 Prior PCI (%) 38.9 38.90.99 Prior CABG (%) 6.8 6.10.99 LVEF (%) 56.5 580.98 Stable CAD (%) 65 690.78 Unstable CAD (%) 35 310.51 1-Vessel Disease (%) 27 280.78 Multi-Vessel Disease (%) 73 720.99 ASA Steady State (%) 1001000.99 Clopid. Steady State (%) 1001000.99 Tirofiban Placebo P-Value (n=132) (n=131) Age (yr) 69 (62-75) 69 (61-75) 0.84 Male Sex (%) 74.2 72.5 0.78 BMI (kg/m 2 ) 28 (25-30) 27 (25-29) 0.27 Diabetes (%) 24 280.57 Hypertension (%) 67 760.10 CrCl (ml/min) 75.6 74.50.77 Prior MI (%) 47.7 38.20.13 Prior PCI (%) 38.9 38.90.99 Prior CABG (%) 6.8 6.10.99 LVEF (%) 56.5 580.98 Stable CAD (%) 65 690.78 Unstable CAD (%) 35 310.51 1-Vessel Disease (%) 27 280.78 Multi-Vessel Disease (%) 73 720.99 ASA Steady State (%) 1001000.99 Clopid. Steady State (%) 1001000.99

12. Tirofiban Placebo P-Value (n=132) (n=131) No treated lesions 1.5±0.6 1.5±0.70.96 Multivessel PCI (%) 24 19 0.37 No Stents implanted 1.6±0.9 1.6±1.0 0.96 Stent Lenght ( mm) 27 270.59 Use of UFH (%) 98 980.99 Use of Bivalirudin (%) 2 20.99 Location of lesion (%) LMCA 2.6 1.60.72 LAD 40.9 34.00.17 CFX 21.8 25.00.47 RCA 65 690.78 Venous Graft 2.1 0.50.37 B2 or C type lesion (%) 58 560.86 Thrombus present (%) 5.7 4.30.64 Bifurcation (%) 25 180.13 Stenting (%) 92 940.82 Tirofiban Placebo P-Value (n=132) (n=131) No treated lesions 1.5±0.6 1.5±0.70.96 Multivessel PCI (%) 24 19 0.37 No Stents implanted 1.6±0.9 1.6±1.0 0.96 Stent Lenght ( mm) 27 270.59 Use of UFH (%) 98 980.99 Use of Bivalirudin (%) 2 20.99 Location of lesion (%) LMCA 2.6 1.60.72 LAD 40.9 34.00.17 CFX 21.8 25.00.47 RCA 65 690.78 Venous Graft 2.1 0.50.37 B2 or C type lesion (%) 58 560.86 Thrombus present (%) 5.7 4.30.64 Bifurcation (%) 25 180.13 Stenting (%) 92 940.82 Procedural Results

13. Primary Endpoint Tp >3  ULN w/in 48 hs Placebo Tirofiban 0 5 10 15 20 25 30 35 40 45 50 35.1% 20.4% P=0.009 for superiority RRR: 42% 95%CI: 61-12 Bail-out Tirofiban 2.3 8.4 % P=0.053

14. Overall < 70 yr ≥ 70 yr Male Female No Diabetes Diabetes Stable Angina Unstable Angina 1 Treated lesion > 1 Treated Lesion A/B1 Treated Lesion(s) B2/C Treated Lesion(s) Aspirin Poor Responders PRIMARY END POINT Tirofiban Placebo P-VALUE (%) Tirofiban Better Placebo Better LOG RISK RATIO (95% CI) Clopidogrel Poor Responders Poor Responders to Both 0.11 10 % Inhibition ≥21 % Inhibition <21 20.4 35.1 21.4 38.5 20.3 30.6 21.4 40.0 17.6 22.2 22.1 39.3 16.2 21.8 21.9 40.4 16.5 30.8 17.1 25.5 15.9 37.5 0 25.0 22.1 34.1 18.3 37.5 15.2 26.7 28.3 51.1 8.1 20.3 27.7 45.4 0.68 0.38 0.51 0.78 0.47 0.87 0.69 0.35 1° Endpoint: Subgroup Analysis

15. Secondary Endpoints 62% 50% 70% Relative Risk Reduction

16. 48 hour Outcomes Efficacy Endpoints (CEC adjudicated) MACE Death MI Definite ST P=0.009 Placebo Tirofiban 40% 10% 25% uTVR

17. 48 hour/30-day Outcomes Efficacy Endpoints (CEC adjudicated) MACE Death MI Definite ST Placebo Tirofiban 40% 10% 25% uTVR 1 2 1 11 Pulmonary embolism Pulmonary embolism 1 Type 4a* 1 Type 4b* 1 Type 4a* 1 Type 4b* 1 Type 4a* *: according to universal definition of myocardial infarction

18. 30-Day Outcomes Efficacy Endpoints (CEC adjudicated) MACE Death MI Definite ST P=0.006 Placebo Tirofiban 40% 10% 25% uTVR P=0.006 37% 21%

19. 30-Day Outcomes Safety Endpoints (DSMB adjudicated) Major Minor RBC Tranfusion RBC Tranfusion Mild  PLT P=0.99 Placebo Tirofiban TIMI-Bleeding 2% 6% 4% 8% 0% P=0.99

20. The tailored intensification of platelet inhibition through the infusion of tirofiban in poor responders to aspirin and/or clopidogrel decreased the rate of myocardial infarction after elective PCI and resulted in a lower rate of major adverse cardiovascular events at 30 days Our study provides proof of concept for a new treatment strategy in patients with coronary artery disease which, by assessing response to standard anti-platelet agents by a point-of-care assay, modulates intensity of treatment accordingly Summary