Uric acid and high-residual platelet reactivity in patients treated with clopidogrel or ticagrelor

Accepted Manuscript Uric acid and high-residual platelet reactivity in patients treated with clopidogrel or ticagrelor Lucia Barbieri, MD, Monica Verdoia, MD, Patrizia Pergolini, MD, Matteo Nardin, MD, Roberta Rolla, MD, Paolo Marino, MD, Giorgio Bellomo, MD, Harry Suryapranata, MD, PhD, Giuseppe De Luca, MD, PhD PII:

S0939-4753(15)30125-3

DOI:

10.1016/j.numecd.2015.12.015

Reference:

NUMECD 1536

To appear in:

Nutrition, Metabolism and Cardiovascular Diseases

Received Date: 21 July 2015 Revised Date:

11 September 2015

Accepted Date: 30 December 2015

Please cite this article as: Barbieri L, Verdoia M, Pergolini P, Nardin M, Rolla R, Marino P, Bellomo G, Suryapranata H, De Luca G, on behalf ofthe Novara Atherosclerosis Study Group (NAS), Uric acid and high-residual platelet reactivity in patients treated with clopidogrel or ticagrelor, Nutrition, Metabolism and Cardiovascular Diseases (2016), doi: 10.1016/j.numecd.2015.12.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Uric acid and high-residual platelet reactivity in patients treated with clopidogrel or ticagrelor Lucia Barbieri, MD, Monica Verdoia, MD, Patrizia Pergolini, MD, Matteo Nardin, MD, Roberta Rolla MD, Paolo Marino, MD, Giorgio Bellomo, MD, Harry Suryapranata, MD,

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PhD, Giuseppe De Luca, MD, PhD, on behalf of the Novara Atherosclerosis Study Group

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(NAS)

Division of Cardiology, Azienda Ospedaliera-Universitaria “Maggiore della Carità”,

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Eastern Piedmont University, Novara, Italy (LB, MV, MN, PM, GDL); Clinical Chemistry, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, Eastern Piedmont University, Novara, Italy (PP, RR, GB); Department of Cardiology, UMC St Radboud, Nijmegen, The

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Netherlands (HS).

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Running title: uric acid and platelet reactivity

Correspondence:

Giuseppe De Luca, MD, PhD.

Ospedale “Maggiore della Carità”, Eastern Piedmont University, C.so Mazzini, 18 28100 Novara, Italy E-mail: [email protected] Tel:

+39-0321-3733141

Fax: +39-0321-3733407 1

ACCEPTED MANUSCRIPT Abstract Background. High residual platelet reactivity (HRPR) is still an important challenge, despite the advent of new potent ADP-antagonists. Therefore it is of extreme importance to

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identify factors that can influence platelet activation. Serum uric acid (SUA) has been largely addressed in the past as a possible risk factor for coronary artery disease, with a possible association with platelets hyperreactivity. So far no studies has assessed the role of

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serum uric acid on the response to dual antiplatelet therapy. Therefore, the aim of our study was to evaluate the impact of uric acid levels on platelet function in patients treated with

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dual antiplatelet therapy (DAPT) with clopidogrel or ticagrelor.

Methods. We scheduled for platelet function assessment at 30-90 days post-discharge patients treated with DAPT (ASA + clopidogrel or ticagrelor) for an ACS or elective

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percutaneous coronary intervention (PCI). Platelet function was assessed by whole blood impedance aggregometry (Multiplate®-Roche Diagnostics AG), HRPR was considered for

antagonists).

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ASPI test > 862 AU*min (for ASA) and ADP test values >417 AU*min (for ADP-

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Results. We included a total of 493 patients (262 were on ASA and clopidogrel and 231 on ASA and ticagrelor). Patients were divided according to quartiles of serum uric acid levels measured at the time of platelet aggregation assessment (Group 1 < 4.6mg/dL, n = 114; Group 2, 4.7-5.8mg/dL, n = 133; Group 3, 5.9-6.8 mg/dL, n = 124; Group 4, > 6.9, n = 122). Patients with higher uric acid levels were older, more often smokers, with history of hypertension and previous coronary artery bypass surgery and renal failure and were more often on therapy with diuretics at admission. Patients with higher SUA had higher

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ACCEPTED MANUSCRIPT triglycerides and fibrinogen. Uric acid levels did not influence ASPI, COL, TRAP and ADP tests. High residual platelet reactivity (HRPR) was observed in 1.5% of patients treated with ASA, with no difference according to SUA quartiles (p = 0.60), confirmed at multivariate

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analysis after correction for baseline confounders (adjusted OR[95%CI] = 1.05 [0.44 – 2.52], p = 0.90). HRPR for ADP-antagonists was observed in 23.6% of patients, with no difference according to SUA quartiles (p = 0.47); this result was confirmed also after

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correction for baseline confounders (adjusted OR[95%CI] = 1.04 [0.84 - 1.28], p = 0.73). Moreover, no association was found between HRPR and uric acid levels both among

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patients treated with clopidogrel (p = 0.35) or ticagrelor (p = 0.74), that was confirmed after correction for baseline confounding factors (adjusted OR [95%CI] = 1.18 [0.90 – 1.55], p = 0.23) and (adjusted OR[95%CI] = 0.96 [0.63 – 1.47], p = 0.85). The absence of association between SUA and platelet reactivity was confirmed at linear regression analysis both with

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clopidogrel (r = 0.03, p = 0.55) or ticagrelor (r = -0.01, p = 0.85). Conclusion. This is the first large study showing that in patients receiving DAPT, uric acid

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levels do not influence response to ticagrelor and clopidogrel or the effectiveness of ASA.

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ACCEPTED MANUSCRIPT Introduction Platelet aggregation is a key point in the pathogenesis of coronary artery disease (CAD). In particular, among patients hospitalized after an acute coronary syndrome or undergoing

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elective coronary stent implantation, the use of an optimal dual antiplatelet therapy (DAPT) is of great importance in order to reduce mortality and recurrent thrombotic events (1,2). Despite the introduction of new, more active antiplatelet agents (3-7) suboptimal platelet

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inhibition still represents an important challenge, especially for interventional cardiologists.

therapies, especially ticagrelor.

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To date, very few is known about the predictors of impaired response to antiplatelet

Serum uric acid (SUA), a degradation metabolite of purines, has been addressed in past years as a possible risk factor for cardiovascular disease, in fact high SUA levels has been

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associated with the main determinants of atherosclerosis and metabolic syndrome. Hyperuricemia is a condition characterized by inhibited nitric oxide system, activation of the local rennin-angiotensin system, pro-inflammatory and proliferative actions and

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enhanced synthesis of reactive oxygen species with increased oxidative stress (8,9).

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Moreover, elevated uric acid has been reported to promote vascular smooth muscle proliferation and to up regulate the expression of platelet-derived growth factor and monocyte chemoattractant protein-1 and to induce cyclo-oxigenase-2, that link uric acid to inflammation and potentially to platelet hyperreactivity (10-13). However, elevated uric acid is commonly associated with additional several risk factors, that may by themselves influence platelet reactivity (14,15). Few data have been reported so far on the impact of uric acid on platelet reactivity, especially in the era of new potent ADP antagonists. Therefore, aim of our study is to evaluate the impact of uric acid on high residual platelet 4

ACCEPTED MANUSCRIPT reactivity (HRPR) in patients treated with DAPT with acetylsalicylic acid (ASA) and clopidogrel or ticagrelor.

Methods

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We analyzed a total of 547 patients discharged from our Division of Cardiology, “Maggiore della Carità” Hospital, Novara, with dual antiplatelet therapy with ASA (100mg daily) and

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ADP-antagonist (clopidogrel 75 mg daily or ticagrelor 90 mg b.i.d) due to an acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) in elective patients from

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September 2009 to December 2014. Patients were scheduled for chemistry and platelet function tests evaluation at 30-90 days from discharge. The study was approved by our local Ethical Committee and informed consent was obtained by all patients. Main demographic, clinical and angiographic data, together with the indication to DAPT were recorded at

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discharge and included in a dedicated database, protected by password. Hypertension was defined as systolic pressure > 140 mm Hg and/or diastolic pressure > 90 mm Hg or if the individual was taking antihypertensive medications. Diabetes mellitus was defined as

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previous diagnosis, specific treatment administration (oral drug or insulin), fasting glycemia

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> 126 mg/dL or HbA1c > 6.5%. Chronic kidney disease was considered for history of renal failure at admission or in patients with an estimated glomerular filtrate (GFR) < 60 mol/min/1.73m2 calculating by applying MDRD (Modification of Diet in renal Disease) formula.

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ACCEPTED MANUSCRIPT Biochemical measurements Blood samples were drawn at admission and at the time of platelet function assessment in all patients. Main biochemical chemistry was determined by standard methods. Glucose,

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creatinine, uric acid, blood cells count and lipid profile were determined by standard methods.

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Platelet function assessment

Platelet aggregation was measured by whole blood tests, including impedance aggregometry

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(Multiplate®- multiple platelet function analyser; Roche Diagnostics AG) For Multiplate a whole blood sample was stored in Vacutainer standard lithium heparin tubes and analyzed within 1-2 hours from collection (16). Tests with different agonists were performed: arachidonic acid (ASPI test) for ASA, collagen, adenosine diphosphate (ADP) and

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prostaglandin E1 for ADP test and thrombin receptor activating peptide (TRAP-6). The results were considered as Results were expressed as arbitrary Aggregation Units (AU) and plotted against time, defining platelet function as the area under curve (AUC or AU*min).

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HRPR was considered for AU*min values above lower limit normal

for ASA (HAPR),

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[range: 862 - 1344] or after ADP stimulation [range: 417 - 1030] respectively (17,18). The previously reported (19) cut-off of > 468 AU*min (46 U) was also applied to define poor ticagrelor responders. The test was repeated in patients with HRPR to confirm the findings.

Statistical analysis Statistical analysis was performed using SPSS 15.0 statistical package. Continuous data were expressed as mean + SD and categorical data as percentage. Analysis of variance and the chi-square test were used for continuous and categorical variables, respectively. Patients 6

ACCEPTED MANUSCRIPT were divided into quartiles according to serum uric acid levels measured at the time of platelet aggregation assessment. A linear regression analysis was additionally performed to explore the association between uric acid and platelet aggregation as continuous function. A

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p value < 0.05 was considered statistically significant. Multivariate logistic regression analysis was performed to evaluate the relationship between uric acid levels and platelet

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reactivity, after correction for baseline confounders, that were entered in the model in block.

Results

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We analysed a total of 547 patients. Among them 54 patients were exluded because of missing data about serum uric acid or platelet function. Therefore our final population was represented by 493 patients. Among them, 262 patients (53.2%) patients received ASA and clopidogrel and 231 (46.8%) received ASA and ticagrelor. Patients were divided according

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to quartiles of serum uric acid levels (Group 1 < 4.6mg/dL, n = 114; Group 2, 4.7-5.8mg/dL, n = 133; Group 3, 5.9-6.8mg/dL, n = 124; Group 4, > 6.9, n = 122). Main clinical and demographic characteristics according to SUA levels are listed in Table 1. Patients with

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higher SUA levels were older (p = 0.009), smokers (p = 0.002), with history of hypertension

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(p = 0.002) and previous coronary artery by-pass graft surgery (CABG) (p = 0.002). Moreover, they had more often renal failure (p < 0.001), dilated cardiomyopathy or valvular disease as indication for angiography (p = 0.02) and were more often in therapy with diuretics at admission (p < 0.001). Main biochemical parameters according to quartiles of SUA levels are listed in Table 2. Patients with higher SUA had higher baseline creatinine (p < 0.001), triglycerides (p = 0.001) and fibrinogen (p = 0.003). SUA levels did not influence ASPI test results (after Arachdonic Acid stimulation) (p = 0.45), COL (p = 0.62), TRAP (p = 0.45) or ADP tests (p = 0.18). High residual platelet reactivity (HRPR) was observed in 8 7

ACCEPTED MANUSCRIPT patients treated with ASA (1.5%), with no difference according to quartiles of uric acid levels (1.6%, 0.7%, 1.4%, 2.1%; p = 0.60) (Figure 1), that was confirmed at multivariate analysis after correction for baseline confounding factors (age, hypertension, smoke, renal

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failure, statins or diuretics at admission, creatinine, HDL-cholesterol, triglycerides, haemoglobin, fibrinogen) (adjusted OR[95%CI] = 1.05 [0.44 – 2.52], p = 0.90). On the other side HRPR for ADP-antagonist was observed in 119 patients (23.6%), with no

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difference according to quartiles of uric acid levels (23.1% in Group 1 versus 20% in Group 2, 26.8% in Group 3 and 24.8% in Group 4, p = 0.47) (Figure 2). These results were

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confirmed at multivariate analysis after correction for baseline confounders (adjusted OR[95%CI] = 1.04 [0.84 - 1.28], p = 0.73). These findings were also confirmed at linear regression analysis (r = 0.02, p = 0.60) (Figure 3). Moreover, no association was found between HRPR and uric acid levels both among patients treated with clopidogrel (33.9% in

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Group 1, 26.3% in Group 2, 41.7% in Group 3 and 36.6% in Group 4, p = 0.35) (Figure 4A) or ticagrelor (12.1% in group 1, 11.9% in Group 2, 13.4% in Group 3 and 9.3% in Group 4, p = 0.74) (Figure 4B). These results were confirmed after correction for baseline

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confounding factors (adjusted OR [95%CI] = 1.18 [0.90 – 1.55], p = 0.23) and (adjusted

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OR[95%CI] = 0.96 [0.63 – 1.47], p = 0.85). The absence of association between SUA and platelet reactivity was confirmed at linear regression analysis both with clopidogrel (r = 0.03, p = 0.55) (Figure 5A) or ticagrelor (r = -0.01, p = 0.85) (Figure 5B).

Discussion Our study showed the absence of correlation between HRPR and SUA levels among patients treated with clopidogrel or ticagrelor in association with ASA due to an ACS or an elective PCI. 8

ACCEPTED MANUSCRIPT CAD still represents the leading cause of mortality in developed countries. Even though great efforts have been done to improve antithrombotic therapies and revascularization techniques (20-23) during last decades, the results are still suboptimal, especially regarding

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high-risk subgroups of patients. The introduction of new, more potent ADP antagonists has partially overcome the phenomenon of resistance observed among patients treated with clopidogrel (24,25), anyway the results are still unsatisfactory with a persistent high rate of

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periprocedural complications or ischemic events at distance (26,27).

Platelet aggregation is a key point in the setting of CAD and therefore is of extreme

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importance to identify the most significant predictors of impaired response to antiplatelet agents.

The role of SUA levels as a possible risk factor for CAD has been explored in several studies in last decades with conflicting results (28,29). We previously found no association

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between uric acid and the extent of CAD (30). On the other side several studies in literature showed the association between elevated SUA and higher mortality and higher rate of cardiovascular events (31). Several factors have been advocated for this impact, such as

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increased oxidative stress and reduction of nitric oxide bioavailability, with consequent

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endothelial dysfunction and smooth muscle cells proliferation (32). Other studies showed that uric acid induces vascular smooth muscle cell proliferation by the activation or induction of extracellular signal regulate kinase and by mitogen activated protein kinases (33). Platelet activation may potentially contribute to explain the link between elevated uric acid and atherothrombosis. In fact, elevated serum uric acid levels seems to up regulate the expression of platelet-derived growth factor and monocyte chemoattractant protein-1 and to induce cyclo-oxigenase-2 with consequent association to increased inflammation and therefore to platelet hyperreactivity. On the basis of this assumption it is supposed that 9

ACCEPTED MANUSCRIPT elevated uric acid could influence platelet aggregation and be associated with high residual platelet reactivity in patients treated with DAPT. It is well know that elevated uric acid is associated with impaired renal function, and while several studies showed a significant

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correlation between renal failure and an increased incidence of high residual platelet reactivity in patients treated with clopidogrel (34,35), so far, no data have been reported on the impact of elevated uric acid on HRPR. Confirming all previous reports, elevated uric

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acid was associated with impaired renal function and overall higher cardiovascular risk profile. Despite that, we did not find any significant correlation between uric acid levels and

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HRPR both in patients treated clopidogrel or ticagrelor. In addition, no impact was observed on the response to ASA. Our results were all confirmed after correction for all baseline confounding factors. Future large studies are certainly needed to confirm our finding and to identify risk factors for high residual platelet reactivity in order to manage high risk

Limitations.

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subgroups of patients in the best way possible.

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Our study have no data regarding long term follow-up, therefore we cannot tell whether

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higher platelet reactivity related to the occurrence of cardiovascular events or mortality in our patients.

We did not use light transmission aggregometry to assess platelet function, but rather we preferred a whole blood test, being a bedside test and providing a more physiological stimulus for platelet activation, as several circulating factors can influence aggregation. Multiplate represents the only aggregation test to have demonstrated a significant impact on outcome, when antiplatelet therapy was tailored according to its results (36,37).

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ACCEPTED MANUSCRIPT Several differences in baseline characteristics were observed between the groups of patients in our study and could have influenced our findings. However, thee results were confirmed

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after correction for baseline confounders.

Conclusions.

This is the first large study showing that in patients receiving dual antiplatelet therapy, uric

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acid levels do not influenced ADP-mediated platelet reactivity or the effectiveness of ASA. These results were observed both in case of ticagrelor or clopidogrel. Therefore, increased

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platelet reactivity and impaired response to antiplatelet therapies can not be considered a factor involved in the negative prognostic implications of elevated uric acid among patients

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with CAD.

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ACCEPTED MANUSCRIPT Disclosure

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The authors declare no conflict of interest and no funding source

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ACCEPTED MANUSCRIPT References 1. Stone GW, Witzenbichler B, Weisz G et al. Platelet reactivity and clinical outcomes after coronary artery implantation of drug-eluting stents (ADAPT-DES): a

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prospective multicentre registry study. Lancet 2013 17;382(9892):614-23. 2. Giustino G, Baber U, Sartori S et al. Duration of Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation: A Systematic Review and Meta-

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Analysis of Randomized Controlled Trials. J Am Coll Cardiol. 2015 [Epub ahead of print].

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3. De Luca G, Suryapranata H, Marino P. Reperfusion strategies in acute ST-elevation myocardial infarction: an overview of current status. Prog Cardiovasc Dis 2008; 50: 352-82.

4. De Luca G, Bellandi F, Huber K et al. Early glycoprotein IIb-IIIa inhibitors in

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primary angioplasty-abciximab long-term results (EGYPT-ALT) cooperation: individual patient's data meta-analysis. J Thromb Haemost 2011; 9: 2361-70.

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5. Wallentin L, Becker RC, Budaj A et al. PLATO Investigators, Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J

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Med. 2009;361:1045-57.

6. Wiviott SD, Braunwald E, McCabe CH et al. TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15. 7. Verdoia M, Schaffer A, Cassetti E et al. Benefits from new ADP-antagonists as compared to clopidogrel in patients with stable angina or acute coronary syndrome: a meta-analysis of randomized trials. J Cardiovasc Pharmacol. 2014 Apr;63(4):339-50.

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ACCEPTED MANUSCRIPT 8. Filiopoulus V, Hadjiyannakos D, Vlassopoulos D. New insights into uric acid effects on the progression and prognosis of chronic kidney disease. Ren Fail. 2012;34(4):510-20.

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9. Elbasan Z, Şahin DY, Gür M et al. Contrast-induced nephropathy in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention. Angiology. 2014 Jan;65(1):37-42.

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10. Rao GN, Corson MA, Berk BC. Uric acid stimulates vascular smooth muscle cell proliferation by increasing platelet-derived growth factor A-chain expression. J Biol

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Chem1991;266:8604e8.

11. Zweier L, Kuppusamy P, Lutty GA. Measurement of endothelial cell free radical generation: evidence for a central mechanism of free radical injury in postischemic tissues. Proc Natl Acad Sci U S A 1988;85:4046e50.

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12. Aroor AR, McKarns S, Demarco VG, Jia G, Sowers JR. Maladaptive immune and inflammatory pathways lead to cardiovascular insulin resistance. Metabolism. 2013;62(11):1543-52.

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13. Cattaneo M. Resistance to antiplatelet drugs: molecular mechanisms and laboratory

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detection. J Thromb Haemost 2007;5(Suppl 1):230e7. 14. Lazzeri C, Valente S, Chiostri M et al. Uric acid in the acute phase of ST elevation myocardial infarction submitted to primary PCI: its prognostic role and relation with inflammatory markers: a single center experience. Int J Cardiol 2010;138:206–9. 15. Barbieri L, Verdoia M, Schaffer A et al. Impact of sex on uric acid levels and its relationship with the extent of coronary artery disease: A single-centre study. Atherosclerosis. 2015 Mar 20. [Epub ahead of print].

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ACCEPTED MANUSCRIPT 16. Verdoia M, Pergolini P, Camaro C, et al. PlA(1)/PlA(2) polymorphism does not influence response to Gp IIb-IIIa inhibitors in patients undergoing coronary angioplasty. Blood Coagul Fibrinolysis. 2013 Jun;24(4):411-8.

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17. Vidali M, Rolla R, Parrella M et al. Role of the laboratory in monitoring patients receiving dual antiplatelet therapy. Int J Lab Hematol. 2012; 34: 484-94.

18. Sibbing D, Braun S, Morath T, et al., Platelet reactivity after clopidogrel treatment

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assessed with point-of-care analysis and early drug-eluting stent thrombosis. J Am Coll Cardiol, 2009; 53: 849-856.

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19. Bonello L, Tantry US, Marcucci R et al. Working Group on High On-Treatment Platelet Reactivity. Consensus and future directions on the definition of high ontreatment platelet reactivity to adenosine diphosphate. J Am Coll Cardiol. 2010;56:919-33.

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20. Montalescot G, Helft G.The arranged marriage of cangrelor and bivalirudin. JACC Cardiovasc Interv. 2015 Mar;8(3):434-5. 21. De Luca G, Verdoia M, Suryapranata H. Benefits from intracoronary as compared to

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intravenous abciximab administration for STEMI patients undergoing primary

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angioplasty: a meta-analysis of 8 randomized trials. Atherosclerosis. 2012 Jun;222(2):426-33.

22. Koch KT, Grundeken MJ, Vos NS et al. One-year clinical outcomes of the STENTYS Self-Apposing® coronary stent in patients presenting with ST-segment elevation myocardial infarction: results from the APPOSITION III registry. EuroIntervention. 2015 Feb 19;10(11).

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ACCEPTED MANUSCRIPT 23. De Luca G, Dirksen MT, Spaulding C et al. Time course, predictors and clinical implications of stent thrombosis following primary angioplasty. Insights from the DESERT cooperation. Thromb Haemost. 2013;110(4):826-33.

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24. Muller I, Besta F, Schulz C et al. Prevalence of clopidogrel non-responders among patients with stable angina pectoris scheduled for elective coronary stent placement. Thromb Haemost 2003; 89:783–7.

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25. Angiolillo DJ, Fernandez-Ortiz A, Bernardo E et al. Variability in individual responsiveness to clopidogrel: clinical implications, management, and future

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perspectives. J Am Coll Cardiol 2007; 49:1505–16.

26. Stone GW, Witzenbichler B, Weisz G et al. Platelet reactivity and clinical outcomes after coronary artery implantation of drug-eluting stents (ADAPT-DES): a prospective multicentre registry study. Lancet. 2013. 17;382(9892):614-23.

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27. Patti G, Mangiacapra F, Ricottini E et al. Correlation of platelet reactivity and Creactive protein levels to occurrence of peri-procedural myocardial infarction in patients undergoing percutaneous coronary intervention (from the ARMYDA-CRP

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study). Am J Cardiol. 2013 Jun 15;111(12):1739-44.

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28. Culleton BF, Larson MG, Kannel WB, Levy D. Serum uric acid and risk for cardiovascular disease and death: the Framingham Heart Study. Ann Intern Med 1999;131:7e13.

29. Lazzeri C, Valente S, Chiostri M et al. Uric acid in the acute phase of ST elevation myocardial infarction submitted to primary PCI: its prognostic role and relation with inflammatory markers: a single center experience. Int J Cardiol 2010;138:206–9.

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ACCEPTED MANUSCRIPT 30. De Luca G, Secco GG, Santagostino M et al. Uric acid does not affect the prevalence and extent of coronary artery disease. Results from a prospective study. Nutr Metab Cardiovasc Dis. 2012; 22: 426-33.

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31. Ndrepepa G, Braun S, King L et al. Association of uric acid with mortality in patients with stable coronary artery disease. Metabolism. 2012;61(12):1780-6.

32. Ohtsubo T, Rovira II, Starost MF et al. Xanthine oxidoreductase is an endogenous

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regulator of cyclooxygenase-2. Circ Res 2004;95:1118e24.

33. Kanellis J, Watanabe S, Li JH et al. Uric acid stimulates monocyte chemoattractant

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Protein 1 productionin vascular smooth muscle cells via mitogen activated protein kinase and cyclooxygenase 2. Hypertension. 2003; 41:1287-1293. 34. Angiolillo DJ, Bernardo E, Capodanno D et al. Impact of chronic kidney disease on platelet function profiles in diabetes mellitus patients with coronary artery disease

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taking dual antiplatelet therapy. J Am Coll Cardiol 2010; 55: 1139–1146. 35. Gremmel T, Müller M, Steiner S et al. Chronic kidney disease is associated with increased platelet activation and poor response to antiplatelet therapy. Nephrol Dial

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Transplant. 2013 Aug;28(8):2116-22.

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36. Siller-Matula JM, Delle-Karth G, Lang IM et al. Phenotyping vs. genotyping for prediction of clopidogrel efficacy and safety: the PEGASUS-PCI study. J Thromb Haemost. 2012;10(4):529-42 37. Siller-Matula JM, Gruber C, Francesconi M et al. The net clinical benefit of personalized antiplatelet therapy in patients undergoing percutaneous coronary intervention. Clin Sci (Lond). 2015;128(2):121-30.

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ACCEPTED MANUSCRIPT p-value

0.02 0.04 0.15 0.07 0.009 0.004 0.4 0.22

0.11 0.56 0.01 0.38 <0.001

0.19

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Table 1. Baseline Clinical Characteristics according to quartiles of uric acid levels. I Quartile II Quartile III Quartile IV Quartile Variable Uric acid Uric acid 4.7Uric acid Uric acid < 4.6mg/dL 5.8mg/dL 5.9-6.8mg/dL > 6.9 (n = 114) (n = 133) (n = 124) (n = 122) Demographic and clinical characteristics Age (M-SD) 66.6+/-10.3 65.5+/-11.2 65.+/-11.2 69.9+/-10.8 Age > 75 (%) 24.6 24.2 22.6 36.9 Sex (M %) 66.7 79.7 82.3 74.6 Body mass index kg/m2 2.69+/-4.44 2.65+/-4.07 2.72+/-4.20 2.79+/-4.86 (M-SD) Hypertension (%) 71.1 62.1 76.6 81.7 Smoking (%) 18.4 28 26.6 27.5 Hypercolesterolemia (%) 55.7 59.4 61.9 60.4 Diabetes (%) 46.5 40.6 37.1 39.3 Family history of CAD (%) Previous AMI (%) 19.3 20.6 21.1 28.1 Previous PCI (%) 35.2 29.9 34.5 30 Previous CABG (%) 7.9 7.6 10.5 17.4 Previous Stroke (%) 7.4 4.9 7.2 9.3 Renal failure (%) 10.7 10.4 15.1 36.9 Indication for angiography Stable angina or silent 28.7 28.3 25.9 25.5 ischemia (%) Acute Coronary Syndrome 66.4 65.5 69.8 67.4 (%) DCM or valvular disease 4.9 6.2 4.3 7.1 (%) Theraphy at admission ACE I (%) 48.4 46.9 47.5 48.9 ARB (%) 19.7 20.7 23.7 22 Statins (%) 80.3 73.8 74.1 68.8 Nitrate (%) 39.3 42.8 43.2 45.4 Beta-Blockers (%) 75.4 68.3 74.1 67.4 Calcium Antagonist (%) 25.4 15.9 23.7 23.4 Diuretics (%) 18.9 25.5 25.9 46.8

0.55 0.02

0.89 0.54 0.05 0.34 0.32 0.82 <0.001

CAD = Coronary Artery Disease; MI = Myocardial Infarction; PCI = Percutaneous Coronary Interventions; CABG = Coronary Artery Bypass Grafting; STEMI = ST-Elevation Myocardial Infarction; ACS = Acute Coronary Syndrome; CMD =Dilated Cardiomyopathy; LV = Left Ventricle; ACE = Angiotensin Converting Enzyme; ARB = Angiotensin Receptor Blockers;

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II Quartile III Quartile IV Quartile Uric acid 4.7Uric acid Uric acid P value 5.9-6.8mg/dL 5.8mg/dL > 6.9 (n = 133) (n = 124) (n = 122) 220.3+/-57.3 219.9+/-66.5 223.8+/-69.7 0.07 13.7+/-1.6 13.8+/-1.8 13.3+/-1.7 0.53 8.5+/-3.9 8.6+/-5.4 8.2+/-2.5 0.80 144.9+/-38.7 148.4+/-45.1 144.2+/0.13 42.79+/-14.6 40.15+/-12.7 39.6+/-14.3 0.02 78.6+/-34.2 84.2+/-35.5 85+/-38.3 0.15 124+/-82.5 134.9+/-76.8 152.5+/-90.6 0.001 126.5+/-45.4 120.6+/-39 130.9+/-70.8 0.43 6.37+/-1.42 6.2+/-1.17 6.5+/-1.46 0.13 0.96+/-0.53 1.01+/-0.37 1.26+/-0.48 <0.001 0.46+/-1 0.54+/-1.3 0.69+/-1.3 0.78 426.5+/-127 438.2+/-139 454.2+/-128 0.03 305+/-196.1 291+/-175.3 311+/-205.5 0.45 427.5+/-152 422.9+/-166 445.1+/-191 0.62 1010+/-316 1055+/-340 1010+/-313 0.45 294.3+/-155 318.4+/-171 340.7+/-176 0.18

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I Quartile Uric acid Biochemistry parameters < 4.6mg/dL (n = 114) Platelet (M-SD) (10^5/ml) 239.8+/-77.8 Haemoglobin (M-SD) (g/dl) 13.2+/-1.5 White blood cells (10^3/µl) (M-SD) 8+/-2.4 Total Cholesterol (M-SD) (mg/dL) 144+/-35.6 HDL-Cholesterol (M-SD) (mg/dL) 44.4+/-14.6 LDL-Cholesterol (M-SD) (mg/dL) 76.9+/-28.3 Triglycerides (M-SD) (mg/dL) 115+/-68.3 Glycaemia (M-SD) (mg/dL) 126.8+/-47.3 Glycated Haemoglobin (M-SD) (%) 6.56+/-1.26 Basal Creatinine (M-SD) (mg/dL) 0.9+/-0.73 Reactive C protein 0.48+/-1.14 Fibrinogen (M-SD) (mg/dL) 403.9+/-147 330+/-195.4 421.6+/-149 993.6+/-102 326.1+/-187

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ASPI test (AU*min) COL test (AU*min) TRAP test (AU*min) ADP test (AU*min)

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reactivity and quartiles of uric acid levels

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Figure 3 Linear regression analysis showing the absence of association between platelet

Figure 4 Bar graph showing the prevalence of high-residual on treatment platelet reactivity

clopidogrel (Figure 4A) and ticagrelor (Figure 4B)

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Figure 5 Linear regression analysis showing the absence of association between platelet

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• High-on treatment platelet reactivity increases the risk or recurrent ischemic events • Very few is known about the predictors of impaired response to antiplatelet therapies • Possible association between serum uric acid and platelets hyperreactivity. • We showed no impact of SUA on response to ticagrelor and clopidogrel and ASA