Appendices

Appendix 1. Definition of myocardial infarction in TRACER

The definitions of myocardial infarction (MI) were as follows for the 4 clinical settings in which it may occur:

  1. For patients with no recent revascularization in whom biomarkers were never elevated or have been documented to return to normal after a qualifying (or recent) MI, criteria 1 and 2 or criterion 3 or 4 must be met:

1)typical cardiac biomarker rise and/or fall with the following degrees of elevation accepted as biochemical evidence of myocardial necrosis:

a) troponin T or I—maximal concentration greater than the MI decision limit

b)creatine kinase–MB (CK-MB)—maximal concentration greater than the local upper limit of normal (ULN)

2)at least 1 of the following additional supportive criteria:

a) ischemic discomfort at rest lasting ≥10 minutes

b)electrocardiographic (ECG) changes indicative of ischemia (ST elevation ≥0.1 mV or ST depression ≥0.05 mV, or new T-wave inversions)

3)development of new, abnormal Q waves (≥30 milliseconds in duration and ≥1 mm in depth) in ≥2 contiguous precordial leads or ≥2 adjacent limb leads; or increased R amplitude in V1–V3 consistent with posterior infarction

4)pathologic findings of an acute MI

  1. For patients with no recent revascularization in whom biomarkers from a qualifying (or recent) MI remain elevated, criteria 1 and 2 or criterion 3 or 4 must be met:

1)cardiac biomarker re-elevation defined as:

a) increase by at least 20% of the previous value and documentation that the biomarker assayed was decreasing before the suspected new MI

2)at least 1 of the following additional supportive criteria:

a) ischemic discomfort at rest lasting ≥10 minutes

b)ECG changes indicative of ischemia (ST elevation ≥0.1 mV or ST depression ≥0.05 mV, or new T-wave inversions)

3)development of new, abnormal Q waves (≥30 milliseconds in duration and ≥1 mm in depth) in ≥2 contiguous precordial leads or ≥2 adjacent limb leads; or increased R amplitude in V1–V3 consistent with posterior infarction

4)new elevation of ST segments ≥0.1 mV in ≥2 contiguous precordial or adjacent limb leads AND one of the following:

a) ischemic discomfort at rest lasting ≥20 minutes

b)ischemia-mediated new hemodynamic decompensation requiring pharmacologic or mechanical support

c) angiographic evidence of acute coronary occlusion

  1. Within 24 hours after percutaneous coronary intervention (PCI), a patient must have one of the following:

1)CK-MB >3×ULN and, if the pre-PCI CK-MB was greater than the ULN, both an increase by at least 50% over the previous value and documentation that CK-MB was decreasing before the suspected recurrent MI

2)pathologic findings of an acute MI

  1. Within 24 hours after coronary artery bypass grafting (CABG), criteria 1 and 2 or criterion 3 must be met:

1)CK-MB >5×ULN and, if the pre-CABG CK-MB was greater than the ULN, both an increase by at least 50% over the previous value and documentation that CK-MB was decreasing before the suspected recurrent MI

2)at least 1 of the following supportive criteria:

a) development of new, abnormal Q waves (≥30 milliseconds in duration and ≥1 mm in depth) in ≥2 contiguous precordial leads or ≥2 adjacent limb leads; or increased R amplitude in V1–V3 consistent with posterior infarction

b)angiographically documented new graft or native coronary occlusion

c) imaging evidence of new loss of viable myocardium

3)pathologic findings of an acute MI

If cardiac troponin measurements are the only cardiac biomarker data available, they may be used by the clinical events committee, along with the ECG and clinical scenario, in the adjudication of suspected MI after revascularization (PCI or CABG).

Appendix 2. MI events post-randomization

Number of patients with MI events post-randomization
Vorapaxar / Placebo
Patients randomized / 6473 / 6471
Total MIs / 735 / 846
Number of MI events
1 / 535 (8.3%) / 597 (9.2%)
2 / 64 (1.0%) / 73 (1.1%)
3 / 16 (0.2%) / 17 (0.3%)
>3 / 6 (0.09%) / 11 (0.17%)

MI = myocardial infarction

Appendix 3. Type 4a MI by time from loading dose to PCI

Placebo
(n=3709) / Vorapaxar
(n=3757)
n (total) / % / n (total) / %
1 hour
LD ≤1 hour of PCI / 6 (220) / 2.7 / 3 (205) / 1.5
LD >1 hour of PCI / 154 (3489) / 4.4 / 145 (3552) / 4.1
2 hours
LD ≤2 hours of PCI / 35 (1102) / 3.2 / 33 (1106) / 3.0
LD >2 hours of PCI / 125 (2607) / 4.8 / 115 (2651) / 4.3

LD = loading dose; MI = myocardial infarction; PCI = percutaneous coronary intervention. Interaction P-value for vorapaxar effect by time of loading dose administration is P=0.044.

Appendix 4. Subgroup analysis

CABG = coronary artery bypass grafting; CI = confidence interval; CrCl = creatinine clearance; DTI = direct thrombin inhibitor; GP = glycoprotein; HR = hazard ratio; MI = myocardial infarction; PAD = peripheral artery disease; PCI = percutaneous coronary intervention; w/ = with