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A Methodological Approach to Non-invasive Assessments of Vascular Function and Morphology
Published on: February 7, 2015
Protocol for an observational study to assess the impact of pharmacogenetics on outcomes in vascular surgery
Kerry Anne Burke1,2, Selman Mirza3, Stuart Wright4
1Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK kerry.burke@nhs.net.
Insights
This study investigates how CYP2C19 gene variations affect clopidogrel effectiveness in chronic limb-threatening ischemia patients. Pharmacogenetics may personalize treatment to improve outcomes and reduce adverse events.
Area of Science:
- Vascular Surgery
- Pharmacogenetics
- Genomics
Background:
- Patients with chronic limb-threatening ischemia (CLTI) often receive clopidogrel to prevent adverse limb and cardiovascular events.
- Clopidogrel metabolism is influenced by CYP2C19 enzyme genetic variations, affecting its efficacy.
- Limited research exists on genotype-outcome relationships in vascular surgery patients.
Purpose of the Study:
- To determine the relationship between patient genotype and outcomes following revascularization in CLTI patients on clopidogrel.
- To explore the potential of pharmacogenetics in optimizing medication selection for improved patient outcomes.
Main Methods:
- Observational cohort study of patients undergoing lower limb revascularization for CLTI.
- Recruitment of patients prescribed clopidogrel or alternative medications post-procedure.
- CYP2C19 genotyping and follow-up via online records; primary outcomes include amputation and major adverse limb events (MALE) or death at 1 year.
Main Results:
- Analysis of primary outcomes (amputation, MALE/death) using Cox models.
- Secondary outcomes (MACE/death, re-interventions, bleeding) analyzed using negative binomial models.
- Comparison of outcomes between patients on clopidogrel and non-clopidogrel regimens.
Conclusions:
- The study aims to establish genotype-outcome correlations in CLTI patients.
- Findings may inform personalized pharmacogenetic approaches to optimize antiplatelet therapy.
- Results will be disseminated through peer-reviewed publications and conferences.
Introduction:
Patients with chronic limb-threatening ischaemia (CLTI) are often prescribed clopidogrel in order to reduce their risk of major adverse limb and cardiovascular events. Clopidogrel is metabolised by the CYP2C19 enzyme and genetic variations in CYP2C19 are common. These variants can influence an individual's ability to metabolise clopidogrel to its active metabolite. Few studies have investigated the relationship between patient genotype and outcomes in vascular surgery. This work aims to establish the relationship between patient genotype and outcomes after revascularisation in patients with CLTI who are prescribed clopidogrel. It will consider whether pharmacogenetics can be used to ensure patients are prescribed effective medications to optimise their outcomes.
Methods And Analysis:
This is an observational cohort study of patients undergoing lower limb surgical, endovascular or hybrid revascularisation for CLTI at Manchester University NHS Foundation Trust. Patients taking clopidogrel post-procedure, as well as those prescribed a non-clopidogrel based medication regimen, will be recruited prior to or shortly after revascularisation. Patients will undergo CYP2C19 genotyping and will be followed up using online records. The study has 90% power to detect 114 amputations with a target sample size of 483 participants. The primary outcomes are risk of amputation at 1 year and a composite endpoint for the risk of major adverse limb events (MALE) or death from any cause at 1 year. Secondary outcomes are risk of MALE at 1 year, risk of major adverse cardiovascular events (MACE) or death from any cause at 1 year, death within 30 days of revascularisation, minor re-interventions at 1 year, total number of re-interventions at 1 year and rate of systemic or gastrointestinal bleed at 1 year.Risk of amputation, MALE and MACE will be analysed using Cox models. All remaining outcomes will be analysed using negative binomial models. Potential competing events for the risk of amputation will be investigated as part of a sensitivity analysis. Patients given a non-clopidogrel-based medication will be compared as an additional analysis.
Ethics And Dissemination:
Manchester University Research Ethics Committee approval obtained as part of the Implementing Pharmacogenetics to Improve Prescribing (IPTIP) trial process (IRAS 305751). The results of the study will be published in a peer-reviewed journal and presented at international conferences.
Registration:
This work is a sub-protocol for the IPTIP study which is registered as ISRCTN14050335.
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