Intra Coronary AdjunctivE Tenecteplase During Primary PCI for STEMI: A Randomized, Open-Label, Placebo Controlled Pilot Study To Evaluate The Feasibility And Safety Of Low-Dose Intracoronary Tenecteplase vs. IC Saline Placebo Administered as Adjunctive Therapy To Aspirin, Clopidogrel, And Glycoprotein IIb/IIIa Inhibition During Primary PCI For STEMI. Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Priyamvada Singh, M.B.B.S.; Jianping Guo; Samer Kazziha, M.D.; Chandan Devireddy, M.D.; Duane Pinto, M.D. M.P.H; J. Jeffrey Marshall, M.D.; George Stouffer, M.D.; Kreton Mavromatis, M.D.; Laura Grip; Eugene Braunwald, M.D.; and C. Michael Gibson M.S., M.D. on behalf of the ICE T TIMI 49 Investigators An Investigator Initiated Trial Funded by a Research Grant from Genentech Inc.

BACKGROUND Distal Embolization During Primary PCI Embolization During Diagnostic Angiography Distal Vessel Cut Off and Stain of Myocardium Despite Excellent Result Upstream in Coronary Artery

The Goal is to Restore Both Normal Epicardial & Normal Myocardial Blood Flow 7.0% 3.7% Mortality (%) n = 487 n = 328 Epicardial TIMI Grade 3 Flow Epicardial TIMI Grade 2 / 1 / 0 Flow 7.5% 5 way p = 0.007 5.4% 4.7% Mortality (%) 2.9% 0.7% n = 64 n = 226 n = 136 n = 34 n = 279 Myocardial Perfusion Grade 3 Myocardial Perfusion Grade 2 Myocardial Perfusion Grades 0/1 Myocardial Perfusion Grade 3 Myocardial Perfusion Grades 2/1/0 Gibson et al, Circulation 2000 3

GOAL Evaluate the feasibility and safety of low-dose IC tenecteplase (TNK) administration as adjunctive therapy to aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibition during primary PCI (PPCI).

TRIAL ORGANIZATION Trial Leadership: TIMI Study Group Chairman: Eugene Braunwald; Principal Investigator: C. Michael Gibson Project Director: Laura Grip; Statistician: Satishkumar Mohanavelu Data Safety Monitoring Board Jeffrey J. Popma, M.D. Enrolling Sites Principal Investigator Research Coordinator Number of Patients Dr. Samer Kazziha Elias Boueiri n=13 Dr. Chandan Devireddy Joanna Duncan n=11 Dr. Duane Pinto Jenifer Kaufman n=6 Dr. J. Jeffrey Marshall Ki-Ling Suen n=5 Dr. George Stouffer Carl Schuler n=3 Dr. Kreton Mavromatis Pamela Hyde n=2

STEMI < 6 hours for 1° PCI ASA 160-325 mg Clopidogrel 300-600 mg UFH Glycoprotein IIb/IIIa inhibitor TIMI 0/1 Flow in Culprit Artery R Advance wire and balloon without crossing lesion or withdrawing wire Study Drug - IC tenecteplase 4 mg bolus Study Drug - IC saline 4 mL bolus 2 min 2 min Angiography of culprit artery to assess percent stenosis, thrombus burden, epicardial flow and myocardial perfusion Check ACT (200-225 sec) UFH if necessary PCI Advance wire and balloon across lesion Study Drug - IC tenecteplase 4 mg bolus Study Drug - IC saline 4 mL bolus 2 min 2 min Angiography of culprit artery to assess epicardial flow and myocardial perfusion

PRIMARY EFFICACY ENDPOINT: Quantitative Coronary Analysis Primary Endpoint: The percent diameter stenosis of the culprit artery following the first administration of tenecteplase bolus vs placebo. 85% 93%

SECONDARY EFFICACY ENDPOINTS Corrected TIMI Frame Count (CTFC) Rate of restoring patency following IC bolus Rates of TIMI Myocardial Perfusion Grade Change in thrombus grade following first tenecteplase bolus

SAFETY ENDPOINTS - TIMI Major bleeding - TIMI Minor bleeding - TIMI Significant bleeding - Stroke through 30 days - ICH through 30 days - Cardiac arrhythmias

BASELINE CHARACTERISTICS IC Tenecteplase N = 18 Placebo N = 16 P-Value Age, mean (SD) 54.0 (±7.5) 55.9 (±9.3) NS Sex, male 14 (77.8%) 13 (81.3%) Prior PCI 3 (16.7%) 2 (12.5%) Diabetes 2 (11.1%) 3 (18.8%) Hypertension 12 (66.7%) 6 (35.5%) Prior MI 1 (6.3%) Hyperlipidemia 9 (50.0%) 6 (37.5%) Prior angina 7 (41.2%) Smoker within past year 12 (75.0%) 10 (55.6%)

PRIMARY EFFICACY END POINT: PERCENT DIAMETER STENOSIS OF THE CULPRIT LESION AFTER FIRST ADMINISTRATION OF STUDY DRUG AND OTHER SECONDARY ENDPOINTS IC Tenecteplase N = 18 Placebo N = 16 P-Value Percent Diameter Stenosis, (SD) 89.5% (±12.5) 93.7% (±10.5) NS Change in Percent Stenosis, (SD) -6.4% (±9.4) -1.9% (±4.4) CTFC 100.0 (60.0,100.0) 100.0 (100.0,100.0) TFG 2/3 9 (50.0%) 4 (25.0%) TMPG 2/3 2 (14.3%) Decrease in Thrombus Grade 8 (44.4%) 2 (12.5%) 0.041

POST-PCI ANGIOGRAPHIC CHARACTERISTICS (BEFORE SECOND BOLUS) IC Tenecteplase N = 18 Placebo N = 16 P-Value CTFC 26.00 (21.0,33.0) 16.00 (12.0,24.0) 0.050 CTFC <14 1 (8.3%) 5 (38.5%) 0.087 TFG 2/3 15 (100.0%) NS TMPG 2/3 8 (61.5%) 10 (71.4%)

% Patients with CTFC < X axis POST-PCI CORRECTED TIMI FRAME COUNT BY TREATMENT GROUP (Cumulative Distribution Function) p=0.05 % Patients with CTFC < X axis CTFC Frames

POST-SECOND BOLUS ANGIOGRAPHIC CHARACTERISTICS IC Tenecteplase N = 18 Placebo N = 16 P-Value CTFC 29.0 (23.0,43.0) 20.0 (14.0,30.0) NS CTFC <14 2 (12.5%) 1 (7.69%) TFG 2/3 16 (94.1%) 15 (100.0%) TMPG 2/3 9 (56.3%) 11 (73.3%)

SAFETY: BLEEDING IC Tenecteplase N = 18 Placebo N = 16 P-Value TIMI Major Bleeds 0.0% (0) N/A TIMI Minor Bleeds 27.8% (5) 6.3% (1) 0.180 TIMI Minimal Bleeds 22.2% (4) 12.5% (2) 0.660 TIMI Major or Minor Bleeds Transfusion of PRBC 5.6% (1) 1.000 Thrombocytopenia 26.7% (4) 0.033 Stroke Intracranial Hemorrhage (ICH)

LIMITATIONS Small sample size limits definitive conclusions regarding efficacy and safety Time needed for study drug to act when administered via intra-coronary route was assumed to be within two minutes

CONCLUSIONS Compared with IC placebo, IC TNK administration did not improve the pre-PCI percent stenosis, but did improve pre-PCI thrombus burden. There was more post-PCI hyperemia following placebo administration, perhaps reflecting greater distal embolization.