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\begin{document}

\title{Association of ITGA2 Dual Site Variants with Recurrent Ischemic Events
in Patients Undergoing Stenting for Symptomatic Intracranial
Atherosclerotic Stenosis}



\author[1]{Xingang Li}%
\author[1]{Yiwen Dong}%
\author[2]{Jiadan Ye}%
\author[1]{Sheng Cheng}%
\author[1]{Hongge Yang}%
\author[1]{Ze Li}%
\author[1]{Xuan Di}%
\author[3]{Xin Lou}%
\author[4]{Ning Ma}%
\affil[1]{Capital Medical University Affiliated Beijing Friendship Hospital}%
\affil[2]{Chinese Academy of Medical Sciences \& Peking Union Medical College Fuwai Hospital}%
\affil[3]{1st Medical Center of Chinese PLA General Hospital}%
\affil[4]{Beijing Tiantan Hospital}%


\vspace{-1em}



  
  \date{June 09, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Objective}: We aimed to investigate the relationship between
gene polymorphisms and the occurrence of adverse clinical events
following dual antiplatelet therapy in Patients with Symptomatic
Intracranial Atherosclerotic Stenosis. \textbf{Methods}: A total of 195
patients were enrolled, categorized into 32 cases (those with clinical
adverse events) and 163 controls (without events). Genotyping of 20 SNPs
from 17 genes was executed. Statistical analyses (Fisher's exact test,
logistic regression) were applied to determine associations.
\textbf{Results}: The ITGA2 rs1126643 (C807T) and rs1062535 (G873A)
polymorphisms were significantly correlated with adverse clinical
events. Specifically, the mutant frequency of allele C (ITGA2 rs1126643)
and allele G (ITGA2 rs1062535) was significantly higher in cases
compared to controls (OR = 2.97, 95\%CI = 1.702-5.172, P = 0.0001; OR =
3.27, 95\%CI = 1.762-6.066, P = 0.0002, respectively). Other genotypes
showed no significant differences between the groups.
\textbf{Conclusion}: The ITGA2 C807T and G873A polymorphisms may elevate
the risk of vascular events in Chinese patients. Detecting these
polymorphisms may be valuable in identifying patients at risk of
recurrent ischemic events.%
\end{abstract}%



\sloppy


\textbf{Title}

Association of ITGA2 Dual Site Variants with Recurrent Ischemic Events
in Patients Undergoing Stenting for Symptomatic Intracranial
Atherosclerotic Stenosis

\textbf{Author list}

Yiwen Dong\textsuperscript{1}, Jiadan Ye\textsuperscript{2}, Sheng
Cheng\textsuperscript{1}, Hongge Yang\textsuperscript{1}, Ze
Li\textsuperscript{1}, Xuan Di\textsuperscript{1}, Xin
Lou\textsuperscript{3}, Xingang Li*\textsuperscript{1}, Ning
Ma*\textsuperscript{4,5}

Yiwen Dong, \emph{dongyw1990@163.com},\textsuperscript{1} Department of
Pharmacy, Beijing Friendship Hospital, Capital Medical University,
Beijing, 100050, China

Jiadan Ye,\emph{yejiadan0118@163.com},\textsuperscript{2} Department of
Pharmacy, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing,
100037, China

Sheng Cheng,\emph{chengsheng\_08@sina.com},\textsuperscript{1}
Department of Pharmacy, Beijing Friendship Hospital, Capital Medical
University, Beijing, 100050, China

Hongge Yang, \emph{oneestnn@126.com},\textsuperscript{1} Department of
Pharmacy, Beijing Friendship Hospital, Capital Medical University,
Beijing, 100050, China

Ze Li, \emph{superlize@163.com},\textsuperscript{1} Department of
Pharmacy, Beijing Friendship Hospital, Capital Medical University,
Beijing, 100050, China

Xuan Di,\emph{dixuan091400@163.com},\textsuperscript{1} Department of
Pharmacy, Beijing Friendship Hospital, Capital Medical University,
Beijing, 100050, China

Xin Lou,\emph{louxin@301hospital.com.cn},\textsuperscript{3} Department
of Radiology, The First Medical Center of Chinese PLA General Hospital,
Beijing, China

Xingang Li,\emph{lxg198320022003@163.com},\textsuperscript{1} Department
of Pharmacy, Beijing Friendship Hospital, Capital Medical University,
Beijing, 100050, China

Ning Ma,\emph{maning\_03@hotmail.com},\textsuperscript{4} Department of
Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical
University, No. 119 South 4th Ring West Road, Fengtai District, Beijing
100070, China. \textsuperscript{5}China National Clinical Research
Center for Neurologic Diseases, Beijing, 100070, China

\textbf{Corresponding authors}

*Xingang Li, and Ning Ma contributed equally to this work and should be
considered co-corresponding authors.

\textbf{Abstract}

\textbf{Objective} : We aimed to investigate the relationship between
gene polymorphisms and the occurrence of adverse clinical events
following dual antiplatelet therapy in Patients with Symptomatic
Intracranial Atherosclerotic Stenosis.

\textbf{Methods} : A total of 195 patients were enrolled, categorized
into 32 cases (those with clinical adverse events) and 163 controls
(without events). Genotyping of 20 SNPs from 17 genes was executed.
Statistical analyses (Fisher's exact test, logistic regression) were
applied to determine associations.

\textbf{Results} : The ITGA2 rs1126643 (C807T) and rs1062535 (G873A)
polymorphisms were significantly correlated with adverse clinical
events. Specifically, the mutant frequency of allele C (ITGA2 rs1126643)
and allele G (ITGA2 rs1062535) was significantly higher in cases
compared to controls (OR = 2.97, 95\%CI = 1.702-5.172, P = 0.0001; OR =
3.27, 95\%CI = 1.762-6.066, P = 0.0002, respectively). Other genotypes
showed no significant differences between the groups.

\textbf{Conclusion} : The ITGA2 C807T and G873A polymorphisms may
elevate the risk of vascular events in Chinese patients. Detecting these
polymorphisms may be valuable in identifying patients at risk of
recurrent ischemic events.

\textbf{Keywords}

Stroke, Ischemic, Dual antiplatelet therapy, Single nucleotide
polymorphism, ITGA2

\textbf{Introduction}

As of the latest Global Burden of Disease (GBD) estimates for 2019,
stroke ranks as the second largest global cause of death, significantly
impacting public health, especially in low and middle-income countries
{[}1{]}. GBD 2017 data indicates that the number of stroke-related
deaths in China is approximately 2 million {[}2{]}. Effective management
strategies for carotid artery stenosis encompass percutaneous
transluminal angioplasty, stent implantation, post-surgery dual
antiplatelet therapy with aspirin and clopidogrel, and proactive risk
factor management to prevent recurrent ischemic events in stroke
patients {[}3,4{]}. Concurrently, high therapeutic platelet reactivity
has emerged as a predictor of major adverse cardiovascular events,
influenced by factors including metabolism, genetics, clinical
complications, and patient compliance {[}5{]}.

The venerable drug, aspirin, cuts the relative risk of recurrent stroke
by around 22\% {[}6{]}. However, not all patients experience its
antithrombotic effects, leading to a phenomenon known as ''aspirin
resistance,'' where platelet aggregation inhibition remains incomplete,
potentially resulting in cardiovascular events post-administration
{[}7{]}. In China, studies on cardiovascular and cerebrovascular
diseases indicate that the rates of aspirin resistance, semi-resistance,
and sensitivity stand at 15.4\%, 4.6\%, and 64.6\% respectively {[}8{]},
with some analyses reporting resistance rates up to 60\% {[}7{]}.
Clopidogrel, a prodrug, undergoes variable absorption and metabolism due
to distinct bodily enzymes {[}6,8{]}. Consequently, gene mutations tied
to these pathways can lead to differential patient reactions, flagging
concerns of ''clopidogrel resistance'' {[}8,9{]}. Research has
documented individual variability in clopidogrel's antiplatelet
response, wherein inadequate or excessive response escalates the risks
of ischemia and bleeding, respectively {[}9{]}.

Post-absorption in the intestinal tract, aspirin swiftly hydrolyzes into
salicylic acid and other compounds. It then undergoes an irreversible
acetylation reaction with the active portion of the platelet COX serine
residue, deactivating the enzyme and curtailing the arachidonic acid AA
metabolism. This suppresses TXA2 generation, a known inducer of platelet
aggregation, exerting an anticoagulant effect {[}7,10{]}. Clopidogrel's
metabolic activation hinges on the hepatic cytochrome P450 system. Gene
mutations such as ABCB1, CYP2C19 {[}11{]}, CYP3A4, CYP3A5, PON1
{[}11{]}, P2Y12 {[}11{]} and CES1{[}12{]}, which play roles in its
pharmacokinetic and pharmacodynamic pathways, influence its antiplatelet
efficacy. Particularly, the CYP2C19 enzyme activity prominently affects
clopidogrel's activation {[}13,14{]}, with its intestinal absorption
chiefly restrained by the activity of the P-glycoprotein intestinal
efflux pump, encoded by the ABCB1 gene {[}15{]}. Grasping the
ramifications of gene polymorphisms on dual antiplatelet therapy can
bolster personalized clinical treatments.

Patients less responsive in producing anti-platelet aggregation effects
tend to be more susceptible to drug resistance. In such cases,
clinicians often advise switching to alternative medications or
combining drugs {[}13{]}. With the pervasive utilization of dual
antiplatelet therapy in combating cardiovascular and cerebrovascular
diseases, and in the absence of alternative medicines, continuous
monitoring of disease progression in potential resistance-risk
individuals becomes imperative {[}9,16{]}. The expanding knowledge on
the genetic underpinnings of stroke and cardiovascular ailments, powered
by advances in genomic technologies, heralds the prospect of precision
drug treatments. Pharmacogenetics offers a vision wherein a patient's
genetic makeup guides clinicians in choosing the most effective therapy
{[}17{]}.

\textbf{Materials and Methods}

\textbf{Study Population}

We conducted a case-control study that enrolled ischemic stroke patients
who underwent stenting for either extracranial or intracranial arterial
stenosis at Beijing Tiantan Hospital, Capital Medical University. The
inclusion criteria encompassed: 1) Confirmed diagnosis of ischemic
cerebrovascular disease accompanied by 70\% to 99\% stenosis of major
intracranial or extracranial arteries, as evidenced by DSA. 2)
Initiation of a regimen consisting of clopidogrel (75 mg/day) and
aspirin (100 mg/day) at least 5 days prior to enrollment. 3) Successful
acquisition of informed consent. Patients were excluded if they had: 1)
Contraindications to extracranial or intracranial stenting. 2) Known
allergic reactions or contraindications to aspirin, clopidogrel,
heparin, or any anesthetics. 3) Conditions like active peptic ulcer
disease, bleeding tendencies, severe liver or kidney disorders. 4)
Comorbid conditions potentially shortening life expectancy to less than
a year. 5) Concurrent participation in a conflicting study.

\textbf{Study Design}

Demographic and clinical data were extracted from medical records,
covering aspects such as gender, age, BMI, intracranial stent, smoking,
alcohol consumption, hypertension, diabetes, or hyperlipidemia.
Clopidogrel 75 mg and aspirin 100 mg were started by all patients at
least 5 days before stenting. A 5 mL venous blood sample was taken from
each patient a day before surgery for genotyping, preserved at -70\selectlanguage{ngerman}°C.
Seasoned neurointerventionalists undertook the stenting procedure.
Post-surgery, patients were maintained on dual antiplatelet therapy for
90 days, transitioning thereafter to mono-antiplatelet therapy. Risk
factors like hypertension, LDL levels, and lifestyle factors were
actively managed. Primary endpoints included TIA, ischemic stroke,
myocardial infarction, and vascular-related mortality. The researchers
defined ischemic stroke as a new focal neurological deficit lasting at
least 24 hours without bleeding on CT or MRI. They defined TIA as a
transient episode of neurological dysfunction caused by focal cerebral
or retinal ischemia, lasting at least 10 minutes but resolving within 24
hours, regardless of DWI changes. Outcomes were tracked through
follow-up visits or phone interviews at regular intervals within a year
(1, 2, 3, 6 and 12 months). The researchers reviewed inpatient
readmission records and outpatient records. Two independent physicians
who were blinded to the subsequent course classified and adjudicated all
clinical events. The patient pool was then bifurcated into a ''case
group'' and a ''control group'' for comparison based on genotypes.

\textbf{Genotyping}

Frequently occurring genetic polymorphisms tied to aspirin and
clopidogrel resistance were prioritized (detailed in \textbf{Table 1} ).
Genomic DNA from leukocytes in blood was extracted using the EZNA\selectlanguage{english} Blood
DNA Midi Kit (Omega Bio-Tek, Norcross, GA, USA). Genotyping was
performed by Boao Biotechnology Co., Ltd (Beijing, China) by MALDI-TOF
mass spectrometry using the MassARRAY system (Sequenom, San Diego, CA,
USA) according to the manufacturer's instructions. Sequenom Assay Design
3.1 software (Sequenom, San Diego, CA, USA) was used to design
single-base extensions and PCR primers. Genotype calling was performed
in real-time using MassARRAY RT software version 3.0.0.4 and analyzed
using MassARRAY Typer software version 3.4 (Sequenom, San Diego, CA,
USA). The analysis was repeated for quality control on randomly selected
subgroups of 10\% of cases and controls; reproducibility was 100\%.

\textbf{Statistical Analysis}

Data were analyzed using the SPSS statistical package (version 17.0) and
PLINK v1.07 software. Continuous variables underwent Student's t-test
analysis and are articulated as mean +- SD. Pearson's \selectlanguage{greek}χ \selectlanguage{english}test evaluated
categorical data, whereas Fisher's exact test was reserved for instances
of expected low cell frequencies. Genotype distributions were compared
using Fisher's exact test (\selectlanguage{greek}χ\selectlanguage{english}\textsuperscript{2} test). The strength of
genetic variant associations with primary outcomes was represented
through ORs and 95\% CIs, assessed via unconditional logistic
regression. Haploview 4.1 software (Daly Lab, USA) was employed to
define LD patterns and haplotype structures, with significance
determined through the \selectlanguage{greek}χ\selectlanguage{english}\textsuperscript{2} test. A P-value below 0.05
was earmarked as statistically significant.

\textbf{Results}

\textbf{Characteristics of the study population}

Out of the total cohort, 195 patients were incorporated into the study.
This comprised 32 cases (those experiencing significant clinical adverse
events) and 163 controls (those without any adverse
events).\textbf{Table 1} delineates the baseline characteristics of
these patients. Out of the 32 adverse events documented, 11 were strokes
(34.3\%), 3 were angina episodes (9.4\%), 4 were myocardial infarctions
(12.5\%), and 14 were TIAs (43.8\%). Notably, the foundational
characteristics of the case group mirrored those of the control group.

\emph{{[}Insert Table 1 here{]}}

\textbf{SNP selection and genotyping}

For genotyping purposes, 20 SNPs derived from 17 genes were pinpointed.
Detailed attributes of these SNPs, including their locations, presumed
functions, along with the findings of MAF and HWE, are catalogued
in\textbf{Table 2} . Here, MAF is indicative of the frequency of the
rarest allele among our study's participants. Three SNPs - rs6787801
(LP2RY12), rs1045642 (ABCB1), and rs2307240 (CES1) - exhibited an MAF
lower than 0.05. This discrepancy might arise due to the limited sample
size. However, when consulting the HapMap database, all SNPs manifested
MAFs exceeding 5\%. Furthermore, the genotype distribution remained
congruent with HWE (P \textgreater{} 0.05), signifying no noteworthy
deviation for any SNP across the patient spectrum.

\emph{{[}Insert Table 2 here{]}}

\textbf{Association of recurrent ischemic events and genotypes}

\textbf{Table 3} chronicles the outcomes from both Fisher's exact test
and logistic regression analysis juxtaposing cases and controls. When
set against controls, the cases manifested a notably elevated mutant
frequency for allele C (ITGA2 rs1126643) (OR = 2.97, 95\%CI =
1.702-5.172, P = 0.0001) and allele G (ITGA2 rs1062535) (OR = 3.27,
95\%CI = 1.762-6.066, P = 0.0002). No marked differences in other
genotypes were discerned between the two groups (P \textgreater{} 0.05).
The statistical power was assessed to determine if the non-significant
outcomes truly stemmed from a lack of correlation within the sample or
were attributable to insufficient statistical potency.

\emph{{[}Insert Table 3 here{]}}

\textbf{Haplotype analysis and association with event}

The LD block and the haplotype structure were measured by D' and
R\textsuperscript{2}, and the final LD analysis revealed two haplotypes
in our patients. Two SNPs of rs41273215 and rs57731889 in PEAR1 are in
Block 1, and rs1126643 and rs1062535 in ITGA2 are in Block 2
(\textbf{Figure 1} ). The significance of any haplotypic association is
shown in \textbf{Table 4} . In Block 2, the linked variant alleles were
observed most frequently as the GC haplotype (frequency 0.700) and AT
haplotype (frequency, 0.278). Both GC and AT haplotypes showed a
significant impact on the recurrence of adverse events. No other
haplotype was associated with the risk of clinical events

\textbf{Discussion}

This study aimed to determine the influence of gene polymorphisms on
clinical adversities following dual antiplatelet therapy. Notably, the
polymorphisms ITGA2 C807T (rs1126643) and G873A (rs1062535) were found
to have a significant association with the onset of adverse clinical
events. ITGA2, located on chromosome 5q23-31, encodes the GP Ia/IIa - a
crucial platelet integrin receptor - with 807T/C situated in exon 7 and
873A/G within the intron of ITGA2. The GP Ia/IIa complex (integrin \selectlanguage{greek}α\selectlanguage{english}2b1)
of platelet glycoprotein receptors binds to exposed collagen,
facilitating stable platelet adhesion and activation {[}18{]}. These
connections trigger potent signaling cascades culminating in thrombosis.
Existing literature reveals that platelet surface \selectlanguage{greek}α\selectlanguage{english}2b1 levels correlate
with the adhesive capacity and extent of platelets to collagen in the
bloodstream {[}19{]}. A deficit in GP Ia/IIa, either congenital or
acquired, can precipitate hemorrhagic tendencies, with SNPs in the ITAG2
gene modulating the expression of GP Ia/IIa {[}20{]}.

The C807T has two alleles, C and T, resulting in three genotypes: CC,
CT, and TT. Preliminary research indicated elevated GP Ia/IIa expression
in individuals possessing the T allele, suggesting its thrombogenic
potential. Consequently, patients with the CC genotype could be more
receptive to aspirin and clopidogrel treatment compared to those with CT
or TT genotypes {[}21,22{]}. Nonetheless, previous studies investigating
the genetic links between glycoprotein gene polymorphism and ischemic
stroke have produced mixed findings. The T allele, in contrast to the C
allele, hasn't been linked with heightened cardiovascular event risks in
patients with cardiovascular and cerebrovascular diseases undergoing
aspirin and clopidogrel treatment {[}23,24{]}. The genetic polymorphism
landscape of ITGA2 varies across populations. Despite expecting
expression patterns of different Gplana/IIa genotypes to abide by
straightforward Mendelian inheritance, the prevalent expression of the
ostensibly low-risk CC/TT genotype in general European demographics
implies its protective nature and potential pre-thrombotic advantage
over TT/AA {[}25{]}. Beyond genetics, other clinical factors might
modulate patients' responsiveness to aspirin and clopidogrel. A
meta-analysis encompassing 15 studies with 2242 cases and 2408 controls
identified a correlation between the ITGA2-C807T polymorphism and
ischemic stroke susceptibility, specifically in Asians and in-patients,
but this was absent in Caucasians and out-patients {[}26{]}.
Additionally, evidence suggests that C807T mutations might elevate
plasma lipid concentrations, amplifying stroke risk {[}27{]}.

The G873A (rs1062535) polymorphism in the ITGA2 gene is characterized by
a G\textgreater{}A transition. Certain studies postulate that patients
with the GG genotype might experience reduced residual platelet
reactivity upon aspirin and clopidogrel treatment in contrast to those
with the AG or AA genotype. In our cohort, we observed a heightened risk
association for clinical outcomes with allele G over allele A. Yet, some
research counters this, suggesting no significant impact of the 873A
locus polymorphism on adverse cardiovascular or cerebrovascular
incidents {[}22{]}.

In summary, the polymorphisms ITGA2 rs1126643 and rs1062535 could
heighten the vulnerability to subsequent vascular incidents in Chinese
patients diagnosed with either extracranial or intracranial occlusive
conditions. Although our study did not identify the effects of
previously documented pharmacogenetic-related SNPs involved in
antiplatelet therapy, it's imperative to note the limited scope of our
research. Hence, larger studies are essential for confirming these
findings.

Acknowledgements

The authors would like to sincerely acknowledge and thank all the study
participants for their valuable involvement to execute this study.

Authors' contributions

Dong Yiwen: Conduct surveys, conduct statistical analysis, and write
preliminary drafts; Ye Jiadan: Investigation, data management; Cheng
Sheng: Methodology; Yang Hongge and Di Xuan: data collection; Li Ze:
Data analysis; Lou Xin and Li Xingang: Project Management, Methodology,
Resources, Writing Review; Ma Ning: Editor. The author has read and
approved the final manuscript.

Xin Lou, Xingang Li, and Ning Ma contributed equally to this work and
should be considered co-corresponding authors.

Funding

This work was supported by Beijing Science and Technology Planning
Project (Z221100007422032) , National Natural Science Foundation of
China (8220101100) and R\&D Program of Beijing Municipal Education
Commission (KM202210025016).

Availability of data and materials

The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Beijing
Tiantan Hospital, Capital Medical University (Ethics approval number:
qx2012-012-01 and KY2014-051-01), and written informed consents were
obtained from patients or their close relatives.

Consent for publication

We have obtained consent from participants/patients for publication.

Competing interests

The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to
influence the work reported in this paper.

Figure legend

Supplemental material: Diagram of the block structure of SNPs generated
by Haploview. The numbers in the boxes are D' (upper panel) and
R\textsuperscript{2} (down panel) values, and the depth of red color
showed computed pairwise D' and R\textsuperscript{2}.

\textbf{References}

1. Collaborators GBDS. Global, regional, and national burden of stroke
and its risk factors, 1990-2019: a systematic analysis for the Global
Burden of Disease Study 2019. Lancet Neurol. 2021;20:795-820.

2. Ma Q, Li R, Wang L, et al. Temporal trend and attributable risk
factors of stroke burden in China, 1990-2019: an analysis for the Global
Burden of Disease Study 2019. Lancet Public Health. 2021;6:e897-e906.

3. Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano
RP. Acute coronary syndromes. Lancet. 2022;399:1347-58.

4. Xian Y, Xu H, Matsouaka R, et al. Analysis of Prescriptions for Dual
Antiplatelet Therapy After Acute Ischemic Stroke. JAMA Netw Open.
2022;5:e2224157.

5. Simonte G, Guglielmini G, Falcinelli E, et al. High-on-treatment
platelet reactivity predicts adverse outcome after carotid artery
stenting: A prospective study. Thromb Res. 2023;222:117-23.

6. Shah J, Liu S, Yu W. Contemporary antiplatelet therapy for secondary
stroke prevention: a narrative review of current literature and
guidelines. Stroke Vasc Neurol. 2022;7:406-14.

7. Khan H, Kanny O, Syed MH, Qadura M. Aspirin Resistance in Vascular
Disease: A Review Highlighting the Critical Need for Improved
Point-of-Care Testing and Personalized Therapy. Int J Mol Sci. 2022;23.

8. Patel S, Arya V, Saraf A, Bhargava M, Agrawal CS. Aspirin and
Clopidogrel Resistance in Indian Patients with Ischemic Stroke and its
Associations with Gene Polymorphisms: A Pilot Study. Ann Indian Acad
Neurol. 2019;22:147-52.

9. Ross S, Krebs K, Pare G, Milani L. Pharmacogenomics in Stroke and
Cardiovascular Disease: State of the Art. Stroke. 2023;54:270-8.

10. Montinari MR, Minelli S, De Caterina R. The first 3500 years of
aspirin history from its roots - A concise summary. Vascul Pharmacol.
2019;113:1-8.

11. Li XQ, Ma N, Li XG, et al. Association of PON1, P2Y12 and COX1 with
Recurrent Ischemic Events in Patients with Extracranial or Intracranial
Stenting. PLoS One. 2016;11:e0148891.

12. Zhao Z, Li X, Sun S, et al. Impact of genetic polymorphisms related
to clopidogrel or acetylsalicylic acid pharmacology on clinical outcome
in Chinese patients with symptomatic extracranial or intracranial
stenosis. Eur J Clin Pharmacol. 2016;72:1195-204.

13. Pereira NL, Rihal CS, So DYF, et al. Clopidogrel Pharmacogenetics.
Circ Cardiovasc Interv. 2019;12:e007811.

14. Saiz-Rodriguez M, Belmonte C, Caniego JL, et al. Influence of CYP450
Enzymes, CES1, PON1, ABCB1, and P2RY12 Polymorphisms on Clopidogrel
Response in Patients Subjected to a Percutaneous Neurointervention. Clin
Ther. 2019;41:1199-212 e2.

15. Pan Y, Elm JJ, Li H, et al. Outcomes Associated With
Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack: A
Pooled Analysis of Clopidogrel in High-Risk Patients With Acute
Non-Disabling Cerebrovascular Events (CHANCE) and Platelet-Oriented
Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trials. JAMA
Neurol. 2019;76:1466-73.

16. Brown T, Gonzales N. Optimizing Choice of Dual Antiplatelet Therapy
in CYP2C19 Loss-of-Function Carriers. Neurology. 2023;100:223-4.

17. Yip VL, Pirmohamed M. Expanding role of pharmacogenomics in the
management of cardiovascular disorders. Am J Cardiovasc Drugs.
2013;13:151-62.

18. Jackson SP. Arterial thrombosis--insidious, unpredictable and
deadly. Nat Med. 2011;17:1423-36.

19. Kunicki TJ, Orchekowski R, Annis D, Honda Y. Variability of integrin
alpha 2 beta 1 activity on human platelets. Blood. 1993;82:2693-703.

20. Deckmyn H, Chew SL, Vermylen J. Lack of platelet response to
collagen associated with an autoantibody against glycoprotein Ia: a
novel cause of acquired qualitative platelet dysfunction. Thromb
Haemost. 1990;64:74-9.

21. Huang XY, Fu WJ, Mei ZZ, et al. Association between platelet
glycoprotein Ia C807T gene polymorphism and ischemic stroke: a
meta-analysis in a separate ethnic group. Cell Mol Biol
(Noisy-le-grand). 2017;63:111-5.

22. Liu H, Wang Y, Zheng J, et al. Platelet glycoprotein gene Ia C807T,
HPA-3, and Ibalpha VNTR polymorphisms are associated with increased
ischemic stroke risk: Evidence from a comprehensive meta-analysis. Int J
Stroke. 2017;12:46-70.

23. de Oliveira MH, Andre C, Spector N, Luiz RR, de Castro Souza G,
Gadelha T. 807C/T polymorphism in the platelet glycoprotein Ia gene in
young patients with ischemic stroke of undetermined etiology. Blood
Coagul Fibrinolysis. 2007;18:599-602.

24. Nikolopoulos GK, Tsantes AE, Bagos PG, Travlou A, Vaiopoulos G.
Integrin, alpha 2 gene C807T polymorphism and risk of ischemic stroke: a
meta-analysis. Thromb Res. 2007;119:501-10.

25. Dodson PM, Haynes J, Starczynski J, et al. The platelet glycoprotein
Ia/IIa gene polymorphism C807T/G873A: a novel risk factor for retinal
vein occlusion. Eye (Lond). 2003;17:772-7.

26. Wu G, Xi Y, Yao L, et al. Genetic polymorphism of ITGA2 C807T can
increase the risk of ischemic stroke. Int J Neurosci. 2014;124:841-51.

27. Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart
disease and stroke statistics--2010 update: a report from the American
Heart Association. Circulation. 2010;121:948-54.\selectlanguage{english}
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