A multicenter, randomized study to test immunosuppressive therapy with oral prednisone for the prevention of restenosis after percutaneous coronary interventions: cortisone plus BMS or DES versus BMS alone to eliminate restenosis (CEREA-DES) - study design and rationale.
BACKGROUND
Several randomized trials and registries have shown a reduction of restenosis after coronary angioplasty with drug-eluting stents (DESs) compared with bare metal stents (BMSs). However, cost-efficacy analysis and long-term outcome of DESs compared to BMSs deserve further assessment. Moreover, concern has been raised regarding adverse clinical events occurring late after DES implantation, in particular, late stent thrombosis related to the suspension of dual antiplatelet therapy. The use of a short-cycle oral treatment with prednisone at immunosuppressive dose after BMS implantation has shown remarkable efficacy in reducing restenosis in nondiabetic patients, with very low additional cost and without the need for long-term dual antiplatelet therapy. Such results are however limited by small sample size.


METHODS
Cortisone plus BMS or DES versus BMS alone to Eliminate Restenosis is an independent, prospective, multicenter, randomized study. It will randomize 375 nondiabetic patients with coronary artery disease in three different arms to BMS (control group), DES (DES group) or BMS followed by a 40-day prednisone treatment (prednisone group). The DES and the prednisone groups will be compared to the control group to investigate the expected clinical advantage. The primary endpoint of the study is the event-free survival of cardiovascular death, myocardial infarction and recurrence of ischemia-needing repeated target vessel revascularization at 1 year. Secondary endpoints are the event-free survival analysis at 2 and 3 years, the restenosis rate at 9 months, and cost-effectiveness at 1, 2 and 3 years.


METHODS
The expected primary endpoint rates are 90% for DESs and for prednisone-treated patients and 77% for BMSs. The study was designed as a superiority trial, to compare DES, and BMS and prednisone, with BMS alone. A sample size of 118 patients per group provides an 80% power, assuming a complete 12-month follow-up information available for each patient. To obviate for cases of drop out, the sample size was increased to 375 patients to be enrolled in five Italian hospitals.


CONCLUSIONS
This study will provide a magnitude of the net clinical and economic benefits of DES and of the safety and efficacy of BMS and cortisone compared to the standard use of BMS alone in nondiabetic patients with coronary artery disease.
Department of Biomedical Sciences and Surgery, University of Verona, Verona, Italy. flavio.ribichini@univr.it
Flavio
F
Ribichini
Fabrizio
F
Tomai
Giuseppe
G
De Luca
Giacomo
G
Boccuzzi
Patrizia
P
Presbitero
Gabriele
G
Pesarini
Valeria
V
Ferrero
Anna S
AS
Ghini
Francesca
F
Pastori
Leonardo
L
De Luca
Denis
D
Zavalloni
Daniela
D
Soregaroli
Roberto
R
Garbo
Elena
E
Franchi
Paolo
P
Marino
Massimo
M
Minelli
Corrado
C
Vassanelli
D000284:Administration, Oral; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation*; D023903:Coronary Restenosis / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D023921:Coronary Stenosis / Q000191:economics / Q000628:therapy*; D003348:Cortisone / Q000008:administration & dosage* / Q000191:economics; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D054855:Drug-Eluting Stents / Q000191:economics; D017048:Health Care Costs; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000191:economics; D007558:Italy; D008670:Metals; D011241:Prednisone / Q000008:administration & dosage* / Q000191:economics; D011446:Prospective Studies; D011474:Prosthesis Design; D012107:Research Design; D015607:Stents / Q000191:economics
D007166:Immunosuppressive Agents; D008670:Metals; D003348:Cortisone; D011241:Prednisone