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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

Ribichini, Flavio; Tomai, Fabrizio; De Luca, Giuseppe; Boccuzzi, Giacomo; Presbitero, Patrizia; Pesarini, Gabriele; Ferrero, Valeria; Ghini, Anna S; Pastori, Francesca; De Luca, Leonardo; Zavalloni, Denis; Soregaroli, Daniela; Garbo, Roberto; Franchi, Elena; Marino, Paolo; Minelli, Massimo; Vassanelli, Corrado

Journal of Cardiovascular Medicine: February 2009 - Volume 10 - Issue 2 - p 192–199
doi: 10.2459/JCM.0b013e32831f9176
Research trial protocol

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.

Study design 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.

Sample size 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.

Conclusion 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.

aDepartment of Biomedical Sciences and Surgery, University of Verona, Verona, Italy

bDepartment of Cardiovascular Sciences, European Hospital, Rome, Italy

cDepartment of Clinical and Experimental Medicine, University of Piemonte Orientale, Novara, Italy

dDivision of Cardiology, Ospedale San Giovanni Bosco, Torino, Italy

eInterventional Cardiology Unit, Istituto Clinico Humanitas, Rozzano, Milan, Italy

Received 31 July, 2008

Revised 10 October, 2008

Accepted 27 October, 2008

Correspondence to Professor Dr Flavio Ribichini, MD, Director, Laboratory of Interventional Cardiology, Università di Verona, Ospedale Civile Maggiore, Piazzale A. Stefani 1, 37126 Verona, Italy Tel: +39 045 812 2039; fax: +39 045 802 7307; e-mail:

© 2009 Italian Federation of Cardiology. All rights reserved.