Background: Ischemic stroke is the leading cause of mortality worldwide and a major contributor to neurological disability and dementia. Terutroban is a specific TP receptor antagonist with antithrombotic, antivasoconstrictive, and antiatherosclerotic properties, which may be of interest for the secondary prevention of ischemic stroke. This article describes the rationale and design of the Prevention of cerebrovascular and cardiovascular Events of ischemic origin with teRutroban in patients with a history oF ischemic strOke or tRansient ischeMic Attack (PERFORM) Study, which aims to demonstrate the superiority of the efficacy of terutroban versus aspirin in secondary prevention of cerebrovascular and cardiovascular events. Methods and Results: The PERFORM Study is a multicenter, randomized, double-blind, parallel-group study being carried out in 802 centers in 46 countries. The study population includes patients aged ≥55 years, having suffered an ischemic stroke (≤3 months) or a transient ischemic attack (≤8 days). Participants are randomly allocated to terutroban (30 mg/day) or aspirin (100 mg/day). The primary efficacy endpoint is a composite of ischemic stroke (fatal or nonfatal), myocardial infarction (fatal or nonfatal), or other vascular death (excluding hemorrhagic death of any origin). Safety is being evaluated by assessing hemorrhagic events. Follow-up is expected to last for 2–4 years. Assuming a relative risk reduction of 13%, the expected number of primary events is 2,340. To obtain statistical power of 90%, this requires inclusion of at least 18,000 patients in this event-driven trial. The first patient was randomized in February 2006. Conclusions: The PERFORM Study will explore the benefits and safety of terutroban in secondary cardiovascular prevention after a cerebral ischemic event.

1.
World Health Organization: The Atlas of Heart Disease and Stroke. WHO. http://www.who.int/cardiovascular_diseases/resources/atlas/en/index.html (accessed 2009).
2.
Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, Hailpern SM, Ho M, Howard V, Kissela B, Kittner S, Lloyd-Jones D, McDermott M, Meigs J, Moy C, Nichol G, O’Donnell C, Roger V, Sorlie P, Steinberger J, Thom T, Wilson M, Hong Y: Heart disease and stroke statistics 2008 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25–e146.
3.
Capewell S, Morrison CE, McMurray JJ: Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart 1999;81:380–386.
4.
Unal B, Critchley JA, Capewell S: Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation 2004;109:1101–1107.
5.
Hardoon SL, Whincup PH, Lennon LT, Wannamethee SG, Capewell S, Morris RW: How much of the recent decline in the incidence of myocardial infarction in British men can be explained by changes in cardiovascular risk factors? Evidence from a prospective population-based study. Circulation 2008;117:598–604.
6.
Strong K, Mathers C, Bonita R: Preventing stroke: saving lives around the world. Lancet Neurol 2007;6:182–187.
7.
Hackam DG, Spence JD: Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study. Stroke 2007;38:1881–1885.
8.
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T: Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation 2006;113:e409–e449.
9.
Schneider JA, Arvanitakis Z, Bang W, Bennett DA: Mixed brain pathologies account for most dementia cases in community-dwelling older persons. Neurology 2007;69:2197–2204.
10.
Hachinski V: Shifts in thinking about dementia. JAMA 2008;300:2172–2173.
11.
Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324:71–86.
12.
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996;348:1329–1339.
13.
Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A: European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996;143:1–13.
14.
Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, Matias-Guiu J, Rupprecht HJ: Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004;364:331–337.
15.
Brown DL: Deaths associated with platelet glycoprotein IIb/IIIa inhibitor treatment. Heart 2003;89:535–537.
16.
Fiessinger JN: S18886, a new specific TP-receptor antagonist, is safe and as effective as aspirin in inhibiting platelet aggregation in patients with peripheral arterial disease. Eur Heart J 2004;25:573.
17.
Breyer RM, Bagdassarian CK, Myers SA, Breyer MD: Prostanoid receptors: subtypes and signaling. Annu Rev Pharmacol Toxicol 2001;41:661–690.
18.
Cayatte AJ, Du Y, Oliver-Krasinski J, Lavielle G, Verbeuren TJ, Cohen RA: The thromboxane receptor antagonist S18886 but not aspirin inhibits atherogenesis in apo E-deficient mice: evidence that eicosanoids other than thromboxane contribute to atherosclerosis. Arterioscler Thromb Vasc Biol 2000;20:1724–1728.
19.
Halushka MK, Halushka PV: Why are some individuals resistant to the cardioprotective effects of aspirin? Could it be thromboxane A(2)? Circulation 2002;105:1620–1622.
20.
Pratico D, Cheng Y, FitzGerald GA: TP or not TP: primary mediators in a close runoff? Arterioscler Thromb Vasc Biol 2000;20:1695–1698.
21.
Hong TT, Huang J, Driscoll E, Lucchesi BR: Preclinical evaluation of S18886 in an experimental model of coronary arterial thrombosis. J Cardiovasc Pharmacol 2006;48:239–248.
22.
Osende JI, Shimbo D, Fuster V, Dubar M, Badimon JJ: Antithrombotic effects of S18886, a novel orally active thromboxane A2 receptor antagonist. J Thromb Haemost 2004;2:492–498.
23.
Michel F, Silvestre JS, Waeckel L, Corda S, Verbeuren T, Vilaine JP, Clergue M, Duriez M, Levy BI: Thromboxane A2/prostaglandin H2 receptor activation mediates angiotensin II-induced postischemic neovascularization. Arterioscler Thromb Vasc Biol 2006;26:488–493.
24.
Worth NF, Berry CL, Thomas AC, Campbell JH: S18886, a selective TP receptor antagonist, inhibits development of atherosclerosis in rabbits. Atherosclerosis 2005;183:65–73.
25.
Gaussem P, Reny JL, Thalamas C, Chatelain N, Kroumova M, Jude B, Boneu B, Fiessinger JN: The specific thromboxane receptor antagonist S18886: pharmacokinetic and pharmacodynamic studies. J Thromb Haemost 2005;3:1437–1445.
26.
Belhassen L, Pelle G, Dubois Rande JL, Adnot S: Improved endothelial function by the thromboxane A2 receptor antagonist S18886 in patients with coronary artery disease treated with aspirin. J Am Coll Cardiol 2003;41:1198–1204.
27.
Bal C, Crassard I, Simoneau G, Bergmann JF, Bousser MG, Drouet L: Effect of the TP receptor antagonist terutroban on experimental arterial thrombogenesis after repeated administration in patients treated for the prevention of ischemic stroke. Cerebrovasc Dis, submitted.
28.
Xu S, Jiang B, Maitland KA, Bayat H, Gu J, Nadler JL, Corda S, Lavielle G, Verbeuren TJ, Zuccollo A, Cohen RA: The thromboxane receptor antagonist S18886 attenuates renal oxidant stress and proteinuria in diabetic apolipoprotein E-deficient mice. Diabetes 2006;55:110–119.
29.
Gelosa P, Nobili E, Gianella A, Blanc-Guillemaud V, Lerond L, Guerrini U, Tremoli E, Sironi L: S18886, a thromboxane A2 receptor antagonist, prevents occurrence of spontaneous brain damage in stroke-prone rats via anti-inflammatory activities. Cerebrovasc Dis 2007;23:137.
30.
Shineman DW, Zhang B, Leight SN, Pratico D, Lee VM: Thromboxane receptor activation mediates isoprostane-induced increases in amyloid pathology in Tg2576 mice. J Neurosci 2008;28:4785–4794.
31.
Kasner SE: Clinical interpretation and use of stroke scales. Lancet Neurol 2006;5:603–612.
32.
Folstein MF, Folstein SE, McHugh PR: ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.
33.
Isaacs B, Kennie AT: The Set test as an aid to the detection of dementia in old people. Br J Psychiatry 1973;123:467–470.
34.
Zazzo R: Test des deux barrages. Actualités pédagogiques et psychologiques. Neuchâtel, Delachaux et Nestlé, 1974, vol 7.
35.
Lawton MP, Brody EM: Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179–186.
36.
Wade DT, Collin C: The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud 1988;10:64–67.
37.
Bousser MG, Amarenco P, Chamorro A, Fisher M, Ford I, Fox K, Hennerici MG, Mattle HP, Rothwell PM, on behalf of the PERFORM Study Investigators: The Prevention of cerebrovascular and cardiovascular Events of ischemic origin with teRutroban in patients with a history oF ischemic strOke or tRansient ischeMic attack (PERFORM) study: baseline characteristics of the population. Cerebrovasc Dis, in press.
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