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Sohn M, Lim S. The Role of Cilostazol, a Phosphodiesterase-3 Inhibitor, in the Development of Atherosclerosis and Vascular Biology: A Review with Meta-Analysis. Int J Mol Sci 2024; 25:2593. [PMID: 38473840 DOI: 10.3390/ijms25052593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) stands as the leading global cause of mortality. Addressing this vital and pervasive condition requires a multifaceted approach, in which antiplatelet intervention plays a pivotal role, together with antihypertensive, antidiabetic, and lipid-lowering therapies. Among the antiplatelet agents available currently, cilostazol, a phosphodiesterase-3 inhibitor, offers a spectrum of pharmacological effects. These encompass vasodilation, the impediment of platelet activation and aggregation, thrombosis inhibition, limb blood flow augmentation, lipid profile enhancement through triglyceride reduction and high-density lipoprotein cholesterol elevation, and the suppression of vascular smooth muscle cell proliferation. However, the role of cilostazol has not been clearly documented in many guidelines for ASCVD. We comprehensively reviewed the cardiovascular effects of cilostazol within randomized clinical trials that compared it to control or active agents and involved individuals with previous coronary artery disease or stroke, as well as those with no previous history of such conditions. Our approach demonstrated that the administration of cilostazol effectively reduced adverse cardiovascular events, although there was less evidence regarding its impact on myocardial infarction. Most studies have consistently reported its favorable effects in reducing intermittent claudication and enhancing ambulatory capacity in patients with peripheral arterial disease. Furthermore, cilostazol has shown promise in mitigating restenosis following coronary stent implantation in patients with acute coronary syndrome. While research from more diverse regions is still needed, our findings shed light on the broader implications of cilostazol in the context of atherosclerosis and vascular biology, particularly for individuals at high risk of ASCVD.
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Affiliation(s)
- Minji Sohn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 13620, Republic of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 13620, Republic of Korea
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Manolis AA, Manolis TA, Melita H, Mikhailidis DP, Manolis AS. Update on Cilostazol: A Critical Review of Its Antithrombotic and Cardiovascular Actions and Its Clinical Applications. J Clin Pharmacol 2021; 62:320-358. [PMID: 34671983 DOI: 10.1002/jcph.1988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/17/2021] [Indexed: 12/17/2022]
Abstract
Cilostazol, a phosphodiesterase III inhibitor, has vasodilating and antiplatelet properties with a low rate of bleeding complications. It has been used over the past 25 years for improving intermittent claudication in patients with peripheral artery disease (PAD). Cilostazol also has demonstrated efficacy in patients undergoing percutaneous revascularization procedures for both PAD and coronary artery disease. In addition to its antithrombotic and vasodilating actions, cilostazol also inhibits vascular smooth muscle cell proliferation via phosphodiesterase III inhibition, thus mitigating restenosis. Accumulated evidence has shown that cilostazol, due to its "pleiotropic" effects, is a useful, albeit underutilized, agent for both coronary artery disease and PAD. It is also potentially useful after ischemic stroke and is an alternative in those who are allergic or intolerant to classical antithrombotic agents (eg, aspirin or clopidogrel). These issues are herein reviewed together with the pharmacology and pharmacodynamics of cilostazol. Large studies and meta-analyses are presented and evaluated. Current guidelines are also discussed, and the spectrum of cilostazol's actions and therapeutic applications are illustrated.
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Affiliation(s)
| | | | | | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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Bolinera SV, Tharaknath VR, Reddy SS, Polavarapu RS, Polavarapu A, Polavarapu N, Byrapaneni S, Gangasani S, Chilukuri M, Pamidimukkala V. Safety and performance of everolimus-eluting stents comprising of biodegradable polymers with ultrathin stent platforms. Minerva Med 2020; 111:315-323. [PMID: 33032393 DOI: 10.23736/s0026-4806.20.06205-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The registry investigated clinical outcomes after 12 months of implantation of ultra-thin strut (60 µm) biodegradable polymer-coated Tetrilimus everolimus-eluting stents (EES; Sahajanand Medical Technologies Pvt. Ltd., Surat, India) in patients with atherosclerotic coronary lesions. Additionally, sub-group analysis was performed to evaluate outcomes of ultra-long (44/48 mm) Tetrilimus EES in patients with long lesions. METHODS This was an observational, single-center, single-arm and investigator-initiated retrospective registry. In this all-comers registry, patients who underwent implantation of Tetrilimus EES for treatment of coronary artery disease during routine clinical practice between February-2016 and August-2016 at tertiary care center of India were included. Primary endpoint was occurrence of any major adverse cardiac event (MACE) up to 12 months' follow-up. MACE was a composite of cardiac death, myocardial infarction (MI), and target lesion revascularization (TLR). Similar endpoints were observed in sub-group patients. RESULTS Total 766 stents were implanted to treat 695 lesions in 558 patients. Of treated lesions, 11.4% lesions were type B2 and 78.3% were type C lesions. In sub-group analysis of 143 patients, a total of 155 long coronary lesions were intervened successfully with only one stent been implanted per lesion. At 12 months' follow-up, four (0.7%) cases of cardiac death, eight (1.4%) of MI, and two (0.4%) of TLR were reported, resulting in a 2.5% rate of MACE. The MACE rate was 2.8% in sub-group patients. CONCLUSIONS Twelve months' clinical data demonstrated favorable safety and excellent performance of Tetrilimus EES in high-risk patients and complex coronary lesions in routine clinical practice and also in patients with ultra-long lesions.
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Affiliation(s)
- Sudheer V Bolinera
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
| | - Vemuri R Tharaknath
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
| | - Sanivarapu S Reddy
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
| | - Raghava S Polavarapu
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India -
| | - Anurag Polavarapu
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
| | - Naren Polavarapu
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
| | - Sravanthi Byrapaneni
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
| | | | | | - Vijaya Pamidimukkala
- Heart and Brain Center, Lalitha Super Specialties Hospital, Kothapet, Guntur, India
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The quest for effective pharmacological suppression of neointimal hyperplasia. Curr Probl Surg 2020; 57:100807. [PMID: 32771085 DOI: 10.1016/j.cpsurg.2020.100807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/22/2020] [Indexed: 12/15/2022]
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Kim W, Kim JS, Rha SW, Choi BG, Jang WY, Kang DO, Park Y, Choi JY, Roh SY, Na JO, Choi CU, Kim EJ, Park CG, Seo HS, Choi SY, Byun JK, Cha J, Oh DJ, Jeong MH. Cilostazol-based triple versus potent P2Y12 inhibitor-based dual antiplatelet therapy in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Heart Vessels 2020; 35:1181-1192. [PMID: 32270356 DOI: 10.1007/s00380-020-01598-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/27/2020] [Indexed: 11/28/2022]
Abstract
Although potent P2Y12 inhibitor-based dual antiplatelet therapy (DAPT) has replaced clopidogrel-based therapy as the standard treatment in patients with acute myocardial infarction (AMI), there is a concern about the risk of bleeding in East Asian patients. We compared the efficacy and safety of cilostazol-based triple antiplatelet therapy (TAT) with potent P2Y12 inhibitor-based DAPT in Korean patients. A total of 4152 AMI patients who underwent percutaneous coronary intervention (PCI) in the Korea Acute Myocardial Infarction Registry were analyzed retrospectively. Patients were divided into two groups: the TAT group (aspirin + clopidogrel + cilostazol, n = 3161) and the potent DAPT group (aspirin + potent P2Y12 inhibitors [ticagrelor or prasugrel], n = 991). Major clinical outcomes at 30 days and 2 years were compared between the two groups using propensity score matching (PSM) analysis. After PSM (869 pairs), there were no significant differences between the two groups in the incidence of total death, cardiac death, myocardial infarction (MI), target vessel revascularization, stent thrombosis, and stroke at 30 days and 2 years. However, the Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding rates were significantly lower in the TAT group compared with the potent DAPT group at 2 years (6.4% vs. 3.6%, p = 0.006). In Korean AMI patients undergoing PCI, TAT with cilostazol was associated with lower bleeding than the potent P2Y12 inhibitor-based DAPT without increased ischemic risk. These results could provide a rationale for the use of TAT in East Asian AMI patients.
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Affiliation(s)
- Woohyeun Kim
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jin-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea. .,Cardiovascular Intervention Research Institute, Seoul, Republic of Korea.
| | - Byoung Geol Choi
- College of Medicine, Institute of Health Science, Korea University, Seoul, Republic of Korea
| | - Won Young Jang
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Dong Oh Kang
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Yoonjee Park
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jah Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Seung-Young Roh
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Eung Ju Kim
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Se Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jae Kyeong Byun
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jinah Cha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Dong Joo Oh
- Cardiovascular Intervention Research Institute, Seoul, Republic of Korea
| | - Myung Ho Jeong
- Heart Center of Chonnam, National University Hospital, Gwangju, Republic of Korea
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Zhao S, Zhong Z, Qi G, Shi L, Tian W. Effects of Cilostazol-Based Triple Antiplatelet Therapy Versus Dual Antiplatelet Therapy After Coronary Drug-Eluting Stent Implantation: An Updated Meta-Analysis of the Randomized Controlled Trials. Clin Drug Investig 2019; 39:1-13. [PMID: 30251232 DOI: 10.1007/s40261-018-0711-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE The results of studies on cilostazol-based triple antiplatelet therapy (TAT) after drug-eluting stent (DES) implantation were inconsistent. To assess the effects of TAT compared with dual antiplatelet therapy (DAT) after DES/second-generation DES implantation, we performed a meta-analysis of randomized controlled trials (RCTs). METHODS All relevant studies evaluated were identified by searching the PubMed, EMBASE, Cochrane Library, and ISI Web of Science databases without time and language limitation. Subgroup analyses were performed to evaluate the efficacy and safety of TAT after second-generation DES implantation. RESULTS Eleven RCTs involving a total of 4684 patients were included. The meta-analysis showed TAT was associated with significant beneficial effects on angiographic findings of in-stent restenosis [risk ratio (RR) 0.645, 95% confidence interval (CI) 0.470-0.885; P = 0.007], in-segment restenosis (RR 0.606, 95% CI 0.450-0.817; P = 0.001), in-stent late loss (RR - 0.095, 95% CI - 0.136 to - 0.054; P < 0.0001), in-segment late loss (RR - 0.100, 95% CI - 0.139 to - 0.061; P < 0.0001), target lesion revascularization (TLR) (RR 0.570, 95% CI 0.430-0.755; P < 0.0001), and target vessel revascularization (TVR) (RR 0.523, 95% CI 0.380-0.719; P < 0.0001). No significant difference was found in outcomes of all-cause death, cardiac death, definite/probable stent thrombosis (ST), non-fatal myocardial infarction (MI), overall bleeding, and major bleeding between the two groups, as well as some minor adverse effects including palpitations, thrombocytopenia, neutropenia, and hepatic dysfunction. However, the incidence rate of rash, gastrointestinal disorders, and headache was significantly higher in TAT. The second-generation DES subgroup showed similar results, except for the indicators of all-cause death (RR 2.161, 95% CI 1.007-4.635; P = 0.048) and hepatic dysfunction (RR 0.176, 95% CI 0.031-0.995; P = 0.049). CONCLUSIONS Compared with DAT, cilostazol-based TAT can significantly improve the angiographic findings of in-stent and in-segment late loss, in-stent and in-segment restenosis, TLR, and TVR after DES/second-generation DES implantation. However, no benefits were observed in outcomes of all-cause death, cardiac death, ST, and MI.
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Affiliation(s)
- Shijie Zhao
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, No. 155 Nanjingbei Street, 110001 Heping District, Shenyang, China
| | - Zhaoshuang Zhong
- Department of Respiratory, Central Hospital, Shenyang Medical College, Shenyang, China
| | - Guoxian Qi
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, No. 155 Nanjingbei Street, 110001 Heping District, Shenyang, China
| | - Liye Shi
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, No. 155 Nanjingbei Street, 110001 Heping District, Shenyang, China
| | - Wen Tian
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, No. 155 Nanjingbei Street, 110001 Heping District, Shenyang, China.
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Liu M, Lu W, Chen L, Wang Y, Zhao Z, Zhang M, Du W, Lv Z. An up-dated meta-analysis of major adverse cardiac events on triple versus dual antiplatelet therapy after percutaneous coronary intervention in patients with type 2 diabetes mellitus. Data Brief 2018; 20:448-453. [PMID: 30186892 PMCID: PMC6122306 DOI: 10.1016/j.dib.2018.06.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 05/03/2018] [Accepted: 06/27/2018] [Indexed: 11/30/2022] Open
Abstract
This meta-analysis is conducted to assess the efficiency and safety of triple antiplatelet therapy in patients with type 2 diabetes mellitus (T2DM) who have received coronary stents implantation. The risk of major adverse cardiac events (MACEs), target vessel revascularization (TVR), target lesion revascularization (TLR), myocardial infarction (MI) and bleeding events were evaluated in this meta-analysis. Eight randomized controlled trials incorporating 1700 participants were included. During a follow-up of 12 months after stents implantation, the risk of TVR, TLR and MACEs in Triple group were lower than that of Dual group. There was no significant difference in the comparison of stent thrombosis and bleeding events between the two groups. Triple antiplatelet therapy is effective in reducing adverse cardiovascular outcomes in T2DM patients after stents implantation, without increasing the risk of bleeding events. Advanced designed and large-scale trails are deserved in the future.
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Affiliation(s)
- Mao Liu
- Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China
- Cardiovascular Research Center, the Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan Province, PR China
- Corresponding author at: Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China.
| | - Wenjing Lu
- Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai 519000, PR China
| | - Ling Chen
- Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China
- Cardiovascular Research Center, the Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan Province, PR China
| | - Yanmei Wang
- Department of Clinical Medicine, Yaan Polytechnic College, Yaan 625000, PR China
| | - Zhuoling Zhao
- Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China
| | - Mei Zhang
- Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China
| | - Weiwei Du
- Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China
| | - Zhan Lv
- Department of Cardiology, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, PR China
- Cardiovascular Research Center, the Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan Province, PR China
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Comparison of 1-Year Outcomes of Triple (Aspirin + Clopidogrel + Cilostazol) Versus Dual Antiplatelet Therapy (Aspirin + Clopidogrel + Placebo) After Implantation of Second-Generation Drug-Eluting Stents into One or More Coronary Arteries: from the DECREASE-PCI Trial. Am J Cardiol 2018; 121:423-429. [PMID: 29273207 DOI: 10.1016/j.amjcard.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/01/2017] [Accepted: 11/07/2017] [Indexed: 11/22/2022]
Abstract
This study sought to evaluate the impact of triple antiplatelet therapy on clinical outcomes in patients treated with second-generation drug-eluting stents (DES) for coronary artery disease. There are limited data regarding the impact of triple antiplatelet therapy in patients who underwent implantation of second-generation DES. We planned to randomly assign 2,110 patients treated with second-generation DES to triple (aspirin, clopidogrel, and cilostazol) and dual (aspirin, clopidogrel, and placebo) antiplatelet therapy groups. The primary end point was a composite of death, myocardial infarction, ischemic stroke, or target vessel revascularization (TVR) at 1 year since randomization. The study was stopped early owing to slow enrollment. In total, 404 patients (202 patients each in the triple and dual antiplatelet therapy groups) were finally enrolled. At 1 year, the primary end point had occurred in 3.6% and 9.4% of patients in the triple and dual antiplatelet therapy groups, respectively (hazard ratio [HR] of the triple group 0.396; 95% confidence interval [CI] 0.166 to 0.949; p = 0.038). There was no significant difference between the 2 groups regarding the occurrence of a composite of all-cause death, myocardial infarction, or ischemic stroke (HR 0.583; 95% CI 0.229 to 1.481; p = 0.256). However, the rates of TVR were significantly lower in the triple antiplatelet therapy group than in the dual antiplatelet therapy group (HR 0.118; 95% CI 0.015 to 0.930; p = 0.043). In conclusion, triple antiplatelet therapy with cilostazol after implantation of second-generation DES improved clinical outcomes, mainly by reducing TVR.
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The efficacy and safety of cilostazol as an alternative to aspirin in Chinese patients with aspirin intolerance after coronary stent implantation: a combined clinical study and computational system pharmacology analysis. Acta Pharmacol Sin 2018; 39:205-212. [PMID: 28933424 DOI: 10.1038/aps.2017.85] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/19/2017] [Indexed: 12/18/2022] Open
Abstract
Dual antiplatelet therapy (DAT) with aspirin and clopidogrel is the standard regimen to achieve rapid platelet inhibition and prevent thrombotic events. Currently, little information is available regarding alternative antiplatelet therapy in patients with an allergy or intolerance to aspirin. Although cilostazol is already a common alternative to aspirin in clinical practice in China, its efficacy and safety remain to be determined. We retrospectively analyzed 613 Chinese patients who had undergone primary percutaneous coronary intervention (PCI). Among them, 405 patients received standard DAT (aspirin plus clopidogrel) and 205 patients were identified with intolerance to aspirin and received alternative DAT (cilostazol plus clopidogrel). There were no significant differences between the two groups in their baseline clinical characteristics. The main outcomes of the study included major adverse cardiac events (MACEs) and bleeding events during 12 months of follow-up. The MACEs endpoint was reached in 10 of 205 patients treated with cilostazol (4.9%) and in 34 of 408 patients treated with aspirin (8.3%). No statistically significant difference was observed in MACEs between the two groups. However, patients in the cilostazol group had less restenosis than did patients in the aspirin group (1.5% vs 4.9%, P=0.035). The occurrence of bleeding events tended to be lower in the cilostazol group (0.49% vs 2.7%, P=0.063). These clinical observations were further analyzed using network system pharmacology analysis, and the outcomes were consistent with clinical observations and preclinical data reports. We conclude that in Chinese patients with aspirin intolerance undergoing coronary stent implantation, the combination of clopidogrel with cilostazol may be an efficacious and safe alternative to the standard DAT regimen.
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Outcome of Triple Antiplatelet Therapy Including Cilostazol in Elderly Patients with ST-Elevation Myocardial Infarction who Underwent Primary Percutaneous Coronary Intervention: Results from the INTERSTELLAR Registry. Drugs Aging 2017; 34:467-477. [PMID: 28456945 DOI: 10.1007/s40266-017-0463-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Compared with dual antiplatelet therapy including aspirin and clopidogrel, triple antiplatelet therapy including cilostazol has a mortality benefit in patients with ST-segment elevation myocardial infarction. However, whether the mortality benefit persists in elderly patients is not clear. METHODS From 2007 to 2014, 1278 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were retrospectively analyzed. The patients were divided into four groups by age (<75 or ≥75 years; young and elderly, respectively) and antiplatelet strategy (triple or dual antiplatelet therapy). We compared the mortality rates between the triple and dual antiplatelet therapy groups. RESULTS There were 1052 (male, 85%; mean age, 56.3 ± 10.4 years) patients in the young group and 241 (male, 52.7%; mean age, 80.3 ± 4.5 years) patients in the elderly group. In the young and elderly groups, 220 (20.9%) and 28 (12.3%) patients were treated with triple antiplatelet therapy. During a 1-year follow-up period, 80 patients died (4.2% in the young group vs. 15.5% in the elderly group). Kaplan-Meier survival analysis revealed that triple antiplatelet therapy was associated with a lower mortality rate in the young group (log-rank, p = 0.005). Although there were more angiographic high-risk patients in the elderly group, similar mortality rates were reported (log-rank, p = 0.803) without increased bleeding rates (1 vs. 3.6% in the elderly group, p = 0.217). CONCLUSIONS Triple antiplatelet therapy might be a better antiplatelet regimen than dual antiplatelet therapy for patients with ST-segment elevation myocardial infarction. Although this benefit was strong in patients aged <75 years, no definite increase in major bleeding was seen for elderly patients (aged ≥75 years).
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Suh JW, Lee SP, Park K, Kang HJ, Koo BK, Cho YS, Youn TJ, Chae IH, Choi DJ, Rha SW, Bae JH, Kwon TG, Bae JW, Cho MC, Kim HS. The Effect of Cilostazol on the Angiographic Outcome of Drug-Eluting Coronary Stents Angiographic Analysis of the CILON-T (Influence of CILostazol-Based Triple Antiplatelet Therapy ON Ischemi Complication after Drug-Eluting StenT Implantation) Trial. Int Heart J 2017; 58:853-860. [DOI: 10.1536/ihj.16-332] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jung-Won Suh
- Cardiovascular Center, Seoul National University Hospital
- Cardiovascular Center, Seoul National University Bundang Hospital
| | - Seung-Pyo Lee
- Cardiovascular Center, Seoul National University Hospital
| | - KyungWoo Park
- Cardiovascular Center, Seoul National University Hospital
| | - Hyun-Jae Kang
- Cardiovascular Center, Seoul National University Hospital
| | - Bon-Kwon Koo
- Cardiovascular Center, Seoul National University Hospital
| | - Young-Seok Cho
- Cardiovascular Center, Seoul National University Bundang Hospital
| | - Tae-Jin Youn
- Cardiovascular Center, Seoul National University Bundang Hospital
| | - In-Ho Chae
- Cardiovascular Center, Seoul National University Bundang Hospital
| | - Dong-Ju Choi
- Cardiovascular Center, Seoul National University Bundang Hospital
| | | | | | | | - Jang-Whan Bae
- Department of Internal Medicine, College of Medicine, Chungbuk National University
| | - Myeong-Chan Cho
- Department of Internal Medicine, College of Medicine, Chungbuk National University
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital
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Fan ZG, Ding GB, Li XB, Gao XF, Gao YL, Tian NL. The clinical outcomes of triple antiplatelet therapy versus dual antiplatelet therapy for high-risk patients after coronary stent implantation: a meta-analysis of 11 clinical trials and 9,553 patients. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:3435-3448. [PMID: 27799743 PMCID: PMC5076804 DOI: 10.2147/dddt.s119616] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The optimal antiplatelet regimen after in-coronary intervention among patients presenting with complex coronary artery lesions or acute coronary syndrome (ACS) has remained unclear. This study sought to evaluate the clinical outcomes of triple antiplatelet treatment (TAPT) (cilostazol added to aspirin plus clopidogrel) in these patients. Methods The PubMed, EMBASE, MEDLINE, and other Internet sources were searched for relevant articles. The primary end point was major adverse cardiac events (MACE), including all-cause mortality, myocardial infarction, and target vessel revascularization. The incidence of definite/probable stent thrombosis and bleeding were analyzed as the safety end points. Results Eleven clinical trials involving 9,553 patients were analyzed. The risk of MACE was significantly decreased following TAPT after stent implantation in the ACS subgroup (odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.61–0.85; P<0.001), which might mainly result from the lower risk of all-cause mortality in this subset (OR: 0.62; 95% CI: 0.48–0.80; P<0.001). The risk of bleeding was not increased with respect to TAPT. Conclusion TAPT after stent implantation was associated with feasible benefits on reducing the risk of MACE, especially on reducing the incidence of all-cause mortality among patients suffering from ACS, without higher incidence of bleeding. Larger and more powerful randomized trials are still warranted to prove the superiority of TAPT for such patients.
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Affiliation(s)
- Zhong-Guo Fan
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing
| | - Guo-Bin Ding
- Department of Cardiology, Taixing People's Hospital, Yangzhou University, Taizhou
| | - Xiao-Bo Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing; Department of Cardiology, Nanjing Heart Center, Nanjing, People's Republic of China
| | - Xiao-Fei Gao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing; Department of Cardiology, Nanjing Heart Center, Nanjing, People's Republic of China
| | - Ya-Li Gao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing
| | - Nai-Liang Tian
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing; Department of Cardiology, Nanjing Heart Center, Nanjing, People's Republic of China
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Lack of Evidence for Dual Antiplatelet Therapy after Endovascular Arterial Procedures: A Meta-analysis. Eur J Vasc Endovasc Surg 2016; 52:253-62. [PMID: 27241270 DOI: 10.1016/j.ejvs.2016.04.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 04/25/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) has mainly replaced mono antiplatelet therapy (MAPT) and is recommended after arterial endovascular revascularization. The aim of this meta-analysis was to summarize the available evidence for DAPT after endovascular revascularization throughout the arterial system. METHODS A systematic search was performed in Medline, Embase, and the Cochrane Register. Two reviewers independently performed data extraction and quality assessment using the Cochrane Collaboration risk of bias assessment tool. Included in the search were randomized controlled trials (RCTs) comparing DAPT with MAPT after endovascular procedures for the treatment of coronary, carotid, or peripheral artery disease, reporting at least one clinical outcome. Articles were excluded if patients received anticoagulation in addition to antiplatelet therapy in the post-procedural phase. The primary outcome was restenosis or stent thrombosis, and secondary outcomes were major adverse cardiac events (MACE), target lesion revascularization, cerebrovascular accident or transient ischemic attack, bleeding, and death. Meta-analyses of binary outcomes were performed using the random effects model and described as risk ratios (RRs) and 95% confidence intervals (95% CIs). Chi-square tests were used to test for heterogeneity. RESULTS Nine articles were included in this study, involving lower limb peripheral arteries (1), carotid arteries (2), and coronary arteries (6). The pooled results of coronary trials showed a RR for restenosis with DAPT of 0.60 (95% CI 0.28-1.31) and for myocardial infarction 0.49 (95% CI 0.12-2.03). In the carotid artery trials the RR for restenosis was 0.22 (95% CI 0.04-1.20) and for peripheral arteries 1.02 (95% CI 0.56-1.82). A meta-analysis of bleeding risk of all the included trials showed a RR of 1.06 (95% CI 0.32-3.52) with DAPT. CONCLUSION The available evidence comparing DAPT with MAPT after endovascular arterial revascularization is limited and the majority of trials were conducted in the cardiology field. No significant evidence for superiority of DAPT compared with MAPT was found, but there was also no evidence of an increased bleeding risk with DAPT over MAPT.
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H A, N E, S A, S C, K D, C A, E T, A T, O C Y, M G, T B, M M. The Effect of High Dose Cilostazol and Rosuvastatin on Periprocedural Myocardial Injury in Patients with Elective Percutaneous Coronary Intervention. ACTA CARDIOLOGICA SINICA 2016; 31:292-300. [PMID: 27122885 DOI: 10.6515/acs20150119b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The aim of our study was to assess the effect of pretreatment with cilostazol and rosuvastatin combination before elective percutaneous coronary intervention (PCI) on peri-procedural myocardial injury (PPMIJ). METHODS We randomly assigned 172 patients with stable angina pectoris scheduled for elective PCI to pre- treatment with Cilostazol 200mg and Rosuvastatin 40 mg (group 1), or to pretreatment with Rosuvastatin 40 mg group (group 2). The primary end-point was the occurrence of PPMIJ defined as any cardiac troponin I (Tn I) level elevated above the upper normal limit (UNL). The occurrence of peri-procedural myocardial infarction (PPMIN) was defined as a post-procedural increase in cTnI level ≥ 5 times above the UNL. RESULTS There was no significant difference in baseline characteristics between group 1 (n = 86) and group 2 (n = 86). The rate of PPMIJ (21% vs. 24%, p = 0.58) and PPMIN (2.3% vs. 7%, p = 0.27) were similar between the two study groups. Subgroup analysis performed on those patients without statin therapy before PCI (53 patients in group 1 and 50 patients in group 2) showed that the incidence of PPMIJ was significantly lower in the group 1 patients without chronic statin treatment [17% (9/53) versus 34% (17/50); p = 0.04], but the rate of PPMIN was similar between the two groups for those patients without chronic statin treatment [1.9% (1/53) versus 10% (5/50); p = 0.07]. CONCLUSIONS We found that adjunct cilostazol and rosuvastatin pre-treatment did not significantly reduce PPMIJ after elective PCI in patients with stable angina pectoris. However, adjunct cilostazol pre-treatment could reduce PPMIJ in patients without chronic statin therapy before elective PCI. KEY WORDS Cilostazol; Myocardial injury; Percutaneous coronary intervention; Statin.
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Affiliation(s)
- Ari H
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Emlek N
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Ari S
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Coşar S
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Doğanay K
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Aydin C
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Tenekecioğlu E
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Tütüncü A
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Yontar O C
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Gürdoğan M
- Edirne State Hospital, Department of Cardiology, Edirne, Turkey
| | - Bozat T
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
| | - Melek M
- Bursa Postgraduate Hospital, Department of Cardiology, Bursa
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Noh Y, Lee J, Shin S, Lim HS, Bae SK, Oh E, Kim GJ, Kim JH, Lee S. Antiplatelet Therapy of Cilostazol or Sarpogrelate with Aspirin and Clopidogrel after Percutaneous Coronary Intervention: A Retrospective Cohort Study Using the Korean National Health Insurance Claim Database. PLoS One 2016; 11:e0150475. [PMID: 26939062 PMCID: PMC4777511 DOI: 10.1371/journal.pone.0150475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/14/2016] [Indexed: 01/08/2023] Open
Abstract
Background/Objectives Addition of cilostazol or sarpogrelate to the standard dual antiplatelet therapy of aspirin and clopidogrel has been implemented in patients that underwent percutaneous coronary intervention (PCI) with stents in Korea. This study aimed to evaluate the efficacy and safety of triple antiplatelet therapies. Methods This retrospective cohort study was performed using the Korean National Insurance Claim Data of the Health Insurance Review and Assessment Service from January 1, 2009 to December 31, 2014. The study cohort population consisted of patients with ischemic heart diseases and a history of PCI. They were treated with antiplatelet therapy of aspirin, clopidogrel (AC); aspirin, clopidogrel, cilostazol (ACCi); or aspirin, clopidogrel, sarpogrelate (ACSa) during the index period from January 1, 2010 to December 31, 2011. During the follow-up period up to December 31, 2014, the major adverse cardiac or cerebral events (MACCE) including death, myocardial infarction, target lesion revascularization, and ischemic stroke were assessed. Bleeding complications were also evaluated as adverse drug events. Results Out of 93,876 patients with PCI during the index period, 69,491 patients started dual (AC) or triple therapy (ACSa or ACCi). The clinical outcomes of comparing ACSa and ACCi therapy showed beneficial effects in the ACSa group in the prevention of subsequent cardiac or cerebral events. After Propensity score-matching between ACSa and ACCi groups, there were significant differences in MI and revascularization, with corresponding HR of 0.38 (95% CI, 0.20–0.73) and 0.66 (95% CI, 0.53–0.82) in ACSa vs. ACCi at 12 months, respectively. At the 24-month follow-up, the triple therapy groups (ACS or ACC) had a higher incidence of MACCE compared to the dual therapy (AC) group; ACSa vs. AC HR of 1.69 (95% CI, 1.62–1.77); ACC vs. AC HR of 1.22 (95% CI, 1.06–1.41). There was no significant difference in severe or life-threatening bleeding risk among three groups; ACSa vs. AC, HR of 0.68 (95% CI, 0.37–1.24), ACCi vs. AC, HR of 0.91 (95% CI, 0.77–1.09). Conclusion Sarpogrelate-containing triple antiplatelet therapy demonstrated comparable rates of MACCE prevention to the conventional dual antiplatelet therapy after PCI without significantly increasing bleeding risk during the two-year follow-up period.
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Affiliation(s)
- Yoojin Noh
- College of Pharmacy, Ajou University, Suwon, South Korea
| | - Jimin Lee
- College of Pharmacy, Ajou University, Suwon, South Korea
| | - Sooyoung Shin
- College of Pharmacy, Ajou University, Suwon, South Korea
| | - Hong-Seok Lim
- Department of Cardiology, School of Medicine, Ajou University, Suwon, South Korea
| | - Soo Kyung Bae
- College of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Euichul Oh
- College of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
| | - Grace Juyun Kim
- Division of Biomedical Informatics, College of Medicine, Seoul National University, Seoul, South Korea
| | - Ju Han Kim
- Division of Biomedical Informatics, College of Medicine, Seoul National University, Seoul, South Korea
| | - Sukhyang Lee
- College of Pharmacy, Ajou University, Suwon, South Korea
- * E-mail:
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16
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Ueda H, Kido A, Matsuhisa S, Asawa K, Yoshida N, Tsujimoto M, Sasaki Y, Kuga Y, Yamasaki M, Ueda K, Shinohara S, Nishida Y. Addition of cilostazol to aspirin therapy for secondary prevention of cardiovascular and cerebrovascular disease in patients undergoing percutaneous coronary intervention: A randomized, open-label trial. Am Heart J 2016; 173:134-42. [PMID: 26920606 DOI: 10.1016/j.ahj.2015.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 12/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with established coronary artery disease are at increased risk for future ischemic events and require secondary prevention for systemic vascular disease. We performed a randomized clinical trial to evaluate the impact of cilostazol on cardiovascular and cerebrovascular disease in patients undergoing percutaneous coronary intervention. METHODS A total of 514 patients who had undergone coronary stent implantation >6 months previously and were thought to no longer need dual antiplatelet therapy with aspirin and a thienopyridine were randomly assigned to receive aspirin plus cilostazol therapy or aspirin therapy alone after discontinuation of thienopyridine therapy. The primary efficacy end point was a composite of all-cause death, myocardial infarction, stroke, or cardiovascular or cerebrovascular revascularization at 2 years after randomization. The main safety end point was major or minor bleeding, according to the Thrombolysis in Myocardial Infarction bleeding definition. RESULTS At 2 years, follow-up clinical data were available for 98.1% of patients. The primary efficacy end point occurred in 13.9% of the aspirin plus cilostazol group versus 22.1% of the aspirin-only group (hazard ratio 0.61, 95% CI 0.40-0.93, P = .021). The rate of major or minor bleeding was not significantly different between the aspirin plus cilostazol and aspirin-only groups (1.6% and 4.0%, respectively, hazard ratio 0.40, 95% CI 0.13-1.28, P = .12). CONCLUSIONS In patients who underwent coronary stent implantation, the addition of cilostazol to aspirin therapy was associated with lower rates of cardiovascular and cerebrovascular events at 2 years compared with aspirin monotherapy.
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Rogers KC, Oliphant CS, Finks SW. Clinical efficacy and safety of cilostazol: a critical review of the literature. Drugs 2016; 75:377-95. [PMID: 25758742 DOI: 10.1007/s40265-015-0364-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cilostazol is a unique antiplatelet agent that has been commercially available for over two decades. As a phosphodiesterase III inhibitor, it reversibly inhibits platelet aggregation yet also possesses vasodilatory and antiproliferative properties. It has been widely studied in a variety of disease states, including peripheral arterial disease, cerebrovascular disease, and coronary artery disease with percutaneous coronary intervention. Overall, cilostazol appears to be a promising agent in the management of these disease states with a bleeding profile comparable to placebo; even when combined with other antiplatelet agents, cilostazol does not appear to increase the rate of bleeding. Despite the possible benefit of cilostazol, its use is limited by tolerability as some patients often report drug discontinuation due to headache, diarrhea, dizziness, or increased heart rate. To date, it has been predominantly studied in the Asian population, making it difficult to extrapolate these results to a more diverse patient population. This paper discusses the evolving role of cilostazol in the treatment of vascular diseases.
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Affiliation(s)
- Kelly C Rogers
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, 881 Madison Ave, Rm 457, Memphis, TN, 38163, USA,
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18
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Zou Y, Hu C, Ye W, Fan L, Xu L, Zhang A. Long-term clinical efficacy and safety of adding cilostazol to dual antiplatelet therapy after drug-eluting stent implantation in coronary arteries: A meta-analysis of randomized controlled trials. Thromb Res 2015; 136:870-7. [DOI: 10.1016/j.thromres.2015.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/18/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022]
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19
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Kim JY, Choi YS, Kwon A, Chung WB, Park CS, Kim HY, Chang K, Lee MY, Chung WS, Seung KB. It Is Not Mandatory to Use Triple Rather Than Dual Anti-Platelet Therapy After a Percutaneous Coronary Intervention With a Second-Generation Drug-Eluting Stent. Medicine (Baltimore) 2015; 94:e2062. [PMID: 26579817 PMCID: PMC4652826 DOI: 10.1097/md.0000000000002062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
It has been shown that triple antiplatelet therapy with cilostazol results in better clinical outcomes than dual therapy in patients treated with a first-generation drug-eluting stent (DES); however, it is unclear whether triple antiplatelet therapy has a similar efficacy after the implantation of second-generation DES.In the COACT (Cath Olic medical center percutAneous Coronary in Tervention) registry, 1248 study subjects who underwent percutaneous coronary intervention with an everolimus- or zotarolimus-eluting stent (Endeavor, Xience V, or Promus) were analyzed. The patients were divided into 2 groups after propensity score matching (n = 724; M = 422 [58.3%]; mean age = 66.1 ± 11.0 years): Group 1: patients treated with dual antiplatelet drugs (aspirin and clopidogrel; n = 362; M = 213 [58.8%]; mean age = 65.6 ± 11.7 years); Group 2: patients treated with triple antiplatelet drugs (aspirin, clopidogrel, and cilostazol; n = 362; M = 209 [57.7%]; mean age = 65.6 ± 11.7 years). The mean follow-up duration was 13 ± 10 months, and the cumulative incidence of major cardiovascular events (MACE) was 6.3% in Group 1 and 7.7% in Group 2. There were no significant differences in MACE (death, nonfatal myocardial infarction, and stroke) between the 2 groups (OR, 1.210; 95% CI: 0.772-1.898; P = 0.406). Kaplan-Meier curves for MACE did not show any survival benefit for triple antiplatelet therapy, even in patients with acute coronary syndrome.In patients treated with a second-generation DES implantation, there is no added clinical benefit to using triple rather than dual antiplatelet therapy.
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Affiliation(s)
- Ju-Youn Kim
- From the Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Konishi H, Miyauchi K, Dohi T, Tsuboi S, Ogita M, Naito R, Kasai T, Tamura H, Okazaki S, Isoda K, Daida H. Impact of stent length on clinical outcomes of first-generation and new-generation drug-eluting stents. Cardiovasc Interv Ther 2015; 31:114-21. [PMID: 26498198 DOI: 10.1007/s12928-015-0362-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 09/30/2015] [Indexed: 11/29/2022]
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Bundhun PK, Qin T, Chen MH. Comparing the effectiveness and safety between triple antiplatelet therapy and dual antiplatelet therapy in type 2 diabetes mellitus patients after coronary stents implantation: a systematic review and meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2015; 15:118. [PMID: 26450578 PMCID: PMC4599328 DOI: 10.1186/s12872-015-0114-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 09/25/2015] [Indexed: 01/04/2023] Open
Abstract
Background Since antiplatelet therapy in type 2 diabetes mellitus (T2DM) patients is very important after intracoronary stenting, and because the most commonly used therapies have been the dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel and the triple antiplatelet therapy (TAPT) consisting of aspirin, clopidogrel and cilostazol, we aim to compare the effectiveness and safety between triple antiplatelet therapy and dual antiplatelet therapy in T2DM patients. Methods Systematic literature search was done from the databases of PubMed, Cochrane, Embase, China National Knowledge Infrastructure (CNKI) and WanFang. Randomized controlled trials (RCTs) comparing the effectiveness and safety between triple therapy and dual therapy in T2DM patients after coronary stents placement were included. Endpoints included major adverse cardiac effects (MACEs), target lesion revascularization (TLR), target vessel revascularization (TVR), death, stent thrombosis, bleeding and adverse drug reactions during a 9–12 months period, as well as platelet activities. Results Four studies including 1005 patients reporting the adverse clinical outcomes and six studies including 519 patients reporting the platelet activities, with a total of 1524 patients have been analyzed in this meta-analysis. The pooling analysis shows that TAPT has significantly decreased the occurrence of MACEs (RR: 0.55; 95 % CI: 0.36–0.86, P = 0.009), TLR (RR 0.41; 95 % CI: 0.21–0.80, P = 0.008), TVR (RR 0.55; 95 % CI: 0.34–0.88, P = 0.01) and the overall incidence of Death/ Myocardial Infarction (MI)/TVR (RR 0.54; 95 % CI: 0.31–0.94, P = 0.03) during this 9 to 12 months follow up period after stents implantation. Stent thrombosis was almost similar in both groups. Bleeding seemed to favor DAPT but the result was not statistically significant. Platelet aggregation, platelet reactivity index (PRI) and platelet reactivity unit (PRU) were also reduced with Weight Mean Difference (WMD) of (−13.80; 95 % CI: −17.03 to −10.56, P < 0.00001), (−22.87; 95 % CI: −23.66 to −22.07, P < 0.00001) and (−44.17; 95 % CI: −58.56 to −29.77, P < 0.00001) respectively. Conclusion Since MACEs have been significantly decreased in the triple group, TAPT appears to be more effective than DAPT in T2DM patients after intracoronary stenting. No significant difference in stent thrombosis and bleeding risks between these 2 groups shows TAPT to be almost as safe as DAPT in these diabetic patients.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, P. R. China.
| | - Tao Qin
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, P. R. China.
| | - Meng-Hua Chen
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, P. R. China.
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Schurtz G, Manchuelle A, Lemesle G. Stent length as a potential indicator to select patients who may benefit from long-term dual antiplatelet therapy. Interv Cardiol 2015. [DOI: 10.2217/ica.15.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Chen J, Meng H, Xu L, Liu J, Kong D, Chen P, Gong X, Bai J, Zou F, Yang Z, Li C, Eikelboom JW. Efficacy and safety of cilostazol based triple antiplatelet treatment versus dual antiplatelet treatment in patients undergoing coronary stent implantation: an updated meta-analysis of the randomized controlled trials. J Thromb Thrombolysis 2015; 39:23-34. [PMID: 24869717 DOI: 10.1007/s11239-014-1090-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to obtain best estimates of the efficacy and safety of cilostazol-based triple antiplatelet therapy (TAPT: aspirin, clopidogrel and cilostazol) compared with dual antiplatelet therapy (DAPT: aspirin and clopidogrel) in patients undergoing coronary stent implantation. We searched the literature to identify all randomized clinical trials examining efficacy and safety of TAPT versus DAPT in patients undergoing coronary stent implantation. Major efficacy outcomes were death, non-fatal myocardial infarction (MI), ischemic stroke and stent thrombosis (ST) and the safety outcome was bleeding. Data were analyzed using the Review Manager 5.0.0 software. A total of 19 trials involving 7,464 patients were included. TAPT and DAPT were associated with similar rates of death, non-fatal MI, ischemic stroke and ST, but compared with DAPT, TAPT had lower rates of target lesion revascularization (TLR) (RR 0.67, 95 % CI 0.56-0.82, P < 0.0001) and target vessel revascularization (TVR) (RR 0.65, 95 % CI 0.55-0.77, P < 0.00001), as well as less late loss of minimal lumen diameter (mean difference -0.14, 95 % CI -0.17--0.11, P < 0.00001), and less binary angiographic restenosis (RR 0.54, 95 % CI 0.45-0.65, P < 0.00001). TAPT and DAPT had similar rates of bleeding, but TAPT had significantly higher rates of headache, palpitation, rash and gastrointestinal side-effects. Cilostazol-based TAPT compared with DAPT is associated with improved angiographic outcomes and decreased risk of TLR and TVR but does not reduce major cardiovascular events and is associated with an increase in minor adverse events.
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Affiliation(s)
- Jun Chen
- Department of Cardiology, First Affiliated Hospital of Nanjing Medical University, 300, Guangzhou Road, Nanjing, 210029, China
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Guerra E, Byrne RA, Kastrati A. Pharmacological inhibition of coronary restenosis: systemic and local approaches. Expert Opin Pharmacother 2014; 15:2155-71. [DOI: 10.1517/14656566.2014.948844] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bangalore S, Singh A, Toklu B, DiNicolantonio JJ, Croce K, Feit F, Bhatt DL. Efficacy of cilostazol on platelet reactivity and cardiovascular outcomes in patients undergoing percutaneous coronary intervention: insights from a meta-analysis of randomised trials. Open Heart 2014; 1:e000068. [PMID: 25332804 PMCID: PMC4189225 DOI: 10.1136/openhrt-2014-000068] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/30/2014] [Accepted: 07/15/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cilostazol overcomes high on-treatment platelet reactivity (HTPR) and reduces adverse cardiovascular (CV) outcomes after percutaneous coronary intervention (PCI). However, the role for triple antiplatelet therapy (TAPT) with cilostazol in addition to aspirin and clopidogrel after PCI is not well defined. METHODS We conducted a MEDLINE/EMBASE/CENTRAL search for randomised trials, until May 2014, evaluating TAPT compared with dual antiplatelet therapy (DAPT) of aspirin and clopidogrel alone in patients undergoing PCI and reporting platelet reactivity and/or CV outcomes. The primary platelet reactivity outcome was differences in platelet reactivity unit (PRU) with secondary outcomes of %platelet inhibition and rate of HTPR. The primary CV outcome was major adverse cardiovascular events (MACE), with secondary outcomes of death, cardiovascular death, myocardial infarction, stent thrombosis (ST), target lesion revascularisation (TLR) and target vessel revascularisation (TVR) as well as safety outcomes of bleeding and drug discontinuations. RESULTS In 17 trials that evaluated platelet reactivity outcomes, the mean PRU value was 47.73 units lower with TAPT versus DAPT (95% CI -61.41 to -34.04, p<0.0001; mean PRU 182.90 vs 232.65). TAPT also increased platelet inhibition by 12.71% (95% CI 10.76 to 14.67, p<0.0001), and led to a 60% reduction in the risk of HTPR (relative risk=0.40; 95% CI 0.30 to 0.53) compared with DAPT. Moreover, among the 34 trials that evaluated CV outcomes, TAPT reduced the risk of MACE (incident rate ratio (IRR)=0.68; 95% CI 0.60 to 0.78), TLR (IRR=0.57; 95% CI 0.44 to 0.73), TVR (IRR=0.69; 95% CI 0.59 to 0.81) and ST (IRR=0.63; 95% CI 0.40 to 0.98) with no difference for other outcomes including bleeding, even in trials using drug-eluting stents. Drug discontinuation due to adverse effects was, however, higher with TAPT vs DAPT (IRR=1.59; 95% CI 1.32 to 1.91). CONCLUSIONS In patients undergoing PCI, addition of cilostazol to DAPT results in decreased platelet reactivity and a significant reduction in CV outcomes including ST, even in the drug-eluting stent era.
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Affiliation(s)
| | - Amita Singh
- New York University School of Medicine, New York, New York, USA
| | - Bora Toklu
- New York University School of Medicine, New York, New York, USA
| | | | - Kevin Croce
- Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Frederick Feit
- New York University School of Medicine, New York, New York, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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Choi IJ, Koh YS, Lim S, Kim JJ, Chang M, Kang M, Hwang BH, Kim CJ, Kim TH, Seo SM, Shin DI, Park MW, Choi YS, Park HJ, Her SH, Kim DB, Kim PJ, Lee JM, Park CS, Moon KW, Chang K, Kim HY, Yoo KD, Jeon DS, Chung WS, Seung KB. Impact of the stent length on long-term clinical outcomes following newer-generation drug-eluting stent implantation. Am J Cardiol 2014; 113:457-64. [PMID: 24332246 DOI: 10.1016/j.amjcard.2013.10.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/05/2013] [Accepted: 10/05/2013] [Indexed: 11/29/2022]
Abstract
Stent length has been considered an important predictor of adverse events after percutaneous coronary intervention, even with the first-generation drug-eluting stents (DESs). The introduction of newer-generation DES has further reduced the rates of adverse clinical events such as restenosis, myocardial infarction, and stent thrombosis. The aim of this study was to compare the impact of stent length on the long-term clinical outcomes between first- and newer-generation DESs. The effects of stent length (≥32 vs <32 mm) on the clinical outcomes were evaluated in 8,445 patients who underwent percutaneous coronary intervention using either a first-generation DES (sirolimus- and paclitaxel-eluting stents, n = 6,334) or a newer-generation DES (everolimus- and zotarolimus-eluting stents, n = 2,111) from January 2004 to December 2009. The 3-year adverse outcomes (composite of all-cause death, nonfatal myocardial infarction, target vessel revascularization, and stent thrombosis) were compared using the inverse probability of treatment-weighted method according to the stent length. After adjustment for differences in the baseline risk factors, a stent length of ≥32 mm was significantly associated with higher cumulative rates of target vessel revascularization and stent thrombosis in the patients treated with a first-generation DES (adjusted hazard ratio 1.875, 95% confidence interval 1.531 to 2.297, p <0.001; adjusted hazard ratio 2.964, 95% confidence interval 1.270 to 6.917, p = 0.012), but it was not associated with the clinical outcomes in patients treated with a newer-generation DES. In conclusion, stent length might not be associated with long-term clinical outcomes in newer-generation DES era, whereas stent length might be associated with long-term clinical outcomes in the first-generation DESs.
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Affiliation(s)
- Ik Jun Choi
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yoon-Seok Koh
- Cardiovascular Center, Uijeongbu St Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea.
| | - Sungmin Lim
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jin Jin Kim
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Mineok Chang
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Minkyu Kang
- Cardiovascular Center, Uijeongbu St Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Byung-Hee Hwang
- Cardiovascular Center, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chan Jun Kim
- Cardiovascular Center, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Korea
| | - Tae-Hoon Kim
- Cardiovascular Center, Uijeongbu St Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Suk Min Seo
- Cardiovascular Center, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Dong Il Shin
- Cardiovascular Center, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Mahn Won Park
- Cardiovascular Center, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Korea
| | - Yun-Seok Choi
- Cardiovascular Center, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hun-Jun Park
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung-Ho Her
- Cardiovascular Center, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Korea
| | - Dong-Bin Kim
- Cardiovascular Center, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Pum-Joon Kim
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jong Min Lee
- Cardiovascular Center, Uijeongbu St Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Chul Soo Park
- Cardiovascular Center, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Keon Woong Moon
- Cardiovascular Center, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Kiyuk Chang
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hee Yeol Kim
- Cardiovascular Center, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Ki Dong Yoo
- Cardiovascular Center, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Doo Soo Jeon
- Cardiovascular Center, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Wook-Sung Chung
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ki-Bae Seung
- Cardiovascular Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Youn YJ, Lee JW, Ahn SG, Lee SH, Choi H, Yu CW, Hong YJ, Kwon HM, Hong MK, Jang Y, Yoon J. Multicenter randomized trial of 3-month cilostazol use in addition to dual antiplatelet therapy after biolimus-eluting stent implantation for long or multivessel coronary artery disease. Am Heart J 2014; 167:241-248.e1. [PMID: 24439986 DOI: 10.1016/j.ahj.2013.08.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There are conflicting data on the use of cilostazol as triple antiplatelet therapy (TAPT) for improving clinical outcomes after drug-eluting stent implantation. We aimed to evaluate whether 3-month use of cilostazol in addition to dual antiplatelet therapy (DAPT) improved clinical outcomes in patients with long or multivessel coronary artery disease (CAD) after biolimus-eluting stent (BES) implantation. METHODS Patients (n = 630) who had been successfully treated with BES implantation for lesions with ≥28 mm in stent length or ≥2 stents for different coronary arteries were enrolled in this prospective randomized multicenter trial. All patients were randomly assigned to receive either DAPT (aspirin and clopidogrel for 12 months, n = 314) or TAPT (DAPT plus 3-month cilostazol use, n = 316). The primary end point was a device-oriented composite consisting of cardiac death, myocardial infarction (not clearly attributable to a nontarget vessel), and ischemia-driven target lesion revascularization at 1-year follow-up. RESULTS A total of 314 patients in DAPT and 308 patients in TAPT were analyzed. Multivessel CAD was present in 65.7% of patients. Stents ≥28 mm in length were implanted in 58.1% of lesions. There were no significant differences in baseline and angiographic characteristics between the 2 groups. The primary end point was similar between the 2 groups (2.3% in DAPT vs 1.9% in TAPT, log-rank P = .799). CONCLUSIONS In patients treated with BES implantation for long or multivessel CAD, 3 months of cilostazol use in addition to DAPT did not improve clinical outcome at 1-year follow-up.
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Chen Y, Zhang Y, Tang Y, Huang X, Xie Y. Long-term clinical efficacy and safety of adding cilostazol to dual antiplatelet therapy for patients undergoing PCI: a meta-analysis of randomized trials with adjusted indirect comparisons. Curr Med Res Opin 2014; 30:37-49. [PMID: 24083626 DOI: 10.1185/03007995.2013.850067] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the long-term clinical efficacy and safety of adding cilostazol to aspirin plus clopidogrel (triple antiplatelet therapy, TAT) in patients undergoing percutaneous coronary intervention (PCI) and explore its role in the era of new generation adenosine diphosphate (ADP)-receptor antagonists. METHODS PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) comparing TAT versus dual antiplatelet therapy (DAT), followed by a manual search. Then, a meta-analysis of RCTs comparing TAT versus standard DAT in patients undergoing PCI was performed. Furthermore, indirect comparisons of TAT versus new generation ADP-receptor antagonist based DAT (prasugrel or ticagrelor based DAT) were undertaken, with standard DAT as a common comparator. The included end-points were major adverse cardiovascular event (MACE), target lesion revascularization (TLR), target vessel revascularization (TVR), death, myocardial infarction (MI), stent thrombosis, bleeding and other drug adverse events. RESULTS Twelve RCTs with a total of 31,789 patients were included. Compared with standard DAT (n = 2551), TAT (n = 2545) significantly reduced the incidence of MACE (OR: 0.56, 95% CI: 0.47-0.68, P < 0.00001), TLR (OR: 0.51, 95% CI: 0.34-0.75, P = 0.0006) and TVR (OR: 0.59, 95% CI: 0.46-0.75, P < 0.0001), and did not change significantly in death (OR: 0.68, 95% CI: 0.44-1.05, P = 0.08), MI (OR: 0.80, 95% CI: 0.45-1.44, P = 0.46), stent thrombosis (OR: 0.61, 95% CI: 0.27-1.36, P = 0.23), major bleeding (OR: 1.42, 95% CI: 0.52-3.85, P = 0.49) and overall bleeding (OR: 1.16, 95% CI: 0.79-1.69, P = 0.45). Compared with prasugrel (n = 6813) or ticagrelor based DAT (n = 6732), TAT (n = 2545) further reduced the incidence of MACE (OR: 0.80, 95% CI: 0.72-0.90, P = 0.0012; OR: 0.83, 95% CI: 0.75-0.92, P = 0.0003, respectively). CONCLUSIONS Compared with standard DAT, the long-term use of TAT in patients with PCI gives more benefits in reducing the incidence of MACE, TLR and TVR without increasing bleeding. Furthermore, it might be superior to prasugrel or ticagrelor based DAT in term of MACE, which needs to be confirmed by future studies with direct comparisons.
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Affiliation(s)
- Yu Chen
- Division of Cardiology, Xinhua Hospital School of Medicine, Shanghai Jiaotong University , Shanghai , China
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29
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Lee SW, Lee JY, Ahn JM, Park DW, Han S, Park YK, Lee WS, Jang JY, Kwon CH, Park GM, Cho YR, Kim WJ, Kang SJ, Kim YH, Lee CW, Kim JJ, Park SW, Park SJ. Comparison of dual versus triple antiplatelet therapy after drug-eluting stent according to stent length (from the pooled analysis of DECLARE trials). Am J Cardiol 2013; 112:1738-44. [PMID: 24063835 DOI: 10.1016/j.amjcard.2013.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 08/14/2013] [Accepted: 08/14/2013] [Indexed: 10/26/2022]
Abstract
There are no practical criteria for the use of triple antiplatelet therapy after drug-eluting stent (DES) implantation. In our present report, pooled analysis of 3 randomized studies in patients with diabetes mellitus (Drug-Eluting Stenting Followed by Cilostazol treatment reduces LAte Restenosis in patients with diabetes mellitus trial) and long coronary narrowings (Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients with Long Coronary Lesions trials I and II) compared triple (aspirin, clopidogrel, and cilostazol; triple group, n = 700) and dual antiplatelet therapies (aspirin and clopidogrel; dual group, n = 699) after DES implantation. Among pooled population (n = 1,399 patients), 1,173 patients with follow-up angiography were divided into 3 stent length categories (≤20, 20 to 40, and >40 mm). There was no statistical significance of in-stent restenosis (ISR) in ≤20- and 20- to 40-mm categories between 2 groups. However, ISR rate was significantly reduced in triple versus dual group in >40-mm stent length category (12.4% vs 22.1%, p = 0.008). In diabetic patients, triple group also showed significant reduction in the ISR rate in >40-mm stent length category (15.4% vs 32.3%, p = 0.003). According to postprocedural minimal lumen diameter, triple group showed a trend toward a lower ISR than that of the dual group in all categories (p = 0.033 for ≤2.5 mm, p = 0.087 for 2.5 to 3.0 mm, and p = 0.119 for >3.0 mm). In conclusion, the triple group had a significantly reduced ISR in patients with >40-mm stent length after DES implantation compared with the dual group. Therefore, this suggestion for use of triple antiplatelet therapy could be easily applied after DES implantation in routine clinical practice.
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30
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Lee SW, Ahn JM, Han S, Park GM, Cho YR, Lee WS, Jang JY, Kwon CH, Lee JY, Kim WJ, Kang SJ, Kim YH, Lee CW, Kim JJ, Park SW, Park SJ. Differential impact of cilostazol on restenosis according to implanted stent type (from a pooled analysis of three DECLARE randomized trials). Am J Cardiol 2013; 112:1328-34. [PMID: 23890573 DOI: 10.1016/j.amjcard.2013.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/11/2013] [Accepted: 06/11/2013] [Indexed: 11/26/2022]
Abstract
Even in the drug-eluting stent era, restenosis has remained an unresolved issue, particularly in the treatment of complex coronary lesions. In this study, patient-level data from 3 randomized trials (Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients With Diabetes Mellitus [DECLARE-DIABETES] and Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients With Long Native Coronary Lesions [DECLARE-LONG] I and II) were pooled to estimate the differential antirestenotic efficacy of add-on cilostazol according to the implanted drug-eluting stent in patients at high risk for restenosis. A total of 1,399 patients underwent sirolimus-eluting stent (SES; n = 450), paclitaxel-eluting stent (n = 450), and zotarolimus-eluting stent (n = 499) implantation and received triple-antiplatelet therapy (TAT; aspirin, clopidogrel, and cilostazol, n = 700) and dual-antiplatelet therapy (aspirin and clopidogrel, n = 699). Randomization of antiplatelet regimen was stratified by stent type. In-stent late loss after TAT was significantly lower than that after dual-antiplatelet therapy, regardless of implanted stent type. However, the incidence of in-segment restenosis after TAT was significantly lower with SES (0.5% vs 6.7%, p = 0.014) and zotarolimus-eluting stent (12.2% vs 20.0%, p = 0.028) implantation but not paclitaxel-eluting stent implantation (14.4% vs 20.0%, p = 0.244). A significant interaction was present between stent type and antiplatelet regimen for the risk for in-segment restenosis (p = 0.004). Post hoc analysis using bootstrap resampling methods showed that the relative risk reduction for in-segment restenosis after TAT was most prominent with SES implantation. In conclusion, add-on cilostazol effectively reduced restenosis in patients at high risk for restenosis, particularly in those receiving SES, suggesting the sustainable utility of add-on cilostazol therapy in newer generation drug-eluting stents with comparable efficacy with that of SES.
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31
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The impact of triple anti-platelet therapy for endothelialization and inflammatory response at overlapping bioabsorbable polymer coated drug-eluting stents in a porcine coronary model. Int J Cardiol 2013; 168:1853-8. [DOI: 10.1016/j.ijcard.2012.12.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 12/25/2012] [Indexed: 10/27/2022]
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32
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Panchal HB, Shah T, Patel P, Albalbissi K, Molnar J, Coffey B, Khosla S, Ramu V. Comparison of On-Treatment Platelet Reactivity Between Triple Antiplatelet Therapy With Cilostazol and Standard Dual Antiplatelet Therapy in Patients Undergoing Coronary Interventions. J Cardiovasc Pharmacol Ther 2013; 18:533-43. [DOI: 10.1177/1074248413495971] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The recent literature has shown that triple antiplatelet therapy with cilostazol in addition to the standard dual antiplatelet therapy with aspirin and clopidogrel may reduce platelet reactivity and improve clinical outcomes following percutaneous coronary intervention. The purpose of this meta-analysis is to compare the efficacy of triple antiplatelet therapy and dual antiplatelet therapy in regard to on-treatment platelet reactivity. Methods: Nine studies (n = 2179) comparing on-treatment platelet reactivity between dual antiplatelet therapy (n = 1193) and triple antiplatelet therapy (n = 986) in patients undergoing percutaneous coronary intervention were included. Primary end points were P2Y12 reaction unit (PRU) and platelet reactivity index (PRI). Secondary end points were platelet aggregation with adenosine diphosphate (ADP) 5 and 20 µmol/L and P2Y12% inhibition. Mean difference (MD) and 95% confidence intervals (CI) were computed and 2-sided α error <.05 was considered as a level of significance. Results: Compared to dual antiplatelet therapy, triple antiplatelet therapy had significantly lower maximum platelet aggregation with ADP 5 µmol/L (MD: −14.4, CI: −21.6 to −7.2, P < .001) and 20 µmol/L (MD: −14.9, CI: −22.9 to −6.8, P < .001), significantly lower PRUs (MD: −45, CI: −59.4 to −30.6, P < .001) and PRI (MD: −26, CI: −36.8 to −15.2, P < .001), and significantly higher P2Y12% inhibition (MD: 18.5, CI: 2.3 to 34.6, P = .025). Conclusion: Addition of cilostazol to conventional dual antiplatelet therapy significantly lowers platelet reactivity and may explain a decrease in thromboembolic events following coronary intervention; however, additional studies evaluating clinical outcomes will be helpful to determine the benefit of triple antiplatelet therapy.
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Affiliation(s)
- Hemang B. Panchal
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Tejaskumar Shah
- Division of Cardiology, Department of Internal Medicine, Chicago Medical School/RFUMS, North Chicago, IL, USA
| | - Parthavkumar Patel
- Emergency Medicine Observer, Holston Valley Medical Center, Kingsport, TN, USA
| | - Kais Albalbissi
- Division of Cardiology, Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Janos Molnar
- Chicago Medical School/RFUMS, North Chicago, IL, USA
| | - Brandon Coffey
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Sandeep Khosla
- Division of Cardiology, Department of Internal Medicine, Mt Sinai Hospital, Chicago, IL, USA
| | - Vijay Ramu
- Division of Cardiology, Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
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Yang DC, Swaminathan RV, Kim LK, Feldman DN. Pharmacotherapy for the reduction of stent thrombosis. Expert Rev Cardiovasc Ther 2013; 11:567-76. [PMID: 23621139 DOI: 10.1586/erc.13.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The benefits of percutaneous coronary intervention (PCI) can be offset by periprocedural complications such as acute vessel closure and stent thrombosis in the absence of adequate antiplatelet and antithrombotic therapy. Additionally, conditions occurring after 30 days post-PCI, such as in-stent restenosis or late stent thrombosis can occur. Excess antithrombotic therapy, on the other hand, carries a risk of major gastrointestinal or intracranial bleeding as well as vascular access site bleeding complications. In this review, evidence related to the various pharmacological agents for reduction of stent thrombosis available to clinicians during and after PCI will be explored.
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Affiliation(s)
- David C Yang
- Weill Cornell Medical College, New York Presbyterian Hospital, Department of Medicine, Greenberg Division of Cardiology, 520 East 70th Street, Starr-434 Pavilion, New York, NY 10021, USA
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34
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Chen Z, Qian J, Chen Y, Ma J, Ge J. Addition of cilostazol to conventional dual antiplatelet therapy reduces the risk of cardiac events and restenosis after drug-eluting stent implantation: a meta-analysis. J Clin Pharmacol 2013; 53:532-9. [PMID: 23436428 DOI: 10.1002/jcph.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/25/2012] [Indexed: 11/06/2022]
Abstract
This meta-analysis was performed to compare the risk of cardiac events and restenosis between triple antiplatelet therapy (TAT, addition of cilostazol to aspirin and clopidogrel) and conventional dual antiplatelet therapy (DAT, aspirin and clopidogrel) in drug-eluting stents (DES) implantation patients. We performed PUBMED, MEDLINE, EMBASE, and Cochrane CENTRAL searches for randomized clinical trials of TAT versus DAT in patients after DES implantation. Five clinical trials were involved in the study. TAT was associated with a 36% reduction in major adverse cardiac events (MACE; odds ratio (OR) = 0.64; 95% confidence interval (CI) = 0.51-0.81, P < .01), a 40% reduction (OR = 0.60, 95% CI = 0.44-0.80; P < .01) in target vessel revascularization (TVR), a 44% reduction (OR = 0.56, 95% CI = 0.34-0.91; P = .02) in target lesion revascularization (TLR) and a 47%/44% reduction in in-segment/in-stent restenosis (P < .01) and lower in-segment/in-stent late loss (P < .01). As regards to the safety assessment, there was no significant difference about the risk of stent thrombosis and bleeding between TAT and DAT group, while the risk of gastrointestinal trouble was significantly higher in TAT group (OR = 2.46, 95% CI = 1.25-4.86; P < .01). Addition of cilostazol to DAT reduced the incidence of MACE, TVR, and TLR after DES implantation. TAT also reduced the risk of restenosis and late loss in patients after DES implantation.
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Affiliation(s)
- Zhangwei Chen
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032 P.R. China
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35
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Lee GY, Hahn JY, Lee SY, Kim HJ, Kim JH, Lee SY, Song YB, Choi SH, Choi JH, Gwon HC. Adjunctive cilostazol versus high maintenance dose of clopidogrel in patients with hyporesponsiveness to chronic clopidogrel therapy. Yonsei Med J 2013; 54:34-40. [PMID: 23225796 PMCID: PMC3521288 DOI: 10.3349/ymj.2013.54.1.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Whether addition of cilostazol is superior to increasing dose of clopidogrel in patients with hyporesponsiveness to chronic clopidogrel therapy is unknown. MATERIALS AND METHODS We studied 73 patients with hyporesponsiveness to clopidogrel on standard dual antiplatelet therapy for more than 2 weeks. Clopidogrel hyporesponsiveness was defined as percent inhibition of P2Y12 reaction units (PRU) <30% on VerifyNow P2Y12 assay. Patients were randomly assigned to increased dose of clopidogrel (aspirin 100 mg+clopidogrel 150 mg daily: group A, n=38) or to receiving additional cilostazol (aspirin 100 mg+clopidogrel 75 mg+cilostazol 100 mg bid daily: group B, n=35). RESULTS Baseline percent inhibition of PRU and PRU was similar between 2 groups (13.0 ± 10.2% versus 11.8 ± 9.7%, p = 0.61, and 286.3 ± 54.7 versus 295.7 ± 53.7, p=0.44, respectively). At follow-up, percent inhibition of PRU was higher and PRU was lower significantly in group B than in group A (38.5 ± 17.9% versus 28.3 ± 16.6%, p=0.02, and 207.3 ± 68.2 versus 241.3 ± 76.7, p=0.050, respectively). Among those still showing hyporesponsiveness to clopidogrel at follow-up (21 patients in group A, 10 patients in group B), 12 patients completed further crossover study. Compared to the baseline, magnitude of change in percent inhibition of PRU and PRU showed an improved tendency after the crossover (from 2.7 ± 8.7% to 15.8 ± 18.4%, p=0.08, and from -18.6 ± 58.0 to -61.9 ± 84.3, p=0.08). CONCLUSION Adjunctive cilostazol improved clopidogrel responsiveness better than the higher maintenance dose of clopidogrel in hyporesponsive patients with chronic clopidogrel therapy.
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Affiliation(s)
- Ga Yeon Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Hyung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Yup Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Ikeda Y, Sudo T, Kimura Y. Cilostazol. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00057-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee KH, Ahn Y, Kim SS, Rhew SH, Jeong YW, Jang SY, Cho JY, Jeong HC, Park KH, Yoon NS, Sim DS, Yoon HJ, Kim KH, Hong YJ, Park HW, Kim JH, Cho JG, Park JC, Jeong MH, Cho MC, Kim CJ, Kim YJ. Comparison of Triple Anti-Platelet Therapy and Dual Anti-Platelet Therapy in Patients With Acute Myocardial Infarction Who Had No-Reflow Phenomenon During Percutaneous Coronary Intervention. Circ J 2013; 77:2973-81. [DOI: 10.1253/circj.cj-13-0594] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Ding XL, Xie C, Jiang B, Gao J, Zhang LL, Zhang H, Zhang JJ, Miao LY. Efficacy and Safety of Adjunctive Cilostazol to Dual Antiplatelet Therapy After Stent Implantation. J Cardiovasc Pharmacol Ther 2012; 18:222-8. [PMID: 23263383 DOI: 10.1177/1074248412468944] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Aspirin and clopidogrel dual antiplatelet therapy (DAT) reduce ischemic events in patients with cardiovascular disease. However, recurrent ischemic event occurrence during DAT remains a major concern. This systematic review assesses the efficacy and safety of adjunctive cilostazol to DAT in combination with DAT on reducing clinical adverse events. Methods: We searched randomized controlled trials (RCTs) in PubMed, Embase, Cochrane library, clinicaltrial.gov, and Chinese Biomedical Database through July 2011. Pooled risk ratio (RR) with 95% confidence intervals (CIs) was calculated. Two independent reviewers evaluated the included studies. The extracted data were analyzed by Review Manager 5.1.2 (The Cochrane Collaboration, Oxford, UK) and GRADEprofiler 3.6 (GRADE Working Group). Results: A total of 7 RCTs (4351 patients) were included in the analysis, with a follow-up period of 6 to 12 months. Pooled analysis showed that cilostazol was associated with a significant reduction in major adverse cardiac events (MACEs; pooled RR 0.69, 95% CI 0.52-0.91; P = .008) and repeat revascularization (RR 0.74, 95% CI 0.61-0.89; P = .002); however, cilostazol was not associated with a reduction in the risk of stent thrombosis (RR 1.00, 95% CI 0.41-2.45; P = 1.00). Cilostazol seems to be safe, with no significant increase in the risk of bleeding (RR 1.06, 95% CI 0.72-1.56; P = .77). The 4 outcomes were low-quality evidence for MACE, moderate-quality evidence for repeat revascularization, and high-quality evidence for bleeding and stent thrombosis. Conclusions: When compared to the currently recommended DAT, triple antiplatelet therapy with cilostazol can reduce repeat revascularization with no increase in the risk of bleeding.
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Affiliation(s)
- Xiao Liang Ding
- Clinical Pharmacology Research Laboratory, The First Affiliated of Soochow University, Suzhou, China
| | - Cheng Xie
- Clinical Pharmacology Research Laboratory, The First Affiliated of Soochow University, Suzhou, China
| | - Bin Jiang
- Department of Cardiology, The First Affiliated of Soochow University, Suzhou, China
| | - Jie Gao
- Clinical Pharmacology Research Laboratory, The First Affiliated of Soochow University, Suzhou, China
| | - Ling Li Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hua Zhang
- Clinical Pharmacology Research Laboratory, The First Affiliated of Soochow University, Suzhou, China
| | - Jing Jing Zhang
- Clinical Pharmacology Research Laboratory, The First Affiliated of Soochow University, Suzhou, China
| | - Li Yan Miao
- Clinical Pharmacology Research Laboratory, The First Affiliated of Soochow University, Suzhou, China
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Sakurai R, Koo BK, Kaneda H, Bonneau HN, Nagai R. Cilostazol added to aspirin and clopidogrel reduces revascularization without increases in major adverse events in patients with drug-eluting stents: a meta-analysis of randomized controlled trials. Int J Cardiol 2012; 167:2250-8. [PMID: 22727963 DOI: 10.1016/j.ijcard.2012.06.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/31/2012] [Accepted: 06/07/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The effects of cilostazol added to aspirin and clopidogrel (triple antiplatelet therapy: TAT) on clinical outcomes after drug-eluting stent (DES) implantation are unknown. METHODS We conducted a meta-analysis of randomized controlled trials (RCTs) comparing TAT with aspirin and clopidogrel (dual antiplatelet therapy: DAT) in DES patients. Clinical end points were target lesion (TLR) and/or vessel (TVR) revascularization, death, myocardial infarction (MI), stent thrombosis (ST), bleeding, rash, gastrointestinal (GI) side effects, and drug discontinuation. We calculated the pooled estimate based on a fixed-effects model using Peto odds ratio (OR) for rare events. If heterogeneity was observed across an individual RCT, an analysis based on a random-effects model was performed. RESULTS Eight RCTs were included in this meta-analysis, involving 3590 patients (TAT:DAT=1800:1790). Up to 24 months, TAT showed a significant reduction in TLR (OR: 0.58, 95% confidence interval (CI): 0.43 to 0.78, p<0.001) and TVR (OR: 0.58, 95% CI: 0.40 to 0.83, p=0.003) compared with DAT. The incidence of death, MI, ST, or overall or major bleeding was comparable between the 2 groups, whereas the proportion of rash (OR: 2.50, 95% CI: 1.52 to 4.10, p<0.001), GI side effects (OR: 3.14, 95% CI: 1.79 to 5.50, p<0.001), or drug discontinuation (OR: 6.81, 95% CI: 2.12 to 21.86, p<0.001) was higher in TAT than DAT. CONCLUSIONS In this meta-analysis, TAT was associated with significantly effective outcomes for TLR and TVR without any increase in major adverse events but was associated with tolerance issues compared with DAT after DES implantation.
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Affiliation(s)
- Ryota Sakurai
- Department of Planning, Information and Management, The University of Tokyo Hospital, Tokyo, Japan
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Rogers KC, Faircloth JM, Finks SW. Use of Cilostazol in Percutaneous Coronary Interventions. Ann Pharmacother 2012; 46:839-50. [DOI: 10.1345/aph.1q765] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To evaluate the addition of cilostazol to standard dual antiplatelet therapy (DAT) with aspirin and clopidogrel in patients receiving coronary stenting. DATA SOURCES: Relevant information was identified through a search of MEDLINE (1966-November 2011), International Pharmaceutical Abstracts (1960-2011), and Cochrane Databases (publications archived until November 2011) using the terms cilostazol, percutaneous coronary intervention, triple therapy, and antiplatelet agents. STUDY SELECTION AND DATA EXTRACTION: English-language prospective and retrospective studies, including registry data in adults, were eligible for inclusion if triple therapy with cilostazol was compared with DAT with aspirin and clopidogrel in patients undergoing percutaneous coronary intervention (PCI) with stenting. Article bibliographies were also reviewed. DATA SYNTHESIS: Cilostazol uniquely possesses antiproliferative properties in addition to its antiplatelet effects. Several prospective and retrospective clinical trials evaluated it as a third agent in standard antiplatelet regimens after PCI with both bare metal and drug-eluting stents. Both angiographic and clinical outcomes, including major adverse cardiac events (MACEs), have been improved with the addition of cilostazol to DAT in most trials, without increasing bleeding risk. Higher-risk patients, such as elderly individuals and patients with diabetes, long lesions, or small vessels, seem to benefit the most from triple therapy. Patients who are poor responders to clopidogrel also appear to benefit from the addition of cilostazol by improving platelet reactivity with standard DAT. CONCLUSIONS: Triple therapy with cilostazol has been shown to reduce MACEs by providing increased inhibition of platelet aggregation and reducing the rates of in-stent thrombosis compared to DAT without increasing the risk of bleeding complications. Further studies are needed to identify proper patient selection based on risk factors for the addition of cilostazol. Additionally, studies comparing cilostazol with newer antiplatelet therapies, such as prasugrel and ticagrelor, are needed.
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Affiliation(s)
- Kelly C Rogers
- Kelly C Rogers PharmD, Professor, Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee, Memphis; Clinical Pharmacy Specialist, Cardiology, Veterans Affairs Medical Center, Memphis
| | - Jenna M Faircloth
- Jenna M Faircloth PharmD, PGY1 Pharmacy Practice Resident, Vanderbilt University Medical Center, Nashville, TN
| | - Shannon W Finks
- Shannon W Finks PharmD FCCP BCPS (AQ Cardiology), Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee; Clinical Pharmacy Specialist, Cardiology, Veterans Affairs Medical Center, Memphis
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Friedland SN, Eisenberg MJ, Shimony A. Meta-analysis of randomized controlled trials on effect of cilostazol on restenosis rates and outcomes after percutaneous coronary intervention. Am J Cardiol 2012; 109:1397-404. [PMID: 22381162 DOI: 10.1016/j.amjcard.2012.01.349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 01/05/2012] [Accepted: 01/05/2012] [Indexed: 10/28/2022]
Abstract
Cilostazol is a generic drug with antiplatelet and antiproliferative effects. It is unclear whether adding cilostazol to standard dual antiplatelet therapy (aspirin and clopidogrel) after percutaneous coronary intervention reduces restenosis and improves the outcomes. We, therefore, conducted a systematic review and meta-analysis. We systematically searched the Cochrane Library, EMBASE, and MEDLINE databases for randomized controlled trials comparing dual antiplatelet therapy with and without cilostazol after percutaneous coronary intervention. The data were pooled using random-effects models and stratified into short-term (1-month), midterm (1- to 12-month), and long-term (≥12-month) follow-up durations. Twelve randomized controlled trials involving 5,655 patients met our inclusion criteria. The addition of cilostazol to dual antiplatelet therapy was not associated with a significant change in target lesion revascularization (TLR) and target vessel revascularization (TVR) at short-term follow-up. However, TLR and TVR were significantly reduced at midterm follow-up (relative risk 0.57, 95% confidence interval 0.39 to 0.84, and relative risk 0.62, 95% confidence interval 0.47 to 0.83, respectively). Data regarding TLR and TVR at long-term follow-up were limited and inconclusive. We did not find a difference in myocardial infarction, mortality, or major bleeding at any follow-up duration. In conclusion, the addition of cilostazol to dual antiplatelet therapy after percutaneous coronary intervention has favorable effects on TLR and TVR at 1 to 12 months, with no differences in adverse outcomes at any follow-up duration.
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Wang P, Zhou S, Zhou R, Liu G, Tang P, He J, Ma C, He Y, Yang J. The effectiveness and safety of triple-antiplatelet treatment based on cilostazol for patients receiving percutaneous coronary intervention: a meta-analysis. Clin Cardiol 2012; 35:598-604. [PMID: 22585740 DOI: 10.1002/clc.22001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/28/2012] [Indexed: 02/05/2023] Open
Abstract
The combination of cilostazol, aspirin, and clopidogrel (triple therapy) after percutaneous coronary intervention has been considered as an alternative therapy. We performed a meta-analysis based on 8 randomized controlled trials with a total of 3332 patients to compare the effectiveness and safety of this triple therapy with traditional dual therapy (aspirin and clopidogrel). Our findings suggested that the triple therapy is more effective than dual therapy in preventing restenosis (odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.40-0.66, P < 0.00001), maintaining minimal lumen diameter (OR: 0.15, 95% CI: 0.10-0.20, P < 0.00001), and avoiding target-vessel revascularization (OR: 0.62, 95% CI: 0.47-0.82, P = 0.001). There is also no significant difference in major adverse cardiac and cerebrovascular events between the 2 therapies, except the smaller occurrence rate of target-lesion revascularization in the triple-therapy group (OR: 0.42, 95% CI: 0.26-0.69, P = 0.0005). However, the triple therapy is associated with a higher level of adverse drug events, including rash (OR: 2.45, 95% CI: 1.41-4.23, P = 0.001), gastrointestinal disorders (OR: 2.59, 95% CI: 1.26-5.30, P = 0.009), and drug discontinuation (OR: 3.80, 95% CI: 1.59-9.10, P = 0.003), but it has no difference in bleeding compared with the dual therapy (OR: 1.05, 95% CI: 0.71-1.55, P = 0.80).
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Affiliation(s)
- Ping Wang
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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Clopidogrel use before renal artery angioplasty with/without stent placement resulted in tertiary procedure risk reduction. J Vasc Surg 2012; 56:416-23. [PMID: 22560231 DOI: 10.1016/j.jvs.2012.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 12/12/2011] [Accepted: 01/06/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Contrary to coronary artery literature, the effect of preprocedural clopidogrel on renal artery restenosis (RAR) has not been characterized. This study was designed to evaluate the effect of preprocedural clopidogrel on target vessel revascularization (TVR), reintervention, and restenosis for patients who underwent recurrent renal artery angioplasty. METHODS A retrospective analysis of patients treated for RAR in a single tertiary center from January 1999 to December 2009 was conducted. Patients were divided into preadmission use of (1) clopidogrel or (2) aspirin only (acetylsalicylic acid [ASA]) for the initial procedure. TVR was defined as occurrence of a tertiary procedure for symptomatic RAR. Rate of freedom from event (ie, tertiary restenosis and TVR) was analyzed using Kaplan-Meier method. RESULTS Eighty-eight interventions were performed on 77 patients with RAR; 66% were females with average (mean ± SEM) age and body mass index of 68.8 ± 1.1 and 28.6 ± 0.8, respectively. Comorbidities included 96% chronic hypertension, 33% diabetes, 76% hyperlipidemia, 20% renal insufficiency, 39% tobacco use, 58% coronary artery disease, and 51% peripheral vascular disease. Clopidogrel use increased significantly during the index procedure from admission 35.2% to discharge 97.7% (P < .001, McNemar test). There was a trend toward risk reduction of a tertiary intervention (23%) for patients admitted on clopidogrel compared with ASA (P = .052). Likewise, there was a trend (P = .051) toward increased freedom from a tertiary intervention, with cumulative freedom at 8 years 93.5% for clopidogrel vs 61% for ASA. No differences were found for restenosis. CONCLUSIONS The use of preprocedural clopidogrel was associated with a possible risk reduction of TVR reintervention, but this finding needs to be validated in randomized clinical trial.
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Capranzano P, Ferreiro JL, Ueno M, Capodanno D, Dharmashankar K, Darlington A, Desai B, Tello-Montoliu A, Rollini F, Angiolillo DJ. Pharmacodynamic effects of adjunctive cilostazol therapy in patients with coronary artery disease on dual antiplatelet therapy: Impact of high on-treatment platelet reactivity and diabetes mellitus status. Catheter Cardiovasc Interv 2012; 81:42-9. [DOI: 10.1002/ccd.24416] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 02/16/2012] [Accepted: 03/10/2012] [Indexed: 11/07/2022]
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Kang HJ, Oh IY, Chung JW, Yang HM, Suh JW, Park KW, Kwon TK, Lee HY, Cho YS, Youn TJ, Koo BK, Kang WY, Kim W, Rha SW, Bae JH, Chae IH, Choi DJ, Kim HS. Effects of Celecoxib On Restenosis after Coronary Intervention and Evolution of Atherosclerosis (Mini-COREA) Trial: celecoxib, a double-edged sword for patients with angina. Eur Heart J 2012; 33:2653-61. [DOI: 10.1093/eurheartj/ehs001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Parker T, Davé V, Falotico R, Zhao J, Nguyen T, He S, Sun YP, Rogers C. Control of cilostazol release kinetics and direction from a stent using a reservoir-based design. J Biomed Mater Res B Appl Biomater 2012; 100:603-10. [DOI: 10.1002/jbm.b.31954] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 06/03/2011] [Accepted: 08/29/2011] [Indexed: 11/07/2022]
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Passacquale G, Ferro A. Current concepts of platelet activation: possibilities for therapeutic modulation of heterotypic vs. homotypic aggregation. Br J Clin Pharmacol 2012; 72:604-18. [PMID: 21223359 DOI: 10.1111/j.1365-2125.2011.03906.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Thrombogenic and inflammatory activity are two distinct aspects of platelet biology, which are sustained by the ability of activated platelets to interact with each other (homotypic aggregation) and to adhere to circulating leucocytes (heterotypic aggregation). These two events are regulated by distinct biomolecular mechanisms that are selectively activated in different pathophysiological settings. They can occur simultaneously, for example, as part of a pro-thrombotic/pro-inflammatory response induced by vascular damage, or independently, as in certain clinical conditions in which abnormal heterotypic aggregation has been observed in the absence of intravascular thrombosis. Current antiplatelet drugs have been developed to target specific molecular signalling pathways mainly implicated in thrombus formation, and their ever increasing clinical use has resulted in clear benefits in the treatment and prevention of arterial thrombotic events. However, the efficacy of currently available antiplatelet drugs remains suboptimal, most likely because their therapeutic action is limited to only few of the signalling pathways involved in platelet homotypic aggregation. In this context, modulation of heterotypic aggregation, which is believed to contribute importantly to acute thrombotic events, as well to the pathophysiology of atherosclerosis itself, may offer benefits over and above the classical antiplatelet approach. This review will focus on the distinct biomolecular pathways that, following platelet activation, underlie homotypic and heterotypic aggregation, aiming potentially to identify novel therapeutic targets.
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Affiliation(s)
- Gabriella Passacquale
- Department of Clinical Pharmacology, Cardiovascular Division, King's College London, London, UK
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Geng DF, Liu M, Jin DM, Wu W, Deng J, Wang JF. Cilostazol-Based Triple Antiplatelet Therapy Compared to Dual Antiplatelet Therapy in Patients with Coronary Stent Implantation: A Meta-Analysis of 5,821 Patients. Cardiology 2012; 122:148-57. [DOI: 10.1159/000338812] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 04/04/2012] [Indexed: 11/19/2022]
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Jang JS, Jin HY, Seo JS, Yang TH, Kim DK, Kim DS, Kim DK, Seol SH, Kim DI, Cho KI, Kim BH, Park YH, Je HG, Jeong YH, Kim WJ, Lee JY, Lee SW. A Meta-Analysis of Randomized Controlled Trials Appraising the Efficacy and Safety of Cilostazol after Coronary Artery Stent Implantation. Cardiology 2012; 122:133-43. [DOI: 10.1159/000339238] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 04/25/2012] [Indexed: 11/19/2022]
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50
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Jang SW, Rho TH, Kim DB, Cho EJ, Kwon BJ, Park HJ, Shin WS, Kim JH, Lee JM, Moon KW, Oh YS, Yoo KD, Youn HJ, Lee MY, Chung WS, Seung KB, Kim JH. Optimal antithrombotic strategy in patients with atrial fibrillation after coronary stent implantation. Korean Circ J 2011; 41:578-82. [PMID: 22125556 PMCID: PMC3221899 DOI: 10.4070/kcj.2011.41.10.578] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 12/11/2010] [Accepted: 01/12/2011] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives Little evidence is available on the optimal antithrombotic therapy following percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF). We investigated the outcomes of antithrombotic treatment strategies in AF patients who underwent PCI. Subjects and Methods Three hundred sixty-two patients (68.0% men, mean age: 68.3±7.8 years) with AF and who had undergone PCI with stent implantation between 2005 and 2007 were enrolled. The clinical, demographic and procedural characteristics were reviewed and the stroke risk factors as well as antithrombotic regimens were analyzed. Results The accompanying comorbidities were as follows: hypertension (59.4%), diabetes (37.3%) and congestive heart failure (16.6%). The average number of stroke risk factors was 1.6. At the time of discharge after PCI, warfarin was prescribed for 84 patients (23.2%). Cilostazol was used in addition to dual antiplatelet therapy in 35% of the patients who did not receive warfarin. The mean follow-up period was 615±385 days. The incidences of major adverse cardiac events (MACE), stroke and major bleeding were 11.3%, 3.6% and 4.1%, respectively. By Kaplan-Meier survival analysis, warfarin treatment was not associated with a lower risk of MACE (p=0.886), but it was associated with an increased risk of major bleeding (p=0.002). Conclusion Oral anticoagulation therapy after PCI may increase hemorrhagic events in Korean AF patients.
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Affiliation(s)
- Sung-Won Jang
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
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