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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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Comparison of cilostazol versus ticlopidine following coronary stenting in patients with coronary heart disease: A meta-analysis of randomized controlled trials. Exp Ther Med 2013; 6:819-825. [PMID: 24137273 PMCID: PMC3786799 DOI: 10.3892/etm.2013.1190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/24/2013] [Indexed: 11/05/2022] Open
Abstract
Previous studies have shown that the combination of cilostazol and aspirin may be a more effective regimen than ticlopidine plus aspirin in the prevention of late restenosis and acute or subacute stent thrombosis following coronary stenting; however, individually published results are inconclusive. The aim of this meta-analysis was to compare the differences in late restenosis and stent thrombosis between cilostazol plus aspirin and ticlopidine plus aspirin for patients with coronary heart disease (CHD) following coronary stenting. A literature search of Pubmed, Embase, Web of Science and Chinese BioMedicine (CBM) databases was conducted from 1998 to March 1, 2013 and statistical analysis was performed using Stata statistical software, version 12.0. Twelve randomized controlled trials were included in the study, with a total of 2,708 patients with CHD following coronary stenting. The patient population comprised 1,371 patients treated with cilostazol plus aspirin and 1,337 patients treated with ticlopidine plus aspirin. The meta-analysis showed that cilostazol plus aspirin demonstrated a lower rate of restenosis than ticlopidine plus aspirin [odds ratio (OR)=0.83, 95% confidence interval (CI)=0.69–0.99, P=0.047]. A significant difference was also observed in the average percent diameter stenosis between cilostazol plus aspirin and ticlopidine plus aspirin [standardized weight difference (SMD)= −0.57, 95% CI=−0.92, −0.23, P=0.001). However, there were no significant differences in the rates of acute or subacute stent thrombosis between cilostazol plus aspirin and ticlopidine plus aspirin. The present meta-analysis suggests that cilostazol plus aspirin may result in a lower restenosis rate and percent diameter stenosis than ticlopidine plus aspirin for patients with CHD following coronary stenting.
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Allergic reactions to clopidogrel and cross-reactivity to other agents. Curr Allergy Asthma Rep 2011; 11:52-7. [PMID: 20941557 DOI: 10.1007/s11882-010-0152-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Clopidogrel is a widely used antiplatelet agent, particularly after coronary stent implantation. About 1% of patients have allergic or hematologic adverse reactions to clopidogrel. This has important therapeutic implications, as premature discontinuation of clopidogrel is the strongest risk factor for stent thrombosis. Clopidogrel allergy most commonly manifests as a rash. It is important to distinguish this from other causes of rash occurring in patients who have had a recent coronary stent. Although antihistamines and short-term oral corticosteroids are effective in treating most clopidogrel hypersensitivity reactions, some persistent reactions may require discontinuation of clopidogrel. When discontinuation of clopidogrel is required, substitution with an alternative thienopyridine such as ticlopidine traditionally has been performed. However, a recent study suggests that there may be as high as a 27% risk of recurrence of non-life-threatening allergic reactions in such patients, which are usually similar to the allergic reactions that occurred with clopidogrel. No data are available regarding the frequency of cross-reactivity to prasugrel and ticagrelor; these may be potential therapeutic options in some patients.
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Tamhane U, Meier P, Chetcuti S, Chen KY, Rha SW, Grossman MP, Gurm H. Efficacy of cilostazol in reducing restenosis in patients undergoing contemporary stent based PCI: a meta-analysis of randomised controlled trials. EUROINTERVENTION 2009; 5:384-93. [PMID: 19736165 DOI: 10.4244/v5i3a60] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Cilostazol has been associated with reduction in restenosis in patients undergoing coronary and peripheral arterial angioplasty. Our objective was to evaluate the impact of cilostazol on restenosis in patients undergoing contemporary PCI with bare metal (BMS) or drug eluting stents (DES) and treated with aspirin and thienopyridine. METHODS AND RESULTS Ten randomised trials (n=2,809 patients) comparing triple antiplatelet therapy (aspirin, thienopyridine and cilostazol) with standard dual antiplatelet therapy were included. Summary risk ratios for restenosis, late loss, target lesion revascularisation (TLR) and target vessel revascularisation (TVR) were calculated using fixed-effects models. Cilostazol was associated with a significant reduction in late loss in BMS (mean difference 0.24 mm, 95% CI 0.15-0.33, p<0.001) and DES groups (mean difference 0.12 mm, 95% CI 0.07-0.18, p<0.001). Cilostazol therapy was associated with a significant reduction in angiographic restenosis (Odds ratio [OR] 0.52, 95% CI 0.41- 0.66, p<0.001) with consistent benefits in patients treated with BMS (OR 0.49, 95% CI 0.35-0.70, p<0.001) or DES (OR 0.54, 95% CI 0.38-0.76, p=0.001). Addition of cilostazol to dual antiplatelet therapy was associated with a significant reduction in TLR (OR 0.38, 95% CI 0.25-0.58, p<0.001), with no difference in subacute stent thrombosis (OR 1.91, 95% CI 0.33-11.08, p=0.47), or major bleeding (OR 0.87, 95% CI 0.44-1.74, P=0.69) but with an increased risk of skin rash (OR 3.67, 95% CI 1.86-7.24, p<0.001). CONCLUSIONS Cilostazol in addition to dual antiplatelet therapy is associated with a reduction in angiographic restenosis in patients undergoing stent based PCI. This inexpensive drug may be particularly beneficial in patients who are at high risk of restenosis and it should undergo further evaluation in large, definitive randomised controlled trials.
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Affiliation(s)
- Umesh Tamhane
- University of Michigan Cardiovascular Medicine, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
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Lokhandwala JO, Best PJ, Butterfield JH, Skelding KA, Scott T, Blankenship JC, Buckley JW, Berger PB. Frequency of Allergic or Hematologic Adverse Reactions to Ticlopidine Among Patients With Allergic or Hematologic Adverse Reactions to Clopidogrel. Circ Cardiovasc Interv 2009; 2:348-51. [DOI: 10.1161/circinterventions.108.832964.108.832964] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Juzar O. Lokhandwala
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Patricia J.M. Best
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Joseph H. Butterfield
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Kimberly A. Skelding
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Thomas Scott
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - James C. Blankenship
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Jeremy W. Buckley
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
| | - Peter B. Berger
- From the Department of Cardiology (J.O.L., K.A.S., T.S., J.C.B., J.W.B., P.B.B.) and Center for Clinical Studies (P.B.B.), Geisinger Medical Center, Danville, Pa; and Divisions of Cardiovascular Diseases (P.J.M.B.) and Allergic Diseases (J.H.B.), Mayo Clinic, Rochester, Minn
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Biondi-Zoccai GGL, Lotrionte M, Anselmino M, Moretti C, Agostoni P, Testa L, Abbate A, Cosgrave J, Laudito A, Trevi GP, Sheiban I. Systematic review and meta-analysis of randomized clinical trials appraising the impact of cilostazol after percutaneous coronary intervention. Am Heart J 2008; 155:1081-9. [PMID: 18513523 DOI: 10.1016/j.ahj.2007.12.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 12/26/2007] [Indexed: 02/05/2023]
Abstract
BACKGROUND Drug-eluting stents reduce the risk of restenosis after percutaneous coronary intervention (PCI) but may pose a risk of thrombosis. Cilostazol, an oral antiplatelet agent with pleiotropic effects including inhibition of neointimal hyperplasia, could hold the promise of preventing both restenosis and thrombosis. We systematically reviewed randomized clinical trials (RCTs) on the angiographic and clinical impact of cilostazol after PCI. METHODS We searched RCT in BioMedCentral, CENTRAL, clinicaltrials.gov, EMBASE, and PubMed (November 2007). Coprimary end points were binary angiographic restenosis and repeat revascularization, abstracted and pooled by means of random-effect relative risks (RRs). Small study/publication bias was appraised with multiple methods. RESULTS A total of 23 RCTs were included (5428 patients), with median follow-up of 6 months. Pooled analysis showed that cilostazol was associated with statistically significant reductions in binary angiographic restenosis (RR = 0.60 [0.49-0.73], P < .001) and repeat revascularization (RR = 0.69 [0.55-0.86], P = .001). Cilostazol appeared also safe, with no significant increase in the risk of stent thrombosis (RR = 1.35 [0.71-2.57], P = .36) or bleeding (RR = 0.71 [0.43-1.16], P = .17). However, small study bias was evident for both binary restenosis (P < .001) and repeat revascularization (P < .001), suggesting that at least part of the apparent benefits of cilostazol could be due to this type of confounding effect. CONCLUSIONS Cilostazol appears effective and safe in reducing the risk of restenosis and repeat revascularization after PCI, but available evidence is limited by small study effects. Awaiting larger RCTs, this inexpensive treatment can be envisaged in selected patients in which drug-eluting stents are contraindicated or when there is a need for neointimal hyperplasia inhibition.
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Park SJ, Lee SW. Optimal management of platelet function after coronary stenting. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2008; 9:37-45. [PMID: 17378974 DOI: 10.1007/s11936-007-0049-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Coronary stenting elicits vessel wall damage, and subsequent activation of platelets is implicated as a major component of complications such as acute, subacute, and late stent thrombosis. As such, dual antiplatelet therapy using aspirin and clopidogrel has become a routine adjunct to coronary stenting. Use of aspirin and clopidogrel with or without glycoprotein IIb/IIIa inhibitors after coronary stenting reduces the complication rate and improves long-term outcomes. Dual antiplatelet therapy using aspirin and clopidogrel is recommended for at least 4 weeks with bare metal stents, and for 3 to 6 months with drug-eluting stents for prevention of major adverse cardiac events. After coronary stenting, 1 year of dual antiplatelet therapy is recommended for prevention of future cardiac events. However, despite the use of antiplatelet agents, stent thrombosis occurs in approximately 1% of patients, with an increased likelihood of occurrence in high-risk patients or a lesion subset of patients. Although the incidence of stent thrombosis is low, stent thrombosis usually presents as acute coronary syndrome and the mortality rate is up to 45%. Thus, considering the widespread use of stents, a considerable number of people are inadequately protected from thrombotic events despite current standard antiplatelet therapy using aspirin and clopidogrel. A concern with clopidogrel is the loading time and loading dose required to achieve and maintain optimal inhibition of platelet aggregation. The current recommendation for ensuring maximum antiplatelet activity is administration of a 300-mg loading dose of clopidogrel initiated at least 6 hours prior to percutaneous coronary intervention (PCI), and ideally the day before. If this is not possible, a loading dose of 600 mg of clopidogrel should be administered at least 2 hours before PCI. Recently, new combinations of antiplatelet agents (ie, triple therapy using aspirin, clopidogrel, and cilostazol) and new drugs with potent antiplatelet effects (ie, Prasugrel , Cangrelor , and AZD6140) have been evaluated in clinical trials; such treatments may help reduce the number of cardiac events after coronary stenting.
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Affiliation(s)
- Seung-Jung Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea.
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Kim JY, Lee K, Shin M, Ahn M, Choe H, Yoo BS, Yoon J, Choe KH, Lee SH. Cilostazol could ameliorate platelet responsiveness to clopidogrel in patients undergoing primary percutaneous coronary intervention. Circ J 2008; 71:1867-72. [PMID: 18037738 DOI: 10.1253/circj.71.1867] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cilostazol increases the cyclic adenosine monophosphate levels in platelets and might ameliorate the antiplatelet activity of clopidogrel. This study investigated the additional effect of cilostazol on platelet aggregation measured by a VerifyNow analyzer and soluble CD40 ligand (sCD40L) as a marker of activated platelet in patients undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS Sixty cases of primary PCI were randomly assigned to dual (aspirin and clopidogrel) or triple (dual plus cilostazol) therapy. The antiplatelet effects of aspirin and clopidogrel were evaluated by VerifyNow tests. The plasma sCD40L levels at admission, 24 h and 21 days were measured by the ELISA method. The arachidonic acid induced platelet aggregation was similar in both groups. However, the triple group had a significantly lower P2Y12 reaction unit (dual 208.8+/-69.0 vs triple 168.2+/-79.2, p=0.041) and higher % inhibition of adenosine diphosphate (ADP)-induced platelet aggregation (dual 23.8+/-21.4% vs triple 40.5+/-21.0%, p=0.004). In the multivariate analysis, cilostazol was a negative predictor for low responders to clopidogrel (95% confidence interval 0.067-0.711). The plasma sCD40L levels were not significantly different between the 2 groups at the same point of time. CONCLUSIONS The addition of cilostazol to the combination of aspirin plus clopidogrel significantly increases the inhibition of ADP-induced platelet aggregation. However, there was no additive effect on aspirin-induced antiplatelet activity or lowering of sCD40L.
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Affiliation(s)
- Jang-Young Kim
- Institute for Lifelong Health, Yonsei University, Wonju, Korea
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Min PK, Jung JH, Ko YG, Choi D, Jang Y, Shim WH. Effect of cilostazol on in-stent neointimal hyperplasia after coronary artery stenting: a quantative coronary angiography and volumetric intravascular ultrasound study. Circ J 2008; 71:1685-90. [PMID: 17965485 DOI: 10.1253/circj.71.1685] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study was designed to investigate the efficacy of cilostazol on the prevention of in-stent neointimal hyperplasia as measured by both quantitative coronary angiography (CAG) and volumetric intravascular ultrasound (IVUS). METHODS AND RESULTS Fifty-nine patients (39 men, age 62 years) undergoing elective coronary stenting were randomly assigned to receive aspirin plus clopidogrel or ticlopidine (Group I, n=28, 30 lesions) or aspirin plus clopidogrel or ticlopidine plus cilostazol (Group II, n=31, 35 lesions). CAG and IVUS were performed and repeated at 6 months to assess the primary endpoints of minimal luminal diameter (MLD) and in-stent neointimal hyperplasia volume. Follow-up CAG was performed on all patients and follow-up IVUS study was available for 50 lesions in 48 patients (24 lesions in Group I, 26 in Group II). There were no significant differences in the baseline angiographic data between the 2 groups. At 6 months follow-up, in-stent MLD was 1.90+/-0.76 mm in Group I and 2.41+/-0.85 mm in Group II (p=0.006). Volumetric IVUS at 6 months demonstrated that in-stent intimal hyperplasia volume per stent length was 2.2+/-1.4 mm3/mm in Group I and 1.0+/-0.5 mm3/mm in Group II (p=0.001). CONCLUSIONS Triple antiplatelet therapy including cilostazol seems to be more effective at preventing in-stent neointimal hyperplasia than a dual antiplatelet regimen.
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Affiliation(s)
- Pil-Ki Min
- Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Lee BK, Lee SW, Park SW, Lee SW, Park DW, Kim YH, Lee CW, Hong MK, Kim JJ, Jang S, Chi HS, Park SJ. Effects of triple antiplatelet therapy (aspirin, clopidogrel, and cilostazol) on platelet aggregation and P-selectin expression in patients undergoing coronary artery stent implantation. Am J Cardiol 2007; 100:610-4. [PMID: 17697815 DOI: 10.1016/j.amjcard.2007.03.070] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 03/13/2007] [Accepted: 03/13/2007] [Indexed: 01/09/2023]
Abstract
The purpose of this study was to determine the effect of the addition of cilostazol to aspirin plus clopidogrel on platelet aggregation after intracoronary stent implantation. Twenty patients who underwent coronary stent placement were randomly assigned to therapy with aspirin plus clopidogrel (dual-therapy group, n = 10) or aspirin plus clopidogrel plus cilostazol (triple-therapy group, n = 10). A loading dose of clopidogrel (300 mg) and cilostazol (200 mg) was administered immediately after stent placement, and clopidogrel (75 mg/day) and cilostazol (100 mg twice daily) were given for 1 month. Platelet aggregation in response to adenosine diphosphate (ADP; 5 and 20 micromol/L) or collagen and P-selectin (CD-62P) expression was assayed at baseline, 2 hours, 24 hours, 1 week, and 1 month after stent placement. Inhibition of ADP-induced platelet aggregation was significantly higher in patients receiving triple therapy than those receiving dual therapy from 24 hours after stent placement, and inhibition of collagen-induced platelet aggregation was significantly higher in the triple-therapy group beginning 1 week after stent placement. P-Selectin expression was significantly lower in the triple-therapy than dual-therapy group at 1 week and 30 days. In conclusion, compared with dual antiplatelet therapy, triple therapy after coronary stent placement resulted in more potent inhibition of platelet aggregation induced by ADP and collagen. These findings suggest that triple therapy may be used clinically to prevent thrombotic complications after coronary stent placement.
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Affiliation(s)
- Bong-Ki Lee
- Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RSD, Despotis G, Brown JR, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27-86. [PMID: 17462454 DOI: 10.1016/j.athoracsur.2007.02.099] [Citation(s) in RCA: 543] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/21/2007] [Accepted: 02/08/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. METHODS We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme. RESULTS Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions. CONCLUSIONS Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.
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Feldman AM, McNamara DM. Reevaluating the role of phosphodiesterase inhibitors in the treatment of cardiovascular disease. Clin Cardiol 2006; 25:256-62. [PMID: 12058787 PMCID: PMC6654250 DOI: 10.1002/clc.4960250603] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
First developed for clinical use in the late 1980s, the phosphodiesterase inhibitors were found to increase the levels of the ubiquitous second messenger cyclic adenosine monophosphate and could effect changes in vascular tone, cardiac function, and other cellular events. After several early studies using high doses of phosphodiesterase inhibitors in patients with severe heart failure suggested adverse consequences, they fell out of favor. However, recent investigations of phosphodiesterase inhibitors in patients with intermittent claudication have demonstrated profound benefits. Furthermore, these agents have proven useful in prevention of cerebral infarction and coronary restenosis, and their use in the treatment of heart failure is being reevaluated. The reemergence of phosphodiesterase inhibitors can be attributed to a better understanding of dosing and drug-specific pharmacology, the use of concomitant medications, and a recognition of unique ancillary properties; however, their use still requires caution.
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Affiliation(s)
- Arthur M Feldman
- The Cardiovascular Institute, University of Pittsburgh Health System, University of Pittsburgh Medical Center, Pennsylvania 15213, USA,.
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A prospective randomized antiplatelet trial of cilostazol versus clopidogrel in patients with bare metal stent. Chin Med J (Engl) 2006. [DOI: 10.1097/00029330-200603010-00002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Ge J, Han Y, Jiang H, Sun B, Chen J, Zhang S, Du Z. RACTS: a prospective randomized antiplatelet trial of cilostazol versus ticlopidine in patients undergoing coronary stenting: long-term clinical and angiographic outcome. J Cardiovasc Pharmacol 2005; 46:162-6. [PMID: 16044027 DOI: 10.1097/01.fjc.0000167012.82930.8f] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We compared the efficacy of cilostazol for the prevention of late restenosis and acute or subacute stent thrombosis with that of ticlopidine. Cilostazol has been used for antiplatelet therapy after coronary stent implantation, but the results are controversial. Patients scheduled for stent implantation were randomly assigned to receive either cilostazol (100 mg twice daily for 6 months, n=201) or ticlopidine (250 mg twice daily for 1 month, n=196). All patients also received oral aspirin (100 mg once daily for 6 months). Coronary angiography was performed at baseline and immediately and 6 months after coronary stenting. Clinical follow-up was continued up to 9 months postprocedure. There was no significant difference in the composite incidence of death, myocardial infarction, stroke, and stent thrombosis between the 2 groups [cilostazol (1.5%) versus ticlopidine (3.6%), P=0.216], but the target lesion revascularization rate per patient was significantly lower in the cilostazol group than in the ticlopidine group (22.9% vs 32.7%, P=0.030) 9 months post-coronary stenting. Medication withdrawn because of drug-related side effects tended to be higher in the ticlopidine group than that in the cilostazol group (3.5% vs 8.2%, P=0.054). At follow-up angiography, the minimal luminal diameters (2.31+/-1.06 vs 2.10+/-1.16, P=0.057) tended to be larger and the restenosis rates lower (23.3% vs 30.9%, P=0.086) in the cilostazol group than in the ticlopidine group. Aspirin plus cilostazol is a comparable antithrombotic regimen to aspirin plus ticlopidine after elective coronary stenting, but the rate of target lesion revascularization was significantly lower in the cilostazol group than in the ticlopidine group.
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Affiliation(s)
- Junbo Ge
- Shanghai Institite of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China.
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15
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Lee SW, Park SW, Hong MK, Lee CW, Kim YH, Park JH, Kang SJ, Han KH, Kim JJ, Park SJ. Comparison of cilostazol and clopidogrel after successful coronary stenting. Am J Cardiol 2005; 95:859-62. [PMID: 15781016 DOI: 10.1016/j.amjcard.2004.12.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Revised: 12/01/2004] [Accepted: 12/01/2004] [Indexed: 11/17/2022]
Abstract
This study compared the safety and efficacy of cilostazol and clopidogrel after coronary stenting. Patients (n = 689) who underwent successful stenting were randomly assigned to receive cilostazol (group 1, n = 344, 612 lesions) or clopidogrel (group 2, n = 345, 628 lesions). The incidence of subacute stent thrombosis or major adverse cardiac events, including death, myocardial infarction, and target lesion revascularization within 30 days (2.6% in group 1 vs 2.0% in group 2, p = 0.61) and side effects that required cessation of study drug (0.6% each) did not differ statistically between groups. These results indicate that cilostazol is as safe and effective as clopidogrel in preventing thrombotic complications after stenting.
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Affiliation(s)
- Seung-Whan Lee
- Department of Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Kawata M, Kuramoto E, Kataoka T, Saito A, Adachi K, Matsuura A, Sakamoto S. Comparative Inhibitory Effects of Cilostazol and Ticlopidine on Subacute Stent Thrombosis and Platelet Function in Acute Myocardial Infarction Patients With Percutaneous Coronary Intervention. Int Heart J 2005; 46:13-22. [PMID: 15858933 DOI: 10.1536/ihj.46.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We compared the effects of ticlopidine and cilostazol on the prevention of subacute stent thrombosis (SAT) in acute myocardial infarction (AMI) patients with stenting. We also analyzed the cause of the difference by measuring platelet aggregation activity. Consecutive patients who underwent successful stenting for AMI between March 2001 and March 2004 were analyzed. In addition to aspirin (100 mg/day), cilostazol (200 mg/day) was administered to 99 cases between March 2001 and May 2002 and ticlopidine (200 mg/day) was administered to 85 cases between June 2002 and February 2004. The incidence of SAT within four weeks after stenting was analyzed. Thirty-eight AMI patients were randomized and their platelet aggregation activity was measured using a laser-scattered aggregometer (18 cases in the cilostazol group and 20 cases in the ticlopidine group). SAT did not occur in the ticlopidine group while 5 cases (5.1%) of SAT occurred in the cilostazol group (P < 0.05). The inhibitory activity of cilostazol for ADP-induced platelet aggregation was lower than that of ticlopidine (P < 0.05). Cilostazol with aspirin after stenting in AMI patients showed more frequent SAT than ticlopidine with aspirin. One of the causes for this difference was speculated to be the weaker inhibitory activity of cilostazol for ADP-induced platelet aggregation.
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Affiliation(s)
- Masahito Kawata
- Department of Cardiology, Akashi Medical Center, Hyogo, Japan
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Takeyasu N, Watanabe S, Noguchi Y, Ishikawa K, Fumikura Y, Yamaguchi I. Randomized Comparison of Cilostazol vs Ticlopidine for Antiplatelet Therapy After Coronary Stenting. Circ J 2005; 69:780-5. [PMID: 15988102 DOI: 10.1253/circj.69.780] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cilostazol and ticlopidine are commonly prescribed for prevention of thrombosis after coronary stenting, but few studies have compared them. METHODS AND RESULTS In the present study 642 patients who underwent stenting were randomized to treatment either with cilostazol + aspirin (C group, 321 patients) or ticlopidine + aspirin (T group, 321 patients). Quantitative coronary angiography (QCA) was performed immediately after stenting and at the 6-month follow-up. Treatment was continued until follow-up angiography. Baseline patient characteristics did not differ significantly. With the exception of a higher rate of stenting in a venous graft in the C group, there were no differences in angiographic characteristics or stent type. Baseline QCA analysis of the reference diameter, minimal lumen diameter (MLD) showed no significant differences. Follow-up QCA analysis of the MLD showed no significant differences. There were also no differences in restenosis or target lesion revascularization rates, or in the incidence of adverse reactions. However, the rate of subacute thrombosis (SAT) was significantly higher in the C group than in the T group (2% vs 0.3%, p=0.02). CONCLUSION In the present study there was a similar restenosis rate with cilostazol or ticlopidine, but the rate of SAT was significantly higher with cilostazol. There was no significant difference in adverse reactions.
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Affiliation(s)
- Noriyuki Takeyasu
- Cardiovascular Division, Department of Internal Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
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Schleinitz MD, Olkin I, Heidenreich PA. Cilostazol, clopidogrel or ticlopidine to prevent sub-acute stent thrombosis: a meta-analysis of randomized trials. Am Heart J 2004; 148:990-7. [PMID: 15632883 DOI: 10.1016/j.ahj.2004.03.066] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sub-acute thrombosis is a serious complication of coronary artery stenting. Clopidogrel plus aspirin is the accepted prophylactic regimen, but has yet to be proven superior to ticlopidine plus aspirin, and a new regimen combining cilostazol and aspirin has been introduced. METHODS We conducted a meta-analysis of all trials that compared >or=2 oral anti-thrombotic strategies in patients undergoing coronary stent placement to determine which treatment optimally prevents adverse cardiac events in the 30 days following stent insertion. We used meta-regression to compare all strategies to a shared control strategy: ticlopidine plus aspirin. We also compared randomized trials to historically controlled and other non-randomized trials. We conducted sensitivity analysis and subgroup analysis to assess for possible heterogeneity. RESULTS In comparison to ticlopidine plus aspirin the odds-ratios for cardiac events, with 95% confidence intervals were: aspirin alone, 4.29 (3.09-5.97), coumadin plus aspirin, 2.65 (2.18-3.21), clopidogrel plus aspirin, 1.06 (0.86-1.31), cilostazol plus aspirin, 0.73 (0.47-1.14). Among trials that compared clopidogrel plus aspirin to ticlopidine plus aspirin, historically controlled trials were statistically distinct from randomized trials. The analysis of cilostazol was sensitive to the small size of the included studies. CONCLUSIONS Neither clopidogrel plus aspirin nor cilostazol plus aspirin can be statistically distinguished from ticlopidine plus aspirin for the prevention of adverse cardiac events in the 30 days after stenting. A randomized trial including cilostazol is warranted.
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Douglas JS, Weintraub WS, Holmes D. Rationale and design of the randomized, multicenter, cilostazol for RESTenosis (CREST) trial. Clin Cardiol 2004; 26:451-4. [PMID: 14579914 PMCID: PMC6654504 DOI: 10.1002/clc.4960261004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Restenosis of a segment of diseased coronary artery following metallic stenting is a common clinical problem and a major limitation of the procedure. Systemic pharmacologic interventions to deal with this problem have met with little success. Several small studies suggest that cilostazol, a phosphodiesterase III inhibitor whose pharmacologic properties include antiplatelet, antithrombotic, and vasodilatory effects; a beneficial effect on serum lipids; and in vitro inhibition of smooth muscle cell proliferation, may help prevent platelet aggregation and impede the accumulation of new intimal tissue in the stented artery. The Cilostazol for RESTenosis (CREST) trial will aim to evaluate more definitively the ability of cilostazol to prevent restenosis following uncomplicated stent implantation for de novo coronary artery stenosis. In this randomized, double-blind, multicenter study, 700 patients will receive clopidogrel, aspirin, and either cilostazol or placebo after successful intracoronary stent implantation. The primary endpoint is minimal luminal diameter (MLD) of the first lesion stented after 6 months; secondary endpoints include MLD in all lesions, mean percent diameter stenosis, target lesion revascularization, and major angiographic endpoints. Safety endpoints are abnormal complete blood count and liver function tests at 1, 3, and 6 months. The trial has been initiated, and enrollment is anticipated to be concluded in 2003. Cilostazol has properties that may reduce or avert in-stent coronary restenosis. The CREST trial is a large, rigorously conducted trial that may corroborate the favorable effects of cilostazol on coronary stent restenosis suggested by earlier studies.
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Affiliation(s)
- John S Douglas
- Division of Cardiology, Emory Center for Outcomes Research, Emory University School of Medicine, Atlanta, Georgia, USA.
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Huang Z, Katoh O, Nakamura S, Negoro S, Kobayashi T, Tanigawa J. Evaluation of the percusurge guardwire plus temporary occlusion and aspiration system during primary angioplasty in acute myocardial infarction. Catheter Cardiovasc Interv 2003; 60:443-51. [PMID: 14624419 DOI: 10.1002/ccd.10691] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thirty patients with acute myocardial infarction (AMI) underwent primary angioplasty under distal protection of PercuSurge GuardWire Plus Temporary Occlusion and Aspiration System. Before angioplasty, protection of the distal circulation was achieved with the system, followed by balloon angioplasty and/or stenting and debris aspiration. Technical device success was 100%. Distal occlusion was well tolerated in all patients. Mean total distal occlusion time was 7.3 +/- 5.4 min. Macroscopically visible debris was aspirated from 29 cases (96.7%). Postprocedural Thrombolysis in Myocardial Infarction flow grade 3 was achieved in all cases (100%, vs. 16.7% at baseline). Myocardial blush flow grade 3 was achieved in 26 cases (86.7%). Regression of ST segment elevation >/= 50% was shown in 23 cases (76.7%). No patient developed angiographic evidence of no-reflow or distal embolization. Both angiographic and procedural success were 100%. The system is feasible, safe, and effective for distal protection against embolism during primary angioplasty in AMI.
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Affiliation(s)
- Zheng Huang
- Cardiovascular Center, Kyoto Katsura Hospital, Japan.
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Park SJ, Shim WH, Ho DS, Raizner AE, Park SW, Hong MK, Lee CW, Choi D, Jang Y, Lam R, Weissman NJ, Mintz GS. A paclitaxel-eluting stent for the prevention of coronary restenosis. N Engl J Med 2003; 348:1537-45. [PMID: 12700373 DOI: 10.1056/nejmoa021007] [Citation(s) in RCA: 333] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intimal hyperplasia and resulting restenosis limit the efficacy of coronary stenting. We studied a coronary stent coated with the antiproliferative agent paclitaxel as a means of preventing restenosis. METHODS We conducted a multicenter, randomized, controlled, triple-blind study to evaluate the ability of a paclitaxel-eluting stent to inhibit restenosis. At three centers, 177 patients with discrete coronary lesions (<15 mm in length, 2.25 to 3.5 mm in diameter) underwent implantation of paclitaxel-eluting stents (low dose, 1.3 microg per square millimeter, or high dose, 3.1 microg per square millimeter) or control stents. Antiplatelet therapies included aspirin with ticlopidine (120 patients), clopidogrel (18 patients), or cilostazol (37 patients). Clinical follow-up was performed at one month and four to six months, and angiographic follow-up at four to six months. RESULTS Technical success was achieved in 99 percent of the patients (176 of 177). At follow-up, the high-dose group, as compared with the control group, had significantly better results for the degree of stenosis (mean [+/-SD], 14+/-21 percent vs. 39+/-27 percent; P<0.001), late loss of luminal diameter (0.29+/-0.72 mm vs. 1.04+/-0.83 mm, P<0.001), and restenosis of more than 50 percent (4 percent vs. 27 percent, P<0.001). Intravascular ultrasound analysis demonstrated a dose-dependent reduction in the volume of intimal hyperplasia (31, 18, and 13 mm3, in the high-dose, low-dose, and control groups, respectively). There was a higher rate of major cardiac events in patients receiving cilostazol than in those receiving ticlopidine or clopidogrel. Among patients receiving ticlopidine or clopidogrel, event-free survival was 98 percent and 100 percent in the high-dose and control groups, respectively, at one month, and 96 percent in both at four to six months. CONCLUSIONS Paclitaxel-eluting stents used with conventional antiplatelet therapy effectively inhibit restenosis and neointimal hyperplasia, with a safety profile similar to that of standard stents.
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Kodama-Takahashi K, Kurata A, Ohshima K, Yamamoto K, Uemura S, Watanabe S, Iwata T. Effect of cilostazol on the ventricular escape rate and neurohumoral factors in patients with third-degree atrioventricular block. Chest 2003; 123:1161-9. [PMID: 12684307 DOI: 10.1378/chest.123.4.1161] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES This study assessed whether the antiplatelet agent cilostazol, which has potent cyclic nucleotide phosphodiesterase type-3 inhibitory activity, affects the ventricular escape rate and neurohumoral factors in patients with third-degree atrioventricular block. DESIGN Prospective, but nonrandomized, study. SETTING Cardiology division of an acute care hospital. PATIENTS We studied 12 patients with third-degree intra-His or infra-His atrioventricular block who were in functional class II or III of the New York Heart Association classification. None of the patients had experienced Adams-Stokes attacks. INTERVENTIONS These patients were given cilostazol orally at a dose of 200 mg daily for at least 1 week. MEASUREMENTS AND RESULTS Before and after treatment with cilostazol, continuous 24-h ECG monitoring and measurement of plasma natriuretic peptide concentrations were performed. Cilostazol significantly increased the mean (+/- SEM) total 24-h QRS count from 57,300 +/- 2,800 to 74,400 +/- 3,200 beats (p = 0.001) and significantly decreased the maximum geometric mean R-R interval over a 24-h period from 1,900 ms (95% confidence interval [CI], 1,700 to 2,100 ms) to 1,600 ms (95% CI, 1,400 to 1,900 ms; p = 0.02), although none of the patients showed the abolishment of the atrioventricular conduction abnormalities. The total 24-h count of premature ventricular beats was not different before treatment (15 beats; 95% CI, 5 to 44 beats) and after treatment (12 beats; 95% CI, 5 to 30 beats; p = 0.57). Treatment with cilostazol significantly decreased the concentration of plasma atrial natriuretic peptide from 88 pg/mL (95% CI, 49 to 160 pg/mL) to 51 pg/mL (95% CI, 32 to 80 pg/mL; p = 0.007) and of brain natriuretic peptide from 166 pg/mL (95% CI, 71 to 389 pg/mL) to 77 pg/mL (95% CI, 30 to 178 pg/mL; p = 0.02). CONCLUSIONS Cilostazol significantly increased the ventricular escape rate and significantly decreased the level of circulating natriuretic peptides. Thus, cilostazol could be safely given to selected patients over the short term with third-degree atrioventricular block.
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Kamishirado H, Inoue T, Mizoguchi K, Uchida T, Nakata T, Sakuma M, Takayanagi K, Morooka S. Randomized comparison of cilostazol versus ticlopidine hydrochloride for antiplatelet therapy after coronary stent implantation for prevention of late restenosis. Am Heart J 2002; 144:303-8. [PMID: 12177649 DOI: 10.1067/mhj.2002.122874] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cilostazol is a newly developed antiplatelet drug that has been widely applied for clinical use. Its antiplatelet action appears to be mainly related to inhibition of intracellular phosphodiesterase activity. Recently, cilostazol has been used for antiplatelet therapy after coronary stent implantation. However, its evaluation has not been established yet. METHODS This prospective randomized trial was designed to investigate the efficacy of cilostazol for the prevention of late restenosis and acute or subacute stent thrombosis in comparison with ticlopidine hydrochloride. One hundred thirty consecutive patients, scheduled for elective coronary stenting, were randomly assigned to receive oral aspirin (81 mg/day) plus ticlopidine hydrochloride therapy (200 mg/day; group I) or aspirin plus cilostazol therapy (200 mg/day; group II). These medications were started at least 2 days before coronary intervention and continued until follow-up coronary angiography was performed 6 months later. RESULTS Subacute stent thrombosis was observed in 2 patients of group I but in no patients of group II. Major cardiac events were similarly present in both groups. Elevated transaminase levels were observed more frequently in group I than in group II (P <.05). Each of the quantitative coronary angiography variables before and immediately after coronary stenting were similar in both groups. At follow-up angiography, however, late lumen loss (0.69 +/- 0.79 mm vs 0.28 +/- 0.40 mm; P <.01) and loss index (0.42 +/- 0.56 vs 0.16 +/- 0.27; P <.01) were smaller in group II than in group I. Restenosis rate (13% vs 31%; P <.05) and target lesion revascularization rate (7% vs 21%; P <.05) were both lower in group II than in group I. CONCLUSION Aspirin plus cilostazol therapy may be an effective regimen for prevention of not only stent thrombosis but also restenosis.
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Affiliation(s)
- Hirotoshi Kamishirado
- Department of Cardiology, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan
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Schainfeld RM. Potential emerging therapeutic strategies to prevent restenosis in the peripheral vasculature. Catheter Cardiovasc Interv 2002; 56:421-31. [PMID: 12112901 DOI: 10.1002/ccd.10211] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Despite the availability of antiplatelet and antithrombotic therapies, recent advances in catheter and stent technology and improved operator skill, restenosis remains the most frequent problem associated with percutaneous and surgical revascularization interventions for both coronary and peripheral arterial disease. Prevention of restenosis in the coronary vasculature has been demonstrated with cilostazol, trapidil, probucol, tranilast, nitric oxide donors, and clopidogrel. Given the similarities in revascularization procedures and in the pathophysiology of restenosis, it is possible that these results may be extrapolated to the setting of restenosis in the peripheral vasculature, making trials with these agents imperative. Several new agents have shown promising preliminary results for the prevention of restenosis in the peripheral vasculature, including cilostazol, low-molecular-weight heparins, and elastase. Several nonpharmacologic treatment modalities are also under study to prevent peripheral and coronary restenosis and have shown favorable initial results. These include endovascular radiation brachytherapy, arterial gene therapy, photoangioplasty, and several novel treatment delivery systems.
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Affiliation(s)
- Robert M Schainfeld
- Division of Vascular Medicine, St Elizabeth's Medical Center, Boston, Massachusetts 02135, USA.
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Yasutake M, Kunimi T, Sato N, Yokoyama H, Sasaki Y, Kusama Y, Hata N, Takayama M, Munakata K, Kishida H, Takano T, Hayakawa H. Effects of a single oral dose of cilostazol on epicardial coronary arteries and hemodynamics in humans. Circ J 2002; 66:241-6. [PMID: 11922271 DOI: 10.1253/circj.66.241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cilostazol, a novel cyclic adenosine monophosphate phosphodiesterase type III inhibitor, has been developed as an antiplatelet drug with a vasodilating action on peripheral arteries. The present study was designed to test, in humans, whether cilostazol can dilate the epicardial coronary arteries and what are its hemodynamic effects. Eight patients with chest pain syndrome were subjected to serial quantitative coronary arteriography immediately before and at 30, 60 and 150min after a single oral dose of cilostazol (200mg). Luminal cross-sectional areas (mm2) at the proximal and distal sites of major coronary arteries (6 segments at each sampling time) were significantly increased at 150 min after taking the drug. The percent increases relative to the baseline values were 25+/-7 (6.8+/-0.8-->8.3+/-1.0*) and 42+/-7% (2.1+/-0.3-->3.0+/-0.4*) in the right coronary artery, 24+/-5 (5.1+/-0.7-->6.1+/-0.8*) and 28+/-10% (1.6+/-0.31-->9+/-0.3*) in the left anterior descending artery, and 14+/-6 (5.9+/-0.9-->6.6+/-0.9*) and 24+/-10% (1.3+/-0.2-->1.5+/-0.2*) in the left circumflex artery, respectively (*p<0.05 vs baseline). This action, relative to that of nitroglycerine, was between 27% and 54%. Moreover, small but sustained decreases in systolic pulmonary pressure and stroke work index were observed. Thus, cilostazol has a mild coronary vasodilating action with minimal hemodynamic effects, thereby giving it a possible role in the treatment of coronary artery disease.
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Affiliation(s)
- Masahiro Yasutake
- The First Department of Medicine, Nippon Medical School, Tokyo, Japan.
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El-Beyrouty C, Spinler SA. Cilostazol for prevention of thrombosis and restenosis after intracoronary stenting. Ann Pharmacother 2001; 35:1108-13. [PMID: 11573862 DOI: 10.1345/aph.10253] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the potential use of cilostazol in intracoronary stenting. DATA SOURCES Clinical literature was accessed through MEDLINE (1966-March 2001). Key search terms included cilostazol, intracoronary stenting, and coronary angioplasty. Abstracts of clinical trials presented at major cardiology professional association meetings were also reviewed. DATA SYNTHESIS Intracoronary stent placement represents the fastest growing medical device implant. Complications of stent implantation include acute and subacute vessel closure, as well as late restenosis. Currently, antiplatelet agents are used for preventive therapy. Cilostazol is a vasodilating antiplatelet agent that reversibly inhibits platelet aggregation induced by many factors. In seven randomized trials comparing cilostazol with either aspirin or ticlopidine, cilostazol was found to be superior to aspirin and equivalent to ticlopidine in decreasing both cardiac events and rates of restenosis. In addition, cilostazol was found to be well tolerated, with no reports of adverse hematologic events. CONCLUSIONS Although further comparative trials are required, cilostazol appears to be a safe and effective alternative to clopidogrel and glycoprotein IIb/IIIa receptor antagonists following intracoronary stent implantation.
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Affiliation(s)
- C El-Beyrouty
- Thomas Jefferson University Hospital, Philadelphia, PA 19104-4495, USA
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Abstract
Platelet-inhibitory drugs are of proven benefit to individuals who suffer from atherosclerotic cardiovascular disease. Despite substantial effort to identify more potent platelet-inhibitory agents, aspirin, an irreversible inhibitor of platelet cyclooxygenase activity, remains the standard against which other drugs are judged. Drugs that appear to be at least as efficacious as aspirin in specific clinical settings include the thienopyridines ticlopidine and clopidogrel, specific inhibitors of ADP-stimulated platelet function, and the phosphodiesterase 3 inhibitor cilostazol. Ligand binding to the platelet integrin alphaIIbbeta3 (GPIIb-IIIa), a prerequisite for platelet thrombus formation, has been a prominent target for drug development. Currently, three types of alphaIIbbeta3 antagonists are available: the monoclonal antibody Fab fragment abciximab, cyclic peptides based on the Arg-Gly-Asp (RGD) or related amino acid motifs, and RGD-based peptidomimetics. The efficacy of each type of alphaIIbbeta3 antagonist in the setting of acute coronary artery disease has been confirmed in multicenter clinical trials.
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Affiliation(s)
- J S Bennett
- Hematology-Oncology Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Popma JJ, Ohman EM, Weitz J, Lincoff AM, Harrington RA, Berger P. Antithrombotic therapy in patients undergoing percutaneous coronary intervention. Chest 2001; 119:321S-336S. [PMID: 11157657 DOI: 10.1378/chest.119.1_suppl.321s] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- J J Popma
- Interventional Cardiology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Kozuma K, Hara K, Yamasaki M, Morino Y, Ayabe S, Kuroda Y, Tanabe K, Ikari Y, Tamura T. Effects of cilostazol on late lumen loss and repeat revascularization after Palmaz-Schatz coronary stent implantation. Am Heart J 2001; 141:124-30. [PMID: 11136497 DOI: 10.1067/mhj.2001.111548] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cilostazol is an antiplatelet agent that increases the intracellular concentration of cyclic adenosine monophosphate by inhibiting phosphodiesterase III; it has been shown to reduce neointimal hyperplasia in animal balloon injury models. METHODS One hundred thirty patients who underwent elective stenting (Palmaz-Schatz stent) were randomly assigned to cilostazol treatment 200 mg/d (n = 65) or to ticlopidine treatment 200 mg/d (n = 65). Angiographic follow-up was performed at 6 months, and clinical follow-up was continued up to 1 year. RESULTS One sudden death and one myocardial infarction resulting from subacute occlusion were observed in the ticlopidine group. Drug adverse effects were observed in 3 patients in the cilostazol group, as opposed to 6 patients in the ticlopidine group. In the intention-to-treat analysis, 56 patients (61 lesions) in the cilostazol group and 58 patients (58 lesions) in the ticlopidine group were assessed with quantitative coronary angiography. Late loss in the cilostazol group was smaller (0.58+/-0.52 mm vs. 1.09+/-0.65 mm, P<.0001) than in the ticlopidine group. The restenosis rate was lower in the cilostazol group than in the ticlopidine group (16% vs. 33%, P = .044). The target vessel revascularization rate at 1 year was 23% in the cilostazol group and 42% in the ticlopidine group (P =.03). CONCLUSIONS The results of this study suggest that cilostazol may be a safe medication that is effective in preventing restenosis after stent implantation.
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Affiliation(s)
- K Kozuma
- Department of Interventional Cardiology, Thoraxcenter, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands.
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Nagaoka N, Matsubara T, Okazaki K, Masuda N, Shikaura K, Hotta A. Comparison of ticlopidine and cilostazol for the prevention of restenosis after percutaneous transluminal coronary angioplasty. JAPANESE HEART JOURNAL 2001; 42:43-54. [PMID: 11324805 DOI: 10.1536/jhj.42.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Prevention of restenosis after percutaneous transluminal coronary angioplasty (PTCA) continues to be a significant problem. Recent controlled studies have demonstrated that cilostazol suppresses restenosis after PTCA. The effects of ticlopidine, another antiplatelet agent, were compared in terms of outcomes of patients randomized for treatment with the two drugs after PTCA. A total of 35 patients (47 lesions) were assigned prospectively and randomly to ticlopidine (17 patients, 24 lesions) and cilostazol (18 patients, 23 lesions) groups. Minimal luminal diameter (MLD) and percentage of stenosis to reference diameter were estimated before PTCA, just after the procedure and after 4 months follow-up. All patients underwent 4 months angiographic follow-up, at the end of which MLD was 2.03+/-0.71 mm in the ticlopidine group and 2.05+/-0.68 mm in the cilostazol group (p = 0.95), and the percentage of stenosis to reference diameter was 31.4+/-16.7% and 30.0+/-17.0%, respectively (p = 0.78). The restenosis rate was 12.5% in the ticlopidine group and 17.4% in the cilostazol group (p = 0.69), relatively low as compared to the 20% to 30% reported in previous studies. Adverse drug reactions during the follow-up period were observed in two of the ticlopidine group and none of the cilostazol group. We conclude that both ticlopidine and cilostazol are effective for the prevention of restenosis after PTCA, however the former may be associated with slight side effects.
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Affiliation(s)
- N Nagaoka
- Third Department of Internal Medicine, Nagoya University School of Medicine, Aichi, Japan
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31
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Panning CA. Antithrombotic Therapy during and after Intracoronary Stenting. J Pharm Technol 2000. [DOI: 10.1177/875512250001600502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To evaluate the impact on patient outcomes of antithrombotic therapy during and after intracoronary stenting. Data Sources: A MEDLINE search (1966-July 2000) for English-language clinical trials and review articles using the search terms stent and coronary with one or more of the following search terms: abciximab, tirofiban, orofiban, xemilofiban, eptifibatide, aspirin, heparin, enoxaparin, tinzaparin, dalteparin, hirudin, danaparoid, dipyridamole, cilostazol, dextran, warfarin, anticoagulant, ticlopidine, and Clopidogrel. References from these articles were reviewed for additional articles. Pharmaceutical companies were contacted to identify unpublished studies. A total of 177 sources were initially identified. Study Selection: Studies were selected through an unblinded individual review for prospective, randomized clinical trials evaluating patient outcomes related to antithrombotic therapy during or after intracoronary stent placement. Additional human and animal studies were included for background and introductory information. Data Extraction: Patient characteristics in each study were compared with those of the overall stent population. The primary end point measurements were defined. The completeness of follow-up and power analysis was assessed. Data Synthesis: Intracoronary stenting is now a common modality for maintaining patency of occluded arteries. Antithrombotic therapy during coronary artery stent placement is changing as knowledge about the pathophysiology of thrombus formation expands and new medications become available. Development of new stent placement techniques, new stent designs, and methods of restenosis irradiation or prevention have coincided with evolving antithrombotic regimens. Conclusions: The current antithrombotic regimen used in coronary artery stenting is complex, but has a lower incidence of hemorrhagic complications and thrombosis compared with previous anticoagulant regimens. Antithrombotic therapy may need to be tailored to individual patient contraindications.
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Liu Y, Fong M, Cone J, Wang S, Yoshitake M, Kambayashi J. Inhibition of adenosine uptake and augmentation of ischemia-induced increase of interstitial adenosine by cilostazol, an agent to treat intermittent claudication. J Cardiovasc Pharmacol 2000; 36:351-60. [PMID: 10975593 DOI: 10.1097/00005344-200009000-00011] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cilostazol (Pletal), a quinolinone derivative with a cyclic nucleotide phosphodiesterase type 3 (PDE3) inhibitory activity, was recently approved by the Food and Drug Administration for treatment of symptoms of intermittent claudication (IC). However, the underlying mechanisms of action are not entirely clear. In this study, we showed that cilostazol inhibited adenosine uptake into cardiac ventricular myocytes, coronary artery smooth muscle, and endothelial cells with a median effective concentration (EC50) approximately 10 microM. In vivo, cilostazol increased cardiac interstitial adenosine levels after a 2-min ischemia in rabbit hearts (329 +/- 92% increase vs. 102 +/- 29% ischemia alone). The combination of cilostazol and 2-min ischemia reduced infarction from subsequent 30-min regional ischemia and 3 h of reperfusion (infarct size was 18 +/- 4% vs. 53 +/- 3% in the hearts with 2-min ischemia alone or 48 +/- 2% in the hearts treated with cilostazol alone). In contrast, milrinone had no effect on either adenosine uptake or interstitial adenosine levels. These data show that cilostazol, unlike milrinone, inhibits adenosine uptake, and thus potentiates adenosine accumulation from a 2-min ischemia. Future studies are needed to investigate the role of adenosine in the treatment of IC by cilostazol.
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Affiliation(s)
- Y Liu
- Maryland Research Laboratories, Otsuka America Pharmaceutical Inc., Rockville 20850, USA.
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