Use of Cilostazol for Secondary Stroke Prevention: An Old Dog with New Tricks?

A Clinical Update on Antiplatelet Therapy in Secondary Prevention of Ischemic Stroke

PURPOSE OF REVIEW

Antiplatelet therapy remains the standard of care in secondary stroke prevention for non-cardioembolic ischemic stroke and transient ischemic attack. We aim to examine the use of antiplatelet agents in secondary prevention through highlighting relevant clinical trials and meta-analyses as well as providing commentary regarding our practice.

RECENT FINDINGS

In the POINT and CHANCE trials, dual antiplatelet therapy reduced recurrent stroke compared to aspirin monotherapy. Sub-analyses of these trials suggest that genetic polymorphisms could play a role in diminishing the effectiveness of clopidogrel. Similarly, THALES demonstrated better outcomes with ticagrelor-aspirin combination therapy over aspirin monotherapy. Combination antiplatelet therapy with aspirin and the P2Y12 inhibitors, clopidogrel and ticagrelor, reduced stroke recurrence in those presenting with mild ischemic stroke or high risk TIA. Genetic polymorphisms may play a role in determining the appropriate regimen. Questions remain regarding the optimal duration of combination antiplatelet therapy for various stroke etiologies.

Systematic study of cilostazol on secondary stroke prevention: a meta-analysis

BACKGROUND

To study the efficacy and safety of cilostazol on ischemic stroke prevention and treatment, systematic reviews of related clinical randomized controlled trials were analyzed.

METHODS

We searched the main databases for eligible trials including literature from January 1966 to November 2012 in MEDLINE, reports from 1980 to November 2012 in EMBASE, and all the studies published in EBSCO, Springer, Ovid, and Cochrane library citations. We also searched for keywords, including cilostazol and aspirin. RewMan 5.0 software was used to conduct the meta-analysis.

RESULTS

Our search yielded five eligible trials. The effects of cilostazol and aspirin on ischemic stroke prevention and treatment were almost equal (combined odds ratio (OR) 0.78, 95% confidence interval (CI) (0.59, 1.04)). Additionally, both magnetic resonance angiography (MRA) and transcranial Doppler (TCD) examination showed that cilostazol could significantly decrease the incidence of intracranial artery stenosis exacerbation (MRA: combined OR 0.22, 95% CI (0.07, 0.68); TCD: combined OR 0.17, 95% CI (0.05, 0.51)). In terms of adverse reactions, there were slightly fewer incidences of major bleeding with cilostazol than with aspirin (combined OR 0.38, 95% CI (0.24, 0.60)), and there was no difference in the number of heart palpitations between cilostazol and aspirin. However, the incidence of gastrointestinal disorders, dizziness, and headaches caused by cilostazol was greater.

CONCLUSIONS

Cilostazol might be a more effective and safer alternative to aspirin for patients with ischemic stroke. Further studies are required to confirm whether cilostazol is a suitable therapeutic option for secondary stroke prevention in larger cohorts of patients with ischemic stroke.