Cilostazol may reduce secondary stroke risk in ischaemic stroke patients
The phosphodiesterase 3 inhibitor cilostazol may prevent secondary stroke in individuals with a recent history of ischaemic stroke. However, there was a higher incidence of myocardial infarction in this group, according to findings of the PICASSO* study presented at the International Stroke Conference 2017 (ISC 2017) in Houston, Texas, US.
“Cilostazol significantly decreased any stroke in comparison to aspirin in this cohort, but increased myocardial infarction and therefore, failed to demonstrate superiority in reducing composites of cardiovascular events,” said study author Dr Sun U Kwon of Asan Medical Center, Seoul, Korea, who presented the findings.
To assess if cilostazol had comparable efficacy in preventing major vascular events and better safety in reducing cerebral haemorrhage than aspirin, researchers of this international, multicentre (67 institutes in three countries – Hong Kong, Philippines, and Korea) trial randomized 1,512 participants (age >20 years) to either cilostazol (100 mg twice a day, n=755, mean age 65.5 years, 61.9 percent male) or aspirin (100 mg/day, n=757, mean age, 65.8 years, 62.1 percent male).
There was a high prevalence of hypertension in both the cilostazol (88.9 percent) and aspirin (89.3 percent) treatment arms as well as a low prevalence of coronary artery disease (4.0 percent vs 5.4 percent).
To be included in the trial, patients had to have had a noncardioembolic ischaemic stroke or transient ischaemic attack within 180 days prior to recruitment and a history of intracerebral haemorrhage.
After a median follow-up of 1.86 and 1.91 years for cilostazol and aspirin, respectively, there were significantly fewer incidences of any stroke in the cilostazol group compared with the aspirin group (48 vs 73 events, hazard ratio [HR], 0.67, 95 percent confidence interval [CI], 0.46–0.96; p=0.03). [ISC 2017, abstract LB5]
In contrast, the number of myocardial infarctions in the cilostazol group was higher than that of the aspirin group (nine vs two events, HR, 4.60, 95 percent CI, 0.99–21.27; p=0.03). Cilostazol also did not appear to be better than aspirin in reducing the incidence of intracerebral and subarachnoid haemorrhage (nine vs 18 events, HR, 0.51, 95 percent CI, 0.23–1.13; p=0.09).
While previous macro- or micro-cerebral haemorrhage is associated with an increased risk of future cerebral haemorrhage, the optimal antiplatelet treatment for these patients is still unclear, said Kwon.
“The PICASSO study successfully showed noninferiority of cilostazol in the occurrence of major cardiovascular events. However, we failed to show the superiority of cilostazol in preventing cerebral haemorrhage,” said Kwon, who called for future studies into determining which patients would benefit from cilostazol.