Carotid and Cerebrovascular Disease

Cilostazol Versus Aspirin for Secondary Prevention of Vascular Events After Stroke of Arterial Origin

Kamal AK, Naqvi I, Husain MR, et al (Aga Khan Univ Hosp, Karachi, Pakistan) Stroke 42:e382-e384, 2011^§

Abstract

For the secondary prevention of stroke of arterial origin, aspirin is the most widely studied and prescribed agent the world over. Cilostazol is both an antiplatelet and vasodilating agent. This agent has been used mainly in Asian populations with noncardioembolic stroke and no clinically evident cardiac disease.

Methods

Objectives: The objective of this review was to determine the relative effectiveness and safety of cilostazol compared directly with aspirin in the prevention of stroke and other serious vascular events in patients at high vascular risk for subsequent stroke, those with previous transient ischemic attack, or ischemic stroke of arterial origin.

Search Strategy: We searched the Cochrane Stroke Group Trials Register (last searched September 2010), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2009, Issue 4), MEDLINE (1950 to May 2010), and EMBASE (1980 to May 2010). In an effort to identify further published, ongoing, and unpublished studies, we searched journals, conference proceedings, and ongoing trial registers; scanned reference lists from relevant studies; and contacted trialists and Otsuka Pharmaceutical Co Ltd.

Selection Criteria: We selected all randomized controlled trials comparing cilostazol with aspirin in which participants were treated for at least 1 month and followed systematically for development of vascular events (stroke, myocardial infarction, or vascular death).

Data Collection and Analysis: Two review authors independently selected trials for inclusion, extracted the data, and assessed trial quality. We calculated the treatment effect for each outcome in terms of risk ratio by using the Mantel-Haenszel method.

Results

We included 2 trials from Japan and China, which included a total of 3477 participants with a history of ischemic stroke of arterial origin. These trials were of good quality. Compared with aspirin, cilostazol was associated with a significantly lower risk of composite outcome of vascular events (stroke, myocardial infarction, or vascular death; relative risk, 0.72; 95% CI, 0.57 to 0.91; Figure). The proportional benefit of cilostazol over aspirin on the outcome of “strokes of any type (ischemic or hemorrhagic)” was 33% (95% CI, 14% to 48%) compared with aspirin.

In relation to hemorrhagic stroke during follow-up, cilostazol was associated with a risk reduction of 74% (95% CI, 45% to 87%) compared with aspirin. In safety analyses, aspirin overall caused more bleeds with extracranial hemorrhage significantly higher in patients on aspirin compared with cilostazol (relative risk, 0.74; 95% CI, 0.61 to 0.90). Cilostazol was significantly associated with minor adverse effects, namely headache, gastrointestinal intolerance, palpitation, dizziness, tachycardia, angina, and cardiac failure.

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