From the Guidelines
Cilostazol is not acceptable for use in patients with diastolic congestive heart failure (CHF) due to its potential to worsen cardiac function. The 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1 explicitly states that in patients with PAD and congestive heart failure of any severity, cilostazol should not be administered, categorized as a Class III: Harm recommendation with a Level of Evidence of C-LD. This recommendation is based on the medication's phosphodiesterase inhibitor properties, which can increase heart rate and potentially worsen cardiac function 1.
Key considerations for managing diastolic CHF include:
- Controlling blood pressure
- Managing volume status
- Treating underlying conditions
- Following guideline-directed medical therapy, which typically includes:
- ACE inhibitors/ARBs
- Beta-blockers
- Diuretics
- Potentially SGLT2 inhibitors based on recent evidence
For patients with diastolic heart failure who require antiplatelet therapy, alternative medications such as aspirin, clopidogrel, or other antiplatelet agents without inotropic effects would be more appropriate choices 1. The primary goal in managing these patients is to alleviate symptoms and improve quality of life while minimizing the risk of adverse outcomes, and the use of cilostazol in this context would be counterproductive to these aims.
From the FDA Drug Label
Cilostazol tablets are contraindicated in patients with congestive heart failure of any severity. The use of cilostazol in patients with diastolic congestive heart failure (CHF) is not acceptable due to the contraindication of cilostazol in patients with congestive heart failure of any severity 2.
- Key point: Cilostazol is contraindicated in all forms of congestive heart failure.
From the Research
Cilostazol in Diastolic CHF
- Cilostazol is contraindicated in patients with congestive heart failure, including diastolic CHF, as stated in the study 3.
- The studies provided do not specifically address the use of cilostazol in diastolic CHF, but rather focus on its use in intermittent claudication and peripheral artery disease.
- However, it is noted that cilostazol has vasodilating and antiplatelet properties, which may be beneficial in certain cardiovascular conditions, but its use in diastolic CHF is not recommended due to the contraindication 3, 4.
Safety and Efficacy of Cilostazol
- Cilostazol has been shown to be effective in improving walking distances and quality of life in patients with intermittent claudication 3, 5, 6.
- The drug is generally well tolerated, with common adverse events including headache, diarrhea, and peripheral edema 3, 5.
- However, cilostazol should be used with caution in elderly polymedicated patients, and its use is contraindicated in patients with certain conditions, including congestive heart failure 3, 7.
Clinical Applications of Cilostazol
- Cilostazol is primarily used to treat intermittent claudication in patients with peripheral artery disease 3, 5, 6.
- It has also been shown to be effective in patients undergoing percutaneous revascularization procedures for both PAD and coronary artery disease 4.
- Additionally, cilostazol may be useful in patients with multifocal atherosclerosis and resistance to aspirin and clopidogrel 6.