Is cilostazol indicated for a patient with CHF, CAD, and atrial fibrillation on dabigatran and aspirin?

Cilostazol is Contraindicated in This Patient with CHF and Reduced Ejection Fraction

Cilostazol is absolutely contraindicated in this 76-year-old bedridden female patient with CHF with reduced ejection fraction of 20-25% and should be discontinued immediately, regardless of her concomitant dabigatran and aspirin therapy for atrial fibrillation. 1

Rationale for Discontinuing Cilostazol

• Cilostazol is a phosphodiesterase III inhibitor that is explicitly contraindicated in patients with heart failure of any severity according to FDA labeling 1
• Studies of other phosphodiesterase inhibitors (such as oral milrinone) have shown excess mortality in patients with heart failure with reduced ejection fraction treated with these agents 2
• The FDA package insert for cilostazol specifically states that it is contraindicated in patients with heart failure of any severity due to concerns about a potential class effect 2

Current Antithrombotic Management for This Patient

• The patient is already on appropriate antithrombotic therapy for her atrial fibrillation with dabigatran (a direct thrombin inhibitor) 3
• The addition of aspirin to dabigatran increases bleeding risk and should be carefully evaluated, especially in elderly patients 4
• The combination of dabigatran and aspirin already provides sufficient antithrombotic coverage for her atrial fibrillation and CAD status post NSTEMI 2

Risks of Triple Therapy in This Patient

• Adding cilostazol to the existing dual therapy of dabigatran and aspirin creates a "triple antithrombotic" regimen that significantly increases bleeding risk 5
• The patient's advanced age (76 years) and bedridden status further increase her bleeding risk 6
• There is no established consensus that cilostazol should be added to antiplatelet regimens in patients who are already on appropriate anticoagulation for atrial fibrillation 2

Alternative Management Considerations

• For this patient with atrial fibrillation and CAD, the American College of Cardiology/American Heart Association guidelines recommend focusing on appropriate anticoagulation rather than adding additional antiplatelet agents 2
• If peripheral arterial disease is a concern, other management strategies that don't involve cilostazol should be considered due to the absolute contraindication of cilostazol in heart failure 2
• The patient's reduced ejection fraction of 20-25% represents severe heart failure, making the contraindication for cilostazol particularly strong 1

Common Pitfalls to Avoid

• Continuing cilostazol despite the clear contraindication in heart failure patients 1
• Assuming that cilostazol's benefits for peripheral arterial disease outweigh the risks in heart failure patients - they do not 2
• Overlooking the FDA contraindication when managing complex patients with multiple comorbidities 1
• Focusing on potential antiplatelet benefits while ignoring the mortality risk associated with phosphodiesterase inhibitors in heart failure patients 2

The evidence is clear that cilostazol should be discontinued in this patient due to her heart failure with reduced ejection fraction, regardless of any potential benefits for peripheral arterial disease or other conditions.