Antiplatelet Therapy for Chronic Infarct: Aspirin vs Cilostazol
For patients with chronic infarct (prior MI or remote PCI), aspirin 75-100 mg daily is the recommended first-line antiplatelet therapy lifelong, with clopidogrel 75 mg daily as an equally effective alternative. 1 Cilostazol is not recommended as first-line therapy in this population based on current European and American guidelines.
Primary Recommendation for Chronic Coronary Syndrome
Aspirin 75-100 mg daily is recommended lifelong after an initial period of dual antiplatelet therapy (DAPT) in patients with prior MI or remote PCI. 1 This represents a Class I, Level A recommendation from the 2024 ESC Guidelines for chronic coronary syndromes. 1
Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy in patients who cannot tolerate aspirin or have contraindications (Class I, Level A). 1
For patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75-100 mg daily is recommended lifelong (Class I, Level B). 1
Cilostazol's Limited Role in Coronary Disease
The evidence for cilostazol in chronic coronary syndromes is substantially weaker than for aspirin or clopidogrel:
In patients undergoing PCI with stent placement, aspirin and clopidogrel are recommended over cilostazol. 1 The American College of Chest Physicians explicitly recommends using low-dose aspirin 75-100 mg daily and clopidogrel 75 mg daily alone rather than adding cilostazol (Grade 1B). 1
Cilostazol 100 mg twice daily may only be considered as a substitute for either aspirin or clopidogrel in patients with allergy or intolerance to these drugs (Grade 2C). 1 This is a weak recommendation with low-quality evidence.
Cilostazol's Primary Indication: Cerebrovascular Disease
Cilostazol has demonstrated efficacy specifically in secondary prevention of noncardioembolic ischemic stroke, not coronary disease:
In patients with history of noncardioembolic ischemic stroke or TIA, cilostazol (100 mg bid) is listed as one of several acceptable antiplatelet options alongside aspirin, clopidogrel, or aspirin/extended-release dipyridamole (Grade 1A). 1
However, even in stroke patients, clopidogrel or aspirin/extended-release dipyridamole are suggested over cilostazol (Grade 2C). 1
Research shows cilostazol combined with clopidogrel reduced stroke recurrence by 55% (HR 0.447) without increasing bleeding risk in high-risk noncardioembolic stroke patients. 2 This benefit has not been demonstrated in coronary disease populations.
A meta-analysis found cilostazol provided a 47% reduction in recurrent cerebral infarction and 71% reduction in hemorrhagic stroke compared to aspirin in chronic phase stroke prevention. 3 These benefits are specific to cerebrovascular, not coronary, disease.
Critical Distinction: Coronary vs Cerebrovascular Disease
The question asks about "chronic infarct" which in cardiology terminology refers to prior myocardial infarction, not cerebral infarction. For chronic coronary syndromes:
- Aspirin remains the gold standard with the strongest evidence base (Class I, Level A). 1
- Clopidogrel is the only alternative with equivalent recommendation strength (Class I, Level A). 1
- Cilostazol has no established role and is explicitly not recommended over standard therapy. 1
Common Pitfalls to Avoid
Do not confuse cerebral infarction (stroke) with myocardial infarction (heart attack). Cilostazol's evidence base is in stroke prevention, not coronary disease. 1, 2, 3
Do not use cilostazol as first-line therapy in coronary disease patients unless there is documented aspirin and clopidogrel intolerance. 1
After CABG, aspirin 75-100 mg daily is recommended lifelong, initiated as soon as bleeding concerns resolve. 1, 4 Cilostazol has no role in post-CABG management.