Is Cilostazol (Pletal) contraindicated in patients with grade II diastolic dysfunction?

Cilostazol and Grade II Diastolic Dysfunction

Cilostazol is NOT contraindicated in grade II diastolic dysfunction—it is only contraindicated in patients with congestive heart failure of any severity, which is a distinct clinical entity from isolated diastolic dysfunction. 1, 2

Understanding the Contraindication

The absolute contraindication for cilostazol is specifically congestive heart failure (CHF) of any severity, not diastolic dysfunction per se. 1, 2

Key Distinctions:

• Heart failure is a clinical syndrome characterized by symptoms (dyspnea, fatigue, edema) and signs (rales, elevated jugular venous pressure, peripheral edema) resulting from structural or functional cardiac abnormalities. 1

• Grade II diastolic dysfunction is an echocardiographic finding that describes abnormal left ventricular relaxation patterns but does not automatically equate to clinical heart failure. Many patients with diastolic dysfunction remain asymptomatic and do not have heart failure. 1

• The FDA black-box warning states cilostazol is contraindicated in patients with "congestive heart failure of any severity," based on increased mortality seen with other phosphodiesterase III inhibitors (like milrinone) in heart failure patients. 2, 1

Clinical Decision Algorithm

To determine if cilostazol can be used:

1. Assess for clinical heart failure symptoms and signs:

   • Does the patient have dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or exercise intolerance? 1
   • Are there physical exam findings of volume overload (peripheral edema, elevated JVP, pulmonary rales)? 1
   • Has the patient been diagnosed with heart failure (HFrEF or HFpEF)? 1

2. If YES to clinical heart failure: Cilostazol is absolutely contraindicated regardless of ejection fraction or diastolic dysfunction grade. 1, 2

3. If NO to clinical heart failure: Grade II diastolic dysfunction alone is not a contraindication, and cilostazol may be used for appropriate indications (intermittent claudication). 1

Important Caveats

• Limited evidence in HFpEF: The 2024 ACC/AHA guidelines acknowledge that evidence is limited specifically in patients with heart failure with preserved ejection fraction, though the contraindication applies to "heart failure of any severity" out of concern for a class effect. 1

• Monitor closely: Even in patients without overt heart failure, cilostazol can cause palpitations, dizziness, and cardiovascular side effects due to its PDE3 inhibition mechanism. 3 Approximately 20% of patients discontinue the medication within 3 months due to adverse effects. 1

• Assess tolerance early: Evaluate patient tolerance at 2-4 weeks after initiation and clinical benefit within 3-6 months to determine if long-term therapy is appropriate. 1, 3

• Watch for emerging heart failure: If a patient with diastolic dysfunction develops clinical heart failure symptoms while on cilostazol, the medication must be discontinued immediately. 1, 2

Bottom Line

Grade II diastolic dysfunction without clinical heart failure is not a contraindication to cilostazol use. The contraindication applies only when there is symptomatic congestive heart failure present. 1, 2 However, careful patient selection and monitoring remain essential given the drug's cardiovascular effects and the theoretical concern about PDE3 inhibitor class effects. 1, 3