What is the role of Cilostazol (Pletal) in patients with cardiovascular disease (CVD) who have experienced a myocardial infarct (MI) and likely have peripheral arterial disease (PAD)?

Cilostazol Should NOT Be Used in Patients with Myocardial Infarction

Cilostazol is absolutely contraindicated in patients with cardiovascular disease who have experienced myocardial infarction if they have congestive heart failure of any severity, and it provides no benefit for reducing cardiovascular ischemic events—its sole indication is for intermittent claudication in peripheral artery disease. 1, 2

Critical Contraindications in Post-MI Patients

• Cilostazol is contraindicated in patients with heart failure of any severity due to increased mortality observed with phosphodiesterase III inhibitors in this population 2, 3
• The FDA mandates a black-box warning against use in heart failure patients, as other drugs in this class (milrinone, vesnarinone) have demonstrated increased mortality in patients with reduced left ventricular systolic function 1, 4
• Post-MI patients frequently develop heart failure or have subclinical left ventricular dysfunction, making cilostazol particularly hazardous in this population 1

Lack of Cardiovascular Protection

• Cilostazol does NOT reduce cardiovascular ischemic events (MI, stroke, or cardiovascular death) in patients with established cardiovascular disease 1
• The drug's mechanism as a phosphodiesterase III inhibitor provides vasodilatory and antiplatelet effects, but these do not translate into cardiovascular event reduction 1, 4
• Cilostazol can exacerbate angina pectoris or precipitate myocardial infarction in patients with ischemic heart disease 1

Appropriate Use Limited to Claudication Only

• The sole FDA-approved indication for cilostazol is improving walking distance in patients with intermittent claudication who do not have rest pain or tissue necrosis 1, 5
• Cilostazol improves maximal walking distance by 40-60% compared to placebo after 12-24 weeks in claudication patients, but this benefit is symptom-specific, not cardiovascular protective 1, 4
• The drug requires 100 mg orally twice daily dosing, with assessment of tolerance at 2-4 weeks and benefit evaluation at 3-6 months 3, 4

High Discontinuation Rates and Side Effects

• Approximately 20% of patients discontinue cilostazol within 3 months due to adverse effects including headache, diarrhea, palpitations, dizziness, and tachycardia 1, 3
• These cardiovascular side effects (tachyarrhythmia, palpitations) are particularly concerning in post-MI patients who may have residual ischemia or arrhythmia risk 1

Recommended Antiplatelet Strategy for Post-MI with PAD

• For post-MI patients with PAD, use aspirin (75-325 mg daily) or clopidogrel (75 mg daily) as antiplatelet therapy to reduce MI, stroke, and vascular death 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) may be reasonable after lower extremity revascularization to reduce limb-related events, but not for general cardiovascular protection 1
• Anticoagulation should NOT be used to reduce cardiovascular ischemic events in PAD patients, as it increases bleeding without benefit 1

When Cilostazol Might Be Considered (Rare Scenario)

• Only if the post-MI patient has no clinical heart failure symptoms or signs, has stable coronary disease without ongoing ischemia, and has lifestyle-limiting claudication despite optimal medical therapy and exercise rehabilitation 3, 5
• Even in this scenario, careful assessment for any degree of heart failure is mandatory before initiation, as the contraindication applies to "heart failure of any severity" 3, 2
• Patients must be monitored closely for development of heart failure symptoms, which would require immediate discontinuation 3