Is it safe for a patient with a history of atherosclerotic heart disease (ASHD) of the native coronary artery without angina pectoris to take cilostazol?

Cilostazol is Contraindicated in Patients with Atherosclerotic Heart Disease

Cilostazol should NOT be used in patients with a history of atherosclerotic heart disease of native coronary arteries, regardless of whether angina is present, due to the absolute contraindication in patients with heart failure of any severity and the lack of cardiovascular protective benefit. 1, 2, 3

Critical Safety Concerns

Absolute Contraindication in Heart Failure

• Cilostazol carries an FDA black box warning prohibiting its use in patients with heart failure of any severity due to increased mortality risk associated with phosphodiesterase III inhibitors in this drug class. 1, 2, 3

• The American College of Cardiology explicitly states that cilostazol is contraindicated in patients with heart failure of any severity, based on evidence from other phosphodiesterase III inhibitors (such as oral milrinone) showing excess mortality in heart failure patients with reduced ejection fraction. 1, 2

• Patients with atherosclerotic coronary artery disease frequently have subclinical left ventricular dysfunction or may develop heart failure post-MI, making cilostazol particularly hazardous in this population even without overt heart failure symptoms. 4

Lack of Cardiovascular Protection

• Cilostazol does NOT reduce cardiovascular ischemic events (myocardial infarction, stroke, or cardiovascular death) in patients with established cardiovascular disease. 4

• The drug can potentially exacerbate angina pectoris or precipitate myocardial infarction in patients with ischemic heart disease. 4

• The sole FDA-approved indication for cilostazol is improving walking distance in patients with intermittent claudication from peripheral arterial disease—it provides symptom relief for leg claudication only, not cardiovascular protection. 1, 2, 4

Appropriate Antiplatelet Strategy for Your Patient

Recommended Therapy Instead

• For patients with atherosclerotic coronary artery disease, aspirin 75-100 mg daily OR clopidogrel 75 mg daily is recommended to reduce myocardial infarction, stroke, and vascular death. 1

• Aspirin 75-100 mg daily is specifically recommended in patients with a previous MI or revascularization. 1

• Clopidogrel 75 mg daily is recommended as an alternative in patients with aspirin intolerance. 1

• Statin therapy is indicated for all patients with atherosclerotic disease to reduce cardiovascular events. 1

When Cilostazol Might Theoretically Be Considered (Extremely Limited Scenario)

• Cilostazol could only be considered if the patient has concurrent symptomatic peripheral arterial disease with lifestyle-limiting claudication, AND has been definitively ruled out for any degree of heart failure (including preserved ejection fraction), AND has stable coronary disease without ongoing ischemia, AND has failed optimal medical therapy and supervised exercise rehabilitation for claudication. 1, 4

• Even in this rare scenario, approximately 20% of patients discontinue cilostazol within 3 months due to adverse effects including headache, diarrhea, palpitations, dizziness, and tachycardia—side effects particularly concerning in patients with coronary disease. 1, 4

Clinical Screening Required Before Any Consideration

• Before prescribing cilostazol, clinicians must screen for any history or symptoms of heart failure, including dyspnea, orthopnea, peripheral edema, or reduced exercise tolerance. 3

• Assessment of left ventricular function would be prudent given the absolute contraindication in heart failure of any severity. 1, 3