By Matthew E. Fink, MD

Feil Professor and Chairman, Department of Neurology, and Assistant Dean of Clinical Affairs, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital

Dr. Fink reports no financial relationships relevant to this field of study.

SOURCE: Toyoda K, et al. Dual antiplatelet therapy using cilostazol for high-risk ischemic stroke: The cilostazol stroke prevention study for antiplatelet combination. Available at: Accessed March 12, 2019.

In previous studies, dual antiplatelet therapy with aspirin and clopidogrel was shown to reduce early recurrence of ischemic stroke, with short-term benefit and a long-term risk of major bleeding. Cilostazol has been used to reduce the risk of recurrent stroke with a low bleeding risk and is safe for long-term use.

Toyoda et al reported on a multicenter, open-label trial in which high-risk patients with benign cardioembolic ischemic stroke identified on MRI were assigned to receive aspirin or clopidogrel alone, or a combination of cilostazol 100 mg twice daily with aspirin or clopidogrel for secondary stroke prevention. High-risk patients were defined as meeting one or more of the following criteria: > 50% stenosis of a major intracranial or extracranial artery and two or more vascular risk factors. The primary outcome was the first recurrence of an ischemic stroke. Safety outcomes included severe or life-threatening bleeding.

Following enrollment, 1,839 patients were available for analysis, with 756 taking aspirin and 1,083 taking clopidogrel. Ischemic stroke occurred in 29 of 913 patients with dual therapy including cilostazol and in 64 of 926 patients on monotherapy during a median follow-up of 17 months (P = 0.001). Severe bleeding occurred in 0.9% of patients on dual therapy and 1.4% of patients on monotherapy (P = 0.354). Investigators concluded that patients treated with dual antiplatelet therapy combining cilostazol with either aspirin or clopidogrel were at a lower risk of ischemic stroke recurrence and at a similar risk of significant bleeding compared to patients treated with aspirin or clopidogrel alone.