Triple antiplatelet therapy vs. dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: an evidence‐based approach to answering a clinical query

Abstract

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT?• Different strategies have been evaluated for their efficacy in reducing stent thrombosis and restenosis in patients undergoing percutaneous coronary intervention (PCI).• Triple antiplatelet therapy is one such strategy that has been shown to improve the efficacy outcomes associated with PCI.• Cilostazol is an antiplatelet agent that is being prescribed as a component of triple-therapy regimen in various centres in our country, and the beneficial effect of cilostazol addition to other antiplatelet regimens has been observed. • However, the extent of the efficacy is not uniformly in favour of the triple therapy compared with dual therapy. • Moreover, the use of this agent with bare metal stents (commonly used in developing countries) and drug-eluting stents has not been separately looked into. WHAT THIS STUDY ADDS• Triple antiplatelet therapy, with cilostazol as a component, reduces restenosis rates and repeat revascularizations post PCI without any significant increase in bleeding risk.• The beneficial effect of cilostazol is more evident with drug-eluting stents.• Its use with bare metal stents needs to be explored further. AIMSOutcomes of patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare metal stents (BMS) have not been evaluated separately for specific dual and triple antiplatelet agent use. The purpose of this meta-analysis was to determine whether triple antiplatelet therapy (combination of clopidogrel, aspirin and cilostazol) has any advantage in efficacy compared with standard dual antiplatelet therapy (aspirin and clopidogrel) in patients undergoing PCI. METHODSElectronic and printed sources were searched till May 2008 for randomized controlled clinical trials (RCTs) of cilostazol in combination with aspirin and clopidogrel. Pooled weighted mean difference (WMD) and pooled odds ratio (OR) with 95% confidence intervals (CIs) were calculated. RESULTSA total of four RCTs including 1457 patients with a median follow-up period of 6-9 months were included in the analysis. The rates of major adverse cardiac and/or cerebrovascular events (MACE/MACCE), stent thrombosis and bleeding were not significantly different between triple and dual antiplatelet therapy groups. Pooled analysis showed that cilostazol was associated with significantly decreased incidence of in segment restenosis (ISR) (OR 0.51, 95% CI 0.38, 0.68; P < 0.00001), increased minimum luminal diameter (MLD) (WMD 0.16, 95% CI 0.10, 0.22; P < 0.00001) for both DES and BMS and also individually. However, the rates of target vessel revascularization (OR 0.45, 95% CI 0.25, 0.83; P = 0.01 and late lumen loss (pooled WMD 0.14, 95% CI 0.2, 0.07; P = 0.001) were decreased significantly only in the DES group receiving triple therapy. CONCLUSIONSCilostazol appears to be effective in reducing the rates of ISR without any significant benefit for MACE/MACCE.

Triple versus dual antiplatelet therapy for coronary heart disease patients undergoing percutaneous coronary intervention: A meta-analysis

“…This is due to cilostazol inhibiting the progression of carotid intima-media thickness and thus producing an additional anti-proliferative effect, regardless of the fact that DAT itself is a potent therapy (23,29–31). Notably, the significantly reduced rate of MACE in the long-term follow-up subgroup is inconsistent with the findings of two previous meta-analyses, which indicated that there was no difference in the clinical outcomes of MACE between DAT and TAT treatment groups (11,28). A potential reason for the discrepancy may be the limited number of included studies.…”

“…Over the past decade, numerous studies have indicated that the use of adjunctive antiplatelet agents has resulted in decreased stent-associated thrombosis and is important in improving the final outcomes of PCI (27). Two meta-analyses by Tamhane et al (11) and Singh et al (28) also indicated that patients treated with TAT exhibited a lower restenosis rate than those treated with DAT (11,28). However, these meta-analyses did not provide reliable results demonstrating the differences in the clinical outcomes between TAT and DAT for patients with CHD undergoing PCI with coronary stent implantation.…”

Cilostazol-Based Triple Antiplatelet Therapy Compared to Dual Antiplatelet Therapy in Patients with Coronary Stent Implantation: A Meta-Analysis of 5,821 Patients

“…Two meta-analyses [41,42] included only 4–5 RCTs with 1,457–1,597 patients. The meta-analysis by Tamhane et al [43] included 10 RCTs (7 trials as a full text and 3 trials presented at scientific meetings) with 2,809 patients.…”

Cilostazol Eliminates Adverse Smoking Outcome in Patients With Drug-Eluting Stent Implantation

“…This finding is in line with recent meta-analyses showing that cilostazol did not reduce mortality or MI at any point during the follow-up between 6 months and 2 years. 22, 23 Several studies have shown that adding cilostazol to DAT after DES implantation decreased angiographic restenosis compared with DAT. 9,23,24 This beneficial effect of cilostazol was more prominent in patients with long coronary lesions and in diabetic patients.…”