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Cilostazol Added to Dual Antiplatelet Therapy for Patients with High Risk of Restenosis after Drug-Eluting Stent Implantation: A Systematic Review and Meta-Analysis of RCTs

Hai-Bin Chen, Xinlu Zhang, Hongbin Liang, Xuewei Liu and Jiancheng Xiu

Background: Cilostazol added to Dual Antiplatelet Therapy (DAT: aspirin, clopidogrel) reduces revascularization without increased bleeding in patients after Drug-Eluting Stent (DES) implantation. However, doubts remain about which patients benefit most from cilostazol-based Triple Antiplatelet Therapy (TAT) after DES. Materials and

Results: PubMed, EMBASE, CENTRAL databases were systematically searched. Randomized Controlled Trials (RCTs) comparing TAT and DAT for patients with high risk of restenosis (defined as obesity, diabetes, and long and/or multivessel coronary lesions) were included. Five RCTs were included, involving 2442 patients. The TAT group showed a significant reduction in MACEs (4.16% vs. 8.86%, RR: 0.47, 95% CI: 0.32 to 0.68, p<0.001), in-stent late loss (0.34 vs. 0.46, SMD: -0.22, 95% CI: -0.32 to -0.11, p<0.001), TVR (3.36% vs. 6.80%, RR: 0.49, 95% CI: 0.34 to 0.71, p<0.001), and in-stent restenosis (6.86% vs. 11.45%, RR: 0.60, 95% CI: 0.43 to 0.84, p=0.003) compared with the DAT group. There was no difference in all-cause mortality (1.56% vs. 0.82%, RR: 1.82, 95% CI: 0.87 to 3.77, p=0.110), bleeding (3.52% vs. 3.28%, RR: 1.07, 95% CI: 0.71 to 1.63, p=0.745) and stent thrombosis (0.82% vs. 0.66%, RR: 1.4, 95% CI: 0.50 to 3.06, p=0.641) between the two groups, whereas the incidence of other adverse reactions (11.38% vs. 6.39%, RR: 1.78, 95% CI: 1.37 to 2.33, p<0.001) and drug discontinuation (16.29% vs. 5.15%, RR: 4.60, 95% CI: 1.24 to 17.08, p=0.023) was greater in the TAT group than in the DAT group.

Conclusions: Compared with DAT, patients with a high risk of restenosis benefited from TAT in reduced stent restenosis and revascularization after DES implantation, without increases in all-cause mortality and bleeding, but accompanied by a higher incidence of other adverse reactions and drug discontinuation.