Siriraj Medical Journal (May 2025)
Efficacy and Safety of Dual Antiplatelet Therapy Using Cilostazol with Aspirin or Clopidogrel to Reduce the Rate of Recurrent Ischemic Stroke in Asia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Abstract
Objective: The stroke mortality rate in Asia is higher than in other regions worldwide. As an antiplatelet medication and phosphodiesterase-3 inhibitor, cilostazol lacks approval for use in ischemic stroke. We intended to analyze the efficacy and safety of cilostazol dual antiplatelet therapy (DAPT) with clopidogrel or aspirin compared to aspirin or clopidogrel monotherapy. Materials and Methods: This review was carried out under the PRISMA 2020 guidelines, using sources from PubMed, Cochrane Library, EBSCOhost, Proquest, and the Lancet database. The Cochrane Risk of Bias 2 (RoB2) tool for randomized controlled trials was used to grade the quality of studies and Review Manager (RevMan) 5.4 for the meta-analysis. Results: Eight studies were included in this analysis, with four undergoing quantitative evaluation through metaanalysis, involving 3,328 patients. The risk of recurrent ischemic stroke for patients treated with cilostazol DAPT was significantly lower compared to those receiving monotherapy (risk ratio, RR: 0.49; 95% CI: 0.32–0.71; p: 0.0001) and (hazard ratio, HR: 0.48; 95% CI: 0.32–0.74; p: 0.0008). There were no significant differences in any hemorrhagic adverse events between the treatment groups (RR: 0.98; 95% CI: 0.71-1.36; p: 0.91). Acute neurological deterioration showed no significant differences (RR: 0.55; 95% CI: 0.11-2.77; p: 0.47). Conclusion: Cilostazol DAPT is more effective than clopidogrel or aspirin alone in preventing recurrent ischemic strokes without significantly increasing hemorrhagic risks or acute neurological decline. However, the study’s exclusive focus on a Japanese population limits the generalizability of the findings, highlighting the need for more diverse clinical trials across Asia.
Keywords
