Triple antiplatelet therapy vs. dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: an evidence‐based approach to answering a clinical query
Authors: Singh Inderjeet , Shafiq Nusrat , Pandhi Promila , Reddy Srinivas , Pattanaik Smita , Sharma Yashpaul , Malhotra Samir 
Published: March 2009

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.

AIMS

Outcomes 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.

METHODS

Electronic 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.

RESULTS

A 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.

CONCLUSIONS

Cilostazol appears to be effective in reducing the rates of ISR without any significant benefit for MACE/MACCE.