Effects of Antiplatelet Agents on Subacute Thrombosis and Restenosis After Successful Coronary Stenting-A Randomized Comparison of Ticlopidine and Cilostazol-

Abstract

ctivation of platelets is considered to be the main cause of thrombotic occlusion after coronary stenting 1,2 and several antiplatelet agents have been shown to be useful for the prevention of subacute thrombosis (SAT). The combination of aspirin and ticlopidine, a selective adenosine diphosphate (ADP) receptor blocker, has prevented SAT after coronary stenting in several randomized studies. [3][4][5][6] Cilostazol, a cyclic adenosine monophosphate phosphodiesterase inhibitor, has also been shown to be a potent antiplatelet agent with antiproliferative properties, suggesting that it should prevent both thrombosis and restenosis after coronary stenting when coadministered with aspirin. [7][8][9] We conducted a prospective randomized study to compare the preventive effects against SAT and restenosis after coronary stenting between ticlopidine plus aspirin and cilostazol plus aspirin. Methods Study DesignThe study included 282 consecutive patients who successfully underwent coronary stenting for the treatment of acute myocardial infarction or angina pectoris. Patients who had already received ticlopidine or cilostazol were excluded. Patients with contraindications to treatment with aspirin, ticlopidine, or cilostazol were also excluded. All patients gave informed consent to participate in this study.The patients were randomized to the ticlopidine (200 mg/day) plus aspirin (81 mg/day) group or the cilostazol (200 mg/day) plus aspirin (81 mg/day) group. Patients scheduled for elective stenting started on either therapy 2 days before stenting. Those who underwent unplanned stenting because of a suboptimal result after balloon angioplasty or bailout stenting after failed balloon angioplasty received either therapy in the catheterization laboratory. The treatment was continued until follow-up angiography was performed. Coronary AngiographyThe cardiac catheterization and stent implantation were performed according to standard techniques. The technical issues, including the stent type, length, and diameter, and the dilation pressure, were left to the discretion of each attending physician. Coronary angiography was performed before, immediately after and 6 months after stenting.All of the initial angiographic approaches were also used at follow-up. Images with optimum delineation of the target lesions were selected from among all technically suitable angiograms, and quantitative coronary angiography (QCA) was performed using Integris Quantitative Coronary Analysis (Philips Medical Systems Nederland, The Netherlands) by 2 physicians without any knowledge of the patient's clinical history. The measurements were calibrated using a guide catheter for reference. The reference diameter, minimum luminal diameter (MLD), percent diameter stenosis (%DS) and the gain were determined. Effects of Antiplatelet Agents on Subacute Thrombosis and Restenosis After Successful Coronary Stenting A Randomized Comparison of Ticlopidine and CilostazolMakoto Sekiguchi, MD; Hiroshi Hoshizaki, MD; Hitoshi Adachi, MD; Shigeru Ohshima, MD; Koichi Tan...

Effectiveness of a Sirolimus-Eluting Stent (Cypher ) for Diffuse In-Stent Restenosis Inside a Bare Metal Stent

“…The incidences of SAT and/or LST were believed to have increased due to the delayed endothelialization inside SES in addition to the non-premature and non-substitutional antiplatelet treatment. That is, in Japan, a dual antiplatelet regimen (aspirin plus ticlopidine or cilostazol) 13,17) has been the standard following coronary stenting, although ticlopidine and cilostazol are associated with some adverse effects. 13) Moreover, neither clopidogrel 24) nor glycoprotein IIb/IIIa inhibitors 14) were formally approved for the treatment of ischemic heart disease during the present investigation.…”

“…That is, in Japan, a dual antiplatelet regimen (aspirin plus ticlopidine or cilostazol) 13,17) has been the standard following coronary stenting, although ticlopidine and cilostazol are associated with some adverse effects. 13) Moreover, neither clopidogrel 24) nor glycoprotein IIb/IIIa inhibitors 14) were formally approved for the treatment of ischemic heart disease during the present investigation. The similar acute gain with the more frequent usage of IVUS 12) with higher-pressure dilatation 12) in SES compared to those in BMS might offset the influences of significantly longer stented length.…”

“…17) When an adverse effect due to ticlopidine developed, cilostazol (150 to 200 mg/day) was prescribed instead of ticlopidine. As we described in a previous report, 17) clopidogrel 24) was prepared as the third antiplatelet agent from September 2004 for administration if any adverse effects 13) due to either ticlopidine or cilostazol developed. However, clopidogrel was not actually administered to any patient.…”

“…In addition, documented subacute stent thrombosis within 30 days and beyond 30 days (SAT [12][13][14][15][16][17] and LST 12,18,19) ) was evaluated to determine stent thrombotic complications. Statistical analysis: Variables are expressed as the mean ± standard deviation (SD) for continuous variables and as percentages for discrete variables.…”

“…[9][10][11] In Japan, the clinical usefulness of SES, including the outcome when used to treat diffuse ISR inside BMS, has not been confirmed since the SES was approved in August 2004. Thus, in the present study, the incidences of major adverse cardiac events (MACE), the incidences of both early and late stent thrombosis (SAT [12][13][14][15][16][17] and LST), 12,18,19) and angiographic outcome 6 months 20) after SES implantation for diffuse ISR were retrospectively evaluated by comparison with POBA, CB, and BMS without randomization. In addition, in order to ascertain the long-term patency of SES, the 12-month 21) angiographic outcome was compared with the 6-month outcome for some of the lesions in SES implantation.…”