Cilostazol Contraindication in Heart Failure
Mechanism and Contraindication Rationale
- Cilostazol is a phosphodiesterase type III inhibitor that increases cyclic adenosine monophosphate, providing vasodilator and antiplatelet effects, and other phosphodiesterase inhibitors have demonstrated increased mortality in patients with heart failure with reduced ejection fraction 1, 2
- The American College of Cardiology recommends that cilostazol should not be administered to patients with heart failure of any severity due to increased mortality risk associated with phosphodiesterase III inhibitors in this population 3
Evidence Supporting Contraindication
- The American College of Cardiology and American Heart Association guideline for peripheral artery disease explicitly states that cilostazol should not be administered in patients with PAD and congestive heart failure of any severity 3, 4
- The FDA has mandated a black box warning that cilostazol should not be used in patients with heart failure of any severity due to concerns about a potential class effect 3
Clinical Considerations
- When evaluating patients for cilostazol therapy, clinicians must screen for any history or symptoms of heart failure before prescribing, and consider alternative therapies for patients with both PAD and heart failure 1, 2, 5
- For patients with peripheral artery disease and heart failure who need treatment for claudication, supervised exercise therapy remains the first-line non-pharmacological treatment, and alternative pharmacological approaches that don't carry heart failure risks should be considered 5, 6
Cilostazol Contraindication in Heart Failure
Mechanism of Action and Contraindication Rationale
- Cilostazol is a phosphodiesterase type III (PDE3) inhibitor that increases intracellular cyclic adenosine monophosphate (cAMP) levels, providing vasodilatory and antiplatelet effects, and its use can potentially trigger ventricular tachycardia in patients with heart failure 7
- The increased cAMP levels due to cilostazol's PDE3 inhibition can have dangerous effects in heart failure patients, particularly in relation to ventricular tachycardia 7
Pharmacological Considerations
- Cilostazol has a half-life of 11 hours, which is prolonged in patients with severe renal impairment, and is extensively metabolized by cytochrome P450 enzymes, with excretion of metabolites in the urine 7