Patients with Good Collateralization May Profit from Cilostazol

With interest we have read the article by Jang et al. [1]. The authors present data of a systematic review and meta-analysis and demonstrate that cilostazol reduces the risk for restenosis after stenting by about 40%. This was the case for bare metal stents and for drug-eluting stents. Surprisingly, cilostazol is mainly used for symptomatic treatment in peripheral artery disease but very rarely for coronary artery disease. This is astonishing considering that cilostazol is rather cheap and among the very few peroral drugs that are actually able to reduce in-stent restenosis [2]. Another oral drug showing promising results is rapamycin [3]. The most established strategy to reduce the restenosis risk, however, is the use of drug-eluting stents instead of bare metal stents [4,5]. As we know, drug-eluting stents have their draw backs such as higher costs and the need for longer-term dual antiplatelet therapy.Unfortunately, we do have very limited tools to define the individual patient’s risk for restenosis. A recent study demonstrated that the collateral circulation may be a very elegant marker to predict the individual patient’s restenosis risk at the time of the coronary intervention [6]. Those patients with a well-developed collateral circulation, assessed either visually or with intracoronary pressure measurements, have a 40% increased restenosis risk and in these individuals the use of cilostazol and the use of drug-eluting stents should be considered. Overall, we think that cilostazol is an underused drug. It has pleotropic effects and reduces restenosis via inhibition of smooth muscle cell growth but it also has important antiplatelet properties [7]. One reason for its underuse may be the lack of financial interest of the pharmaceutical industry to invest in marketing and further research because cilostazol has become generic.