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Cilostazol Versus Aspirin in Ischemic Stroke Patients With High-Risk Cerebral Hemorrhage: Subgroup Analysis of the PICASSO Trial

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Author(s)
Bum Joon KimSun U. KwonJoung-Ho ParkYong-Jae KimKeun-Sik HongLawrence K.S. WongSungwook YuYang-Ha HwangJi Sung LeeJuneyoung LeeJong-Ho RhaSung Hyuk HeoSeong Hwan AhnWoo-Keun SeoJong-Moo ParkJu-Hun LeeJee-Hyun KwonSung-Il SohnJin-Man JungJose C. NavarroHahn Young KimEung-Gyu KimSeongheon KimJae-Kwan ChaMan-Seok ParkHyo Suk NamDong-Wha Kang
Publication Year
2020
Keyword
cerebral hemorrhagediabetes mellitusfollow-up studiesheart ratewhite matter
Abstract
Background and Purpose:
Although cilostazol has shown less hemorrhagic events than aspirin, only marginal difference was observed in hemorrhagic stroke events among patients at high risk for cerebral hemorrhage. To identify patients who would most benefit from cilostazol, this study analyzed interactions between treatment and subgroups of the PICASSO trial (Prevention of Cardiovascular Events in Asian Ischemic Stroke Patients With High Risk of Cerebral Hemorrhage).

Methods:
Ischemic stroke patients with a previous intracerebral hemorrhage or multiple microbleeds were randomized to treatment with cilostazol or aspirin and followed up for a mean 1.8 years. Efficacy, defined as the composite of any stroke, myocardial infarction, and vascular death, and safety, defined as the incidence of hemorrhagic stroke, were analyzed in the 2 groups. Interactions between treatment and age, sex, presence of hypertension and diabetes mellitus, index of high-risk cerebral hemorrhage, and white matter lesion burden were analyzed for primary and key secondary outcomes. Changes in vital signs and laboratory results were compared in the 2 groups.

Results:
Among all 1534 patients enrolled, a significant interaction between treatment group and index of high risk for cerebral hemorrhage on hemorrhagic stroke (P for interaction, 0.03) was observed. Hemorrhagic stroke was less frequent in the cilostazol than in the aspirin group in patients with multiple microbleeds (1 versus 13 events; hazard ratio, 0.08 [95% CI, 0.01-0.61]; P=0.01). A marginal interaction between treatment group and white matter change on any stroke (P for interaction, 0.08) was observed. Cilostazol reduced any stroke significantly in patients with mild (5 versus 16 events; hazard ratio, 0.36 [95% CI, 0.13-0.97]; P=0.04)-to-moderate (16 versus 32 events; hazard ratio, 0.50 [95% CI, 0.29-0.92]; P=0.03) white matter changes. Heart rate and HDL (high-density lipoprotein) cholesterol level were significantly higher in the cilostazol group than in the aspirin group at follow-up.

Conclusions:
Cilostazol may be more beneficial for ischemic stroke patients with multiple cerebral microbleeds and before white matter changes are extensive.
Department
Dept. of Neurology (신경과학)
Publisher
School of Medicine (의과대학)
Citation
Stroke., Vol.51(3) : 931-937, 2020
Type
Article
ISSN
1524-4628
DOI
10.1161/STROKEAHA.119.023855
URI
http://kumel.medlib.dsmc.or.kr/handle/2015.oak/42649
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