Cilostazol as an alternative to clopidogrel for secondary stroke prevention in patients with ischemic stroke and clopidogrel resistance: a retrospective study

Objective: Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is a standard for secondary prevention.However, clopidogrel resistance is common in East Asian populations and may increase the risk of recurrent stroke.This study evaluated whether switching to cilostazol was more effective than continuing clopidogrel for reducing 1-year ischemic stroke recurrence in patients with confirmed clopidogrel resistance.Methods: We retrospectively analyzed patients with acute ischemic stroke who were admitted between January 2012 and December 2021.Eligible patients had received DAPT for at least 5 days and demonstrated clopidogrel resistance, defined as P2Y12 reaction units 240 on the VerifyNow assay.Patients were assigned to either the clopidogrel group (aspirin plus clopidogrel) or the cilostazol group (aspirin plus cilostazol, 100 mg twice daily).The treatment duration was 1 year in both groups.The primary outcome was recurrent ischemic stroke within 1 year.Results: Among 221 patients(138 clopidogrel, 83 cilostazol), baseline characteristics were similar.At 1 year, recurrent ischemic stroke was less frequent in the cilostazol group than in the clopidogrel group (4.8% [4/83] vs. 13.0%[18/138], P = 0.028).In multivariable logistic regression analysis, continued clopidogrel use was identified as an independent predictor of recurrence after adjustment for potential confounders (odds ratio, 1.33; 95% confidence interval, 0.35-5.04;P = 0.049). Conclusion:In patients with clopidogrel resistance, switching to cilostazol may be associated with a lower 1-year recurrence rate than continuing clopidogrel.Larger prospective trials are needed.