BACKGROUND: Activation of platelets is the major cause of thrombotic occlusion after coronary stenting with restenosis rate occuring 30-50% within the first six months. Oral anti-thrombotic strategies for the prevention of sub-acute stent thrombosis in the initial 30 days following cardiac stent insertion demonstrated similar benefit with aspirin in combination with cilostazole and clopidogrel. OBJECTIVES: To determine the effect ofTiclopidine plus Aspirin (TA), Clopidogrel plus Aspirin (CA), and Cilostazol plus Aspirin (CIA), in reducing the occurrence of major clinical adverse events, six months after coronary stent implantation. SELECTION CRITERIA: Randomized controlled trials involving patients who underwent successful coronary stenting and were maintained on the mentioned anti-thrombotics. DATA COLLECTION AND ANALYSIS: We obtained relevant trials from PubMed, Medline, Cochrane, internet electronic databases. We searched abstracts, lists of review articles and retrieved studies by manual and internet search strategies. We included studies regardless of date and publication. RESULTS: We gathered 46 trials, narrowed down to 10 studies. Three studies compared TA and CA, and 7 studies compared TA and CIA. TA showed a greater benefit over CA in reducing death and incidence of AMI, RR 1.43, 95 percent CI (085, 2.42), RR 1.57, 95 percent CI (0.96, 2.55), respectively. However, CIA showed a significant benefit overTA in reducing AMI, death, bleeding complications, and the improvement of diameter stenosis, RR 6.29, 95 percent CI (5.82,6.77). Homogeneity was observed after removal of 2 studies and showed significant benefit with CIA, RR5.35, 95 percent CI (4.67, 6.03). CONCLUSION: There was a trend towards benefit in using CIA in the reduction of adverse clinical events and significant improvement in diameter stenosis overTIA. On the other hand, TA showed a trend towards benefit over CA in preventing death and AMI. No trials directly compared cilostazol with clopidogrel with long term outcome measurements, which is a limitation of this study. RECOMMENDATIONS: It is wordi pursuing to conduct randomized controlled trials comparing clopidogrel with ticlopidine or cilostazol, which will monitor long term adverse clinical events to be able to demonstrate which anti-thrombotic will show statistically significant benefit.
General Objective: The main objective of this meta-analysis is to determine which among the following anti-thrombotics, ticlopidine, clopidogrel and cilostazol, in combination with aspirin would significantly reduce major adverse clinical events after 6 months of coronary stent implantation. Specific Objective: To determine the effect of the following combination of drugs: TA, CA, and CIA in: 1) Reducing the occurrence of death from all causes 2) Acute myocardial infarction after 6 months of coronary implantation 3) Reducing the incidence of bleeding complications (cerebral hemorrhage, gastro-intestinal bleeding, hematoma, purpura or gingival bleeding) 4) Improving the percentage of diameter stenosis after 6 months of coronary implantation