There are a few medications that are known to worsen heart failure. Cilostazol can contribute to heart failure complications and because of this concern, a boxed warning exists for this medication. In the case below, we depict a case where cilostazol causes heart failure.
JS is a 74-year-old male with a history of:
- Heart failure with reduced ejection fraction (EF 30%)
- Peripheral artery disease (PAD) with intermittent claudication
- Type 2 diabetes
- Hypertension
- Coronary artery disease with prior myocardial infarction
- Chronic kidney disease stage 3
Current Medications
- Carvedilol 25 mg twice daily
- Sacubitril/valsartan 97/103 mg twice daily
- Spironolactone 25 mg daily
- Empagliflozin 10 mg daily
- Furosemide 40 mg daily
- Aspirin 81 mg daily
- Rosuvastatin 40 mg daily
JS has been struggling with intermittent claudication. He complains that calf pain limits him to walking only one block before stopping. His primary care provider diagnoses lifestyle-limiting intermittent claudication and starts cilostazol 100 mg twice daily.
Four weeks after initiation, he has noted some mild improvement in leg pain, but also has been struggling with the following concerns:
- Increasing dyspnea with routine activities
- Three-pound weight gain over one week
- Bilateral ankle edema
- Orthopnea requiring two additional pillows
- Heart rate 92 bpm
- Blood pressure 108/66 mmHg
- BNP has increased substantially from baseline.
- Chest X-ray demonstrates pulmonary vascular congestion.
He is admitted for acute decompensated heart failure requiring intravenous diuretics. During hospitalization, the pharmacist identifies the recent addition of cilostazol. The medication is discontinued, and the patient’s heart failure symptoms gradually improve over several days with diuresis and optimization of heart failure therapy.
Cilostazol inhibits phosphodiesterase-3 (PDE3), increasing intracellular cyclic AMP (cAMP). The vasodilation and increased stress on the heart are what can be problematic for heart failure patients. Because of this class effect, cilostazol carries a boxed warning and is contraindicated in patients with heart failure (excellent board exam nugget).
Cilostazol can improve symptoms of intermittent claudication, but its PDE3 inhibition increases intracellular cAMP within the myocardium, leading to increased heart rate and contractility. In patients with existing heart failure, these effects may accelerate decompensation and contribute to worse outcomes, making cilostazol contraindicated in heart failure.
0 Comments