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EL-MINIA MED., BULL., VOL. 16, NO. 1, JAN., 2005
Zakaria & Abdel Aziz
___________________________________________________________________________________
CARDIAC EFFECTS OF CILOSTAZOL: A SELECTIVE TYPE-3PHOSPHODIASTERASE INHIBITOR, AN EXPERIMENTAL STUDY
By
Mahmoud Samy Zakaria, and Manal Abdel Aziz A.
Department of Forensic Medicine and Clinical Toxicology
El-Minia Faculty of Medicine
ABSTRACT:
This study was done to estimate the effects of cilostazol on the heart. It was
carried out on 60 adult male guinea pigs weighing 400±20 (400-450). Guinea pigs
were divided into three groups, each contained 20 animals. Group (1) was the
negative control group, group (2) was the positive control group received 1ml. benzyl
alcohol ( 15 %) daily by orogastric tube, and group (3) which received cilostazol in a
dose of 6.2 mg/animal/day dissolved in 1ml. (15%) benzyl alcohol also administered
by the orogastric infusion method. The experiment continued for 3 months then the
whole animals were anaesthetized through intraperitoneal injection of 1 ml. (25%)
urethane sodium to facilitate performance of electrocardiogram. Using limb leads
connected to the animal 4 limbs all over a duration of 3 minutes. Lastly animals were
sacrificed and the cardiac specimens were collected for the histopathological
examination. Results of the present study revealed that ECG of the negative control
group was within normal rhythm and rate (150.4±5.914) and without any pathological
changes. The same could be considered for the positive control group but with a mild
increase in the heart rate (165.95±8.71). However cilostazol administered group
showed a well manifest sinus tachycardia with the heart rate ranged from 216 to 246
beats /minute (236.5±5.92) with a short P-R and Q-T intervals. Histopathological
changes were within normal for the whole examined animals. In a conclusion oral
administration of cilostazol is able to induce a potent enhancement of heart rate
which is the early manifestation of heart failure.
KEY WORDS:Cilostazol
Ventricular tachycardia.
Cardiac effects
Antiplatelets aggregation aged
Phosphdiasterase inhibitors
peripheral
vascular
insufficiency
particularly intermittent claudication. It
has been demonstrated that cilostazol
has positive chrontropic and dromotropic effects in patients with supraventricular bradyarrhythmia, such as
those with sick sinus syndrome,and in
those patients with atrioventricular
block (Dormandy & Rutherford, 2000).
INTRODUCTION:
Cilostazol
(6-[4-cyclohexyl1H-tetrazol-5-yl) butoxy]-3,4-dihydro2 (1H)-quinolinone) was opproved for
marketing in Japan in 1988, as an
antiplatelet agent to improve peripheral
ischeamic symptoms, such as pain,
cold sensations, and ulcerations that
were caused by chronic arterial occlusive diseases (Okuda et al., 1993).
Cilostazol is an antiplatelet
drug which inhibits platelets aggregation. Cilostazol specifically inhibits
type III phosphdiasterase (PDEIII),
In 1999, cilostazol was
approved by the U.S. Food and Drug
Administration for treatment of
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which is compartmentalized in cardiac
moncytes and vascular smooth vessels.
PDEIII is also found in platelets.
Inhibition of PDEIII causes cascade of
effects including higher tissue levels of
cAMP, local activation of protein
kinase, and ultimately cardiac contractility. The drug is contraindicated,
however in patients with congestive
heart failure (Bristow et al., 2001).
- Crystalline cellulose
- Corn starch
- Carmellose calcium
-Hydroxypropyl
methylcellulose
- Magnesium stearate
2- Benzyl alcohol (15 %):It was obtained from the faculty of
Agriculture in El- Minia University.
3- The anaesthetic drug:Urethane sodium 25% (PDH, London),
marketed as urethane sodium obtained
from laboratory of biology department, Faculty of Sciences, El Minia
University.
Peripheral arterial disease is a
highly prevalent manifestation of
atherosclerosis that is associated with a
substantial risk of illness and death and
a marked reduction in ambulatory
capacity and quality of life. The
severity of peripheral arterial disease is
closely associated with the risk of
myocardil infarction, ischeamic stroke
and death from vascular causes.
Cilostazol improves both pain- free
and maximal tread mill walking
distance and the quality of life
(William & Hiatt, 2001).
B) Animals:A total of 60 adult male guinea
pigs were used in this expermintal
work, obtained commercially weighing
about 400±20 (400-450).Animals were
acclimatized at the constant environmental condition for one week prior
to the experiment.
A) Instruments:1- Orogastric tube
used for
orogastric infusion of the drug
and its solvent.
2- Plastic syringe graded from 0.1:1
ml. used for intraperitoneal
injection of the anaesthetic drug.
3- Electrocardiogram
apparatus
(Fokoda- Japan), using lead II.
Added to the antiplatelet
activity, cilostazol possesses also a
potent vasodilating properties making
the drug as an interesting candidate for
the future clinical trials of delayed
cerebral vasospasm (Birk et al., 2004).
This study was designed to assess the
cardiovascular toxicity of cilostazol.
MATERIALS AND METHODS:
I) Materials:A) Chemicals:1- Cilostazol:It was obtained from Egypt
Otsuka Pharmaceutical Co., S.A.E.,
marketed as Pletaal. It was in a tablet
form each contained 100mg. cilostazol.
The active ingredient was as an
odourless and tasteless white tablets
formed of pale yellow white crystalline
powder, highly soluble in benzyl
alcohol (Cheng, 1999). Each tablet
contained also inactive ingredients
such as:-
II) Methods:
Administration:1- Cilostazol:- According to
Fumio et al., (2000) who gave a human
oral dose equls 100mg. twice daily for
prevention of recurrence of cerebral
infarction, also according to Dawson et
al., (1998) who used the same dose in
human for treatment of peripheral
vascular disorders such as claudication.
The drug was given to animals in a
dose of 6.2mg/animal/day dissolved in
1 ml. benzyl alcohol (15%). Human
dose was transformed into dosage for
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guinea pigs by Paget and Barnes table
(1964).
2- Benzyl alcohol (15%):According to Ettinger et al., (1978)
who used benzyl alcohol as a solvent.
The alcohol was given to animals in a
dose of 1 ml./animal/day.
Route of administration:- orogastric
infusion using orogastric tube. The
experiment ended after 3 months.
3- Urethane sodium (25%):According to Langou et al., (1980)
who anaesthetized guinea pigs using
urethane sodium, animals were
injected intraperitoneally by 1 ml.
urethane sodium to facilitate perfomance of electroca-rdiogram.
The experiment ended after 3
months. All animals were anaesthetized and electrocardiogram was
performed using lead II over a duration
of 3 minutes.
ECG changes were recorded
and the heart rate changes were
submitted to statistical analysis using
Unpaired student t test.
Autopsy and sampling:Animals were sacrified at the
end of the study and the cardiac
specimens were carefully dissected,
then put into a container felt with 10%
formalin for primary fixation over 24
hours duration. Parrafin sections were
prepared, stained with Heamatoxylin
and Eosin stain (H&E) and examined
microscopically for histopathological
evaluation, then photographs were
taken.
Guinea pigs were divided into 3
groups, each contained 20 animals:
* Group (1):- was the negative control
group.
Animals of this group were kept in the
ordinary environmental and allowed to
free access to food and water.
Handling was only during the routine
weekly cage cleaning.
* Group (2):- was the positive control
group.
Animals of this group received benzyl
alcohol (15 %)
* Group (3):- was the drug examined
group.
Animals of this group received cilostazol dissolved in benzyl alcohol.
RESULTS:
I)Electrocardiographic changes:1-Negative control group:As shown in figure (1), ECG record
was of an average rate equals 150
beat/minute, with a regular rhythm,
normal P-R and Q-T intervals, normal
S-T segment and normal P&T waves.
Figure (1): showing ECG record of the negative control group with heart rate = 150
beat/ minute, with regular rhythm, normal P-R and Q-T intervals, normal S-T
segment and normal P& T waves
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2- Positive control group:Administration of benzyl alcohol resulted into a significant acceleration of the
mean heart rate from (150.4±5.914) for the negative control group up to
(165.95±8.71).
Figure (2): Showing ECG record of the positive control group with the minmal
increase in heart rate (168 beat/minute) with regular rhythm, short P-R and QT intervals.
Figure (3): Showing ECG record of the positive control group with the maximal
increase in heart rate (180 beat/ minute) with regular rhythm, short P-R and QT intervals.
3- Cilostazol administered group:Oral administration of cilostazol significantly accelerated the mean heart rate
from (150.4±5.914) for the negative control group up to (236.5±5.92).
As shown in figure (4) ECG record with the minimal increase in heart rate =
225 beat/minute, (a well manifest sinus tachycardia), with short P-R and Q-T
intervals, but still within its regular rhythm.
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___________________________________________________________________________________
Figure (4): Showing ECG record of cilostazol administered group with the minmal
increase in heart rate = 225 beat/ minute with regular rhythm, short P-R and
Q-T intervals.
Figure (5) showing ECG record with the maximal increase in heart rate =236
beat/minute with a well manifest sinus tachycardia, short P-R and Q-T intervals, but
still within its regular rhythm.
Figure (5): Showing ECG record of cilostazol administered group with the maximal
increase in heart rate =236 beat/ minute (a well manifest tachycardia) but still
within regular rhythm , also with a short P-R and Q-T intervals.
Unpaired t test demonstrated that cilostazol could significantly accelerate the
heart rate in comparison to the negative control group (Table-1), and in comparison to
the group received the benzyl alcohol as a solvent (table-2)
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___________________________________________________________________________________
Table (1): Showing the effects of benzyl alcohol and cilostazol on heart rate in
comparison to the negative control group.
Group (1)
Group (2)
Mean ± SD
150.4 ± 5.914
(141-160)
Group (3)
Mean ± SD
P
value
t
value
65.95±8.71
(148-190)
0.000
**
6.627
Mean ± SD
p
value
t
value
236.5±5.92
(216-246)
0.000
**
46.057
Group (1) : The negative control group
Group (2) : The positive control group received benzyl alcohol
Group (3) : The drug administered group
SD = Standard deviation
*P<0.05
**P<0.001
Table (2) : Showing the effects of cilostazol on heart rate in comparison to the
positive control group
Group(2)
Mean ± SD
Group (3)
Mean ± SD
p
value
165.95±8.71
236.5±5.92
29.97
(141-160)
(216-246)
Group (1) : The negative control group
Group (2) : The positive control group received benzyl alcohol
Group (3) : The drug administered group
SD = Standard deviation
*P<0.05
t
Value
0.000
**
**P<0.001
II) Histopathological changes:There were no evidences indicating any pathological changes in the whole
examined cardiac specimens related to the three examined groups.
.
Photomicrograph (1):- Section of a heart showing normal histological structure
of the negative control group H&E X 400
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Photomicrograph (2):- Section of a heart showing normal histological structure
of the positive control group H&E X 400
Photomicrograph (3): Section of a heart showing normal histological structure of
cilostazol administered group H&E X 400
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Also these results are in agreement
with Gamssari et al., (2002) who
described a 92 year old woman with no
apparent predisposing factors and a
recent history of cilostazol use and
suffered several episodes of ventricular
tachycardia, two days after admission
and intake of cilostazol, and when
cilostazol was discontinued the condition subsided.
DISCUSSION:
Peripheral arterial disaese may
be asymptomatic, or may be associated
with critical limb ischaemia. Coronary
artery disease and other atheroscelerotic vascular disorders may coexist
with the peripheral arterial disease.
Modifiable risk factors such as
cessation of cigarette smoking and
control of dyslipideamia, hypertention
and diabetes should be treated.
Antiplatelet drugs especially aspirin,
exercise rehabilitation programs and
cilostazol improve the limb threatening
ischaemia (Aronow, 2005)
Results of the current study
supported the hypothesis described by
Kishida et al., (2001) who said that
cilostazol has beneficial effects in
patients with bradycardic atrial fibrillation. The increased heart rate may be
mediated by improvement of conductivty in the atrioventricular node and
increase of coronary blood supply
caused by dilatation of the vessels. In
such study, cilostazol increased 24hour total heart beat counts from
69.685±1.690 to 87.532±3.123.
Cilostazol is a quinolinone
derivative with antithrombotic, vasodilator, and cardiotonic properties.
Cilostazol causes positive inotropic
and chronotropic effects both directly
and indirectly. Clinical trials have
shown that the antiplatalet agents are
effective in treatment of peripheral
vascular insufficiency. However, oral
administration of cilostazol is accompanied with an equivilant cardiovascular risk (Ciancerelli et al., 2003).
The minimal increase in cardiac
adverse events following administration of cilostazol, could be related to
its phosphdiasterase type-3 inhibitory
activity, a condition which could
explain the results of the study Shintani
et al., (1985), as cilostazol in anaesthetized dogs, increased the the heart
rate,
cardiac
contractile
force,
myocardial oxygen consumption and
also increased the respiratory rste.
And in conscious rats, the drug
inreased the heart rate, while in guinea
pigs, cilostazol produced a very slight
increase in beating rate of the isolated
atrium and a very slight increase in
contraction of the papillary muscle.
Consequently this study was
done to evaluate the cardiovascular
toxicity following 3 months medication
with cilostazol.
The present study revealed a
highly significant sinus tachycardia
from (141-160 beat/minute) up to
(227-246 beat/minute) following intake
of cilostazol in comparison to the
negative control group, a matter
coinciding with Woo et al., (2002) who
detected approximately the maximal
increase in heart rate 13.49% about 6
hours after administration of cilostazol
in a study which was done to correlate
between the peak plasma level of the
drug and its cardiovascular effects in
healthy individuals.
In the study Toyonaga et al.,
(2000), 13 patients with chronic atrial
fibrillattion associated with episodes of
bradycardia, they received 100mg
cilostazol per day. This study resulted
into increased heart rate by an average
of 3.3±0.8 beats/minute weeks after
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onset of cilostazol treatment. In a
conclusion coinciding with the results
of the present study, that cilostazol
improves the slow heart rate episodes
associated with chronic atrial fibrillation and maintains the heart rate
circadian variation and time- domian
variability, indicating that cilostazol
has therapeutic utility for treatment of
slow heart rate associated with atrial
fibrillation.
premature beats, and non sustained
ventricular tachycardia (Toyonaga et
al., 2000).
The
sinus
tachycardia
following cilostazol administration was
also in agreement with (Atrashi et al.,
1998) who examined 20 patients with
variable types of breadyarrhythmias,
and 2 weeks after oral daily administration of cilostazol, the 24- hour total
heart beat count increased from 77.429
± 11.168) to (107.98 ± 3.536),
p<0.001. In a conclusion, cilostazol
had a beneficial positive chronotropic
effect in patients with bradyarrhythmias, especially with bradycardiac
atrial fibrillation and sick sinus
syndrome.
The positive
chronotropic
effects of cilostazol were in accordance
with Kodama et al., (2003) who
reported a significant increased mean ±
standard error of the mean of total 24
hour QRS count from 57.300±2.8
to74.4±3.2 (p=0.001), and they concluded also that cilostazol significantly
increased the ventricular escape rate,
and recommend usage of the drug
safely to selected patients with third
degree atrio-ventricular block over a
short term therapy.
Results are coinciding with the
data from more than 2000 patients who
were followed up to six months were
presented to the FDA, death from
cardiovascular causes occurred in 0.6%
of cilostazol treated patients and 0.5%
of placebo treated patients. Myocardial
infarction occurred in 1.5% of
cilosatzol treated patients and 1.1% of
placebo- treated patients (Dawson et
al., 1998).
The accelerated heart rate
following cilostazol administration was
in the same line of what had been
mentioned by (Cheng,1999), and
(Cone et al., 1999) in that cilostazol is
contraindicated in patients with severe
heart failure because of the determintal
effects demonstrated by other agents in
the same class.
CONCLUSION:
Cilostazol possesses a propable
risk of ventricular tachyarrhythmia,
aggravation of congestive heart failure
which might alter the risk- to- benefit
ratio in certain patients.
The ability of cilostazol to
increase levels of cAMP could
predipose patients to ventricular arrhythmias.
RECCOMENDATIONS:
Heart rate variability is an
important predictor of mortality in
patients with heart disease. Based on
this fact, it is recommended when
cilostazol is a must, to put such
patients carefully under monitoring for
any anginal signs or symptoms (e.g.
chest pain) since treatment with
cilostazol may potentiate the heart rate
Similarly, in animal studies,
cilostazol increased heart rate, myocardial contractile force, ventricular
automaticity, and ventricular conduction (Approval of New Drug
Application for Pletal, 1999). In human
beings, its use has been associated with
increased mean heart arte, conductivity
in the atrioventricular node, ventricular
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up to the degree of aggravating the
symptoms angina pectoris.
5. Bristow M.R.; Port J.D., and
Kelly R.A. (2001): Treatment of heart
failure: pharmacological methods.In:
(Heart Disaease a Textbook of Cariovascular Medicine) 6th. Edition, edited
by : Braunwold E.; Zipes D.P, and
Lippy P. Philadelphia : W.B. Saunders:
562-599.
6. Cheng J.W. (1999): Cilostazol.
Heart Dis., 1(3):182-186.
7. Ciancerelli I.T.; Ciancerelli
M.G.; Massimo C.; Marini C., and
Carolei A. (2003): Urinary nitric oxide
metabolites and lipid peroxidation byproducts in migraine. Cephalalgia,
23:39-42.
8. Dawson D.L.; Culter B.S.;
Meissner M.H., and Standness D.E.
(1998): Cilostazol has beneficial
effects in treatment of intermittent
claudication: results from a multicenter,
randomized,
prospective,
double-blind trial. Circulation, 98: 678686.
9. Dibianco R.; Shabetai R.;
Kostuk W., and Moran J. (1989): A
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N. Engl. J. Med., 320:677-683.
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R.B. (2000): Management of peripheral disease (PAD). J. Vasc.
Surg.,31: S1-S296.
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12. Fumio G.; Hideo T.; Shunsaku
H.; Akirot., and Yasuo F. (2000):
Cilostazol stroke prevention study: A
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Trial for secondary Prevention of
Cerebral Infarction. Journal of Stroke
and Cerebrovascular Disease, 9(4):
147:157.
13. Gamssari F.; Mohamed H.;
John H.; Rollo P.V., and Brant L.
(2002): Rapid ventricular tachycardias
If any evidences of adverse
reactions such as severe tachycardia
are observed during cilostazol therapy,
the drug should be discontinued
immediately and the appropriate
corrective measures are taken, such as
dosage reduction.
Patients with a pre-existing
heart disease such as the congestive
heart failure, rheumatic, or ischeamic
heart, should not receive the drug as
the condition may be worsened.
Much more studies are needed
to determine exactly which populations
might be affected and being at a higher
risk.The long term chronotropic effect
of cilostazol on human, need to be
evaluated.
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W.S.
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‫التأثيرات القلبية لعقار السيلوستازول المثبط االختيارى‬
‫إلنزيم الفوسفودياستيراز‪3-‬‬
‫"دراسة تجريبية"‬
‫محمود سامي زكريا ‪ -‬منال عبد العزيز عبد الظاهر‬
‫قسم الطب الشرعي و السموم اإلكلينيكية‬
‫كلية الطب –جامعة المنيا‬
‫آل ت ر‬
‫أجريتته هتتلد اسةراتتتي ساآليتتيا الب ت ر استتتلبيي ل ت اسآلل ت واسن اجتتي تتت اتتتاقا‬
‫استيلوتا زو ‪ 0‬وقة اشااله اسةراتي ل ةة ‪ 60‬خنزير غينت لرتر ويتزت لتواس ‪400‬جتا‬
‫واا اآلتيا هلد اسليوان ه إس بالبي اجاو ه بليث ر نه ر اجاو ي ااروت ات ‪ 20‬خنزير‪0‬‬
‫واا إ ط ء اسقآل ر سليوان ه اساج ر بصورة اناظاي يوايت تت طريتل اسوتا وبواتتطي األنبوبتي‬
‫اساقةيي ولسك ساةة بالبي أشهر وبجر ه اا بلي سلجر ه اسقالجيي اساتاخةاي‪0‬‬
‫ور نتتته اساجاو تتتي األوستتت هتتت اساجاو تتتي اساتتت بطي استتتت سبي واساجاو تتتي اسب نيتتتي اتتتا‬
‫إ ط ؤه آل ر استيلوتا زو بجر ي ‪ 6.2‬الجا سر ليوات اج ر يواي والابه ف ‪ 1‬ال ات‬
‫اسرلو اسبنزيل بارريز ‪ 0%15‬أا اساجاو ي اسب سبي فر نه اساجاو ي اسا بطي اساوجبي ليتث‬
‫اا إ ط ؤه ‪ 1‬ال ات اسرلو اسبنزيل واساتاخةا رالي سلقآل ر است بل‪0‬‬
‫وبقة نه يي اساجربي اا اخةير ر اسخن زير اساتاخةاي ف اسبلث ت طريل لآلت ‪ 1‬ال‬
‫ات اخةر اسيوريب ت صوةيوا بارريز ‪ %25‬ولسك ات خال اسلآلت بت ساجوي اسبرياتون بتا اتا‬
‫ا رتا قل سر ليوات ساةة بالبي ةق ئل‪0‬‬
‫وف نه يي اساجربي اا لبح اسليوان ه واا اجايع ين ه اسآلل سلةراتي اسب بوسوجيي‪0‬‬
‫وقة أتوره نا ئج اسبلث ت أت هن ك زي ةة اطرةد وواالي ف تر ي ارب ه اسآلل‬
‫نايجي ان و آل ر استيلوتتا زو بليتث أصتبله ااتراود اقتة اترب ه اسآللت ات بتيت ‪: 216‬‬
‫‪ 246‬سر ةقيآلي اآل رني ب ساقة اسطبيق ‪ 165 : 150‬وهو سر ةقيآلي وه ظت هرة أوسيتي سهبتوط‬
‫اسآلل االلاآل ن ‪0‬‬
‫وات هلا اسبلث نتاخلص أت آل ر استيلوتا زو ق ةرا ل أت يلةث زيت ةة فق سته فت‬
‫ارب ه اسآلل قة اؤةى إس لةوث هبوط بقالي اسآلل ‪0‬‬
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