非ST段抬高急性冠脉综合征介入治疗的系统评价

Benefit of Early Invasive Therapy in Unstable Angina and Non-ST-Elevation Myocardial Infarction:A Systematic Review

目的系统评价早期介入治疗对非ST段抬高急性冠脉综合征的有效性和安全性。方法计算机检索Cochrane图书馆(2009年第4期)、MEDLINE(1966～2009.9)、EMbase(1974～2009.9)、中国生物医学文献数据库(1989～2009.9)、中国期刊全文数据库(1997～2009.9)和万方数据库(1989～2009.9),收集介入治疗非ST段抬高急性冠脉综合征的随机对照试验,由两名评价员按照纳入与排除标准选择文献、评价质量和提取资料,对符合纳入标准的研究用RevMan 5.0软件进Meta分析。结果共纳入7个随机对照试验,11394例患者。Meta分析结果显示:与保守治疗相比,早期介入治疗能降低非ST段抬高急性冠脉综合征6个月时的全因病死率[RR=0.75,95%CI(0.61,0.92),P=0.007];随访1年时,这种优势有下降趋势[RR=0.88,95%CI(0.65,1.18),P=0.38];早期介入治疗能降低6个月时致死性或非致死性心梗发生率[RR=0.74,95%CI(0.63,0.87),P=0.0003];早期介入治疗能显著降低因心绞痛再入院率[RR=0.66,95%CI(0.61,0.73),P<0.00001];6个月时出血发生率早期介入组较高[RR=1.28,95%CI(0.91,1.80),P=0.15],但差异无统计学意义,随访1年时早期介入组出血发生率高[RR=2.22,95%CI(1.55,3.17),P<0.0001];早期介入组与保守治疗组相比,发生介入相关的心肌梗死发生率更高[RR=2.07,95%CI(1.57,2.72),P<0.00001];肌钙蛋白阳性组早期介入治疗的联合终点事件发生率明显降低[RR=0.60,95%CI(0.43,0.82),P=0.002]。结论早期介入治疗能降低非ST段抬高急性冠脉综合征的全因病死率、心梗发生率和因心绞痛再入院率,肌钙蛋白阳性患者更能从早期介入治疗中获益。早期介入治疗发生出血和介入相关的心肌梗死等并发症的风险也比保守治疗要高,故临床决策时应充分权衡利弊。

Objective To determine the bene ts of an invasive compared to a conservative strategy for treating un-stable anguba（UA）/ non-ST-elevation myocardial infarction（NSTEMI）.Methods We searched The Cochrane Library（Issue 4,2009）,MEDLINE（1996 to September 2009）,EMbase（1974 to September 2009）,CBM（1989 to 2009）,CNKI（1997 to 2009）,and VIP（1989 to 2009）.The quality of the included studies was critically evaluated.Data analyses were performed using the Cochrane Collaborationˉs RevMan 5.0 software.Results Seven randomized controlled trials involv-ing 11394 patients met the inclusion criteria.The results meta-analyses showed the incidence of all-cause mortality at six months follow-up was lower in the early invasive group compared with the conservative group（RR=0.75,95%CI 0.61 to 0.92,P=0.007）;the relative risk of myocardial infarction was signi cantly decreased in the early invasive group（RR=0.74,95%CI 0.63 to 0.87）;there was a reduction in rehospitalization for unstable angina in the invasive group（RR=0.66,95%CI 0.61 to 0.73,P0.00001）;the invasive strategy was associated with a two-fold increase in the relative risk of PCI-related myocardial infarction（as variably defined）.There was not a signi cant increase in bleeding by an invasive strategy at six months follow-up,but,a routine invasive strategy was associated with a signi cantly higher bleeding rate at 1-year follow-up（RR=2.22,95%CI 1.55 to 3.17,P0.0001）.Patients with elevated cardiac biomarker levels at baseline bene ted more from routine intervention,with no signi cant benefit observed in patients with negative baseline marker levels.Con-clusion An early invasive strategy is preferable to a conservative strategy in the treatment of UA/NSTEMI,especially higher-risk patients with elevated cardiac biomarker benefit more from invasive strategy.In addition,complications such as procedure-MI and bleeding must be paid great attention to.