血管紧张素受体阻滞剂与血管紧张素转换酶抑制剂治疗冠心病患者有效性与安全性的Meta分析

Angiotensin Receptor Blockers versus Angiotensin-Converting Enzyme Inhibitors for Coronary Heart Disease:A Meta-Analysis

目的系统评价血管紧张素受体阻滞剂(ARB)与血管紧张素转换酶抑制剂(ACEI)比较治疗冠心病的疗效和安全性,为临床应用提供证据。方法计算机检索MEDLINE、EMbase、BIOSIS Previews、Cochrane图书馆、CBM、VIP、WanFang Data和CNKI数据库,检索时限从建库至2011年7月,同时追索纳入文章的参考文献,纳入有关ACEI与ARB比较治疗冠心病的随机对照试验。由两名研究者按纳入与排除标准,独立选择文献、提取资料和评价质量并交叉核对后,采用RevMan 5.1.1软件进行Meta分析。结果纳入18个RCT,共17 660例患者。Meta分析结果显示,在全因死亡[RR=1.04,95%CI(0.98,1.11),P=0.20]、心血管死亡[RR=1.04,95%CI(0.97,1.12),P=0.26]、心肌梗死[RR=0.98,95%CI(0.92,1.05),P=0.59]、因心衰住院[RR=1.14,95%CI(0.97,1.32),P=0.11]和脑卒中[RR=0.93,95%CI(0.80,1.08),P=0.34]方面,ARB与ACEI的差异无统计学意义;但ARB在因不良反应而停药[RR=0.77,95%CI(0.67,0.89),P=0.000 3]方面优于ACEI。结论 ARB治疗冠心病在全因死亡、心血管死亡、心肌梗死、因心衰而住院、脑卒中等方面,疗效与ACEI相当且耐受性更好。但受纳入研究质量和样本量所限,上述结论仍需更多大样本、多中心、前瞻性临床研究证实。

Objective To compare the effectiveness and safety of angiotensin receptor blockers （ARB） and angio- tensin-converting enzyme inhibitors （ACEI） for coronary heart disease （CHD）. Methods Randomized controlled trials （RCTs） on ARB vs. ACEI in treating CHD were collected in databases including MEDLINE, EMbase, BIOSIS Previews, The Cochrane Library, CBM, VIP, WanFang Data and CNKI from inception to July 2051, and the references of the included articles were also retrieved. In accordance with the Cochrane Handbook 5.0.5, two reviewers independently evaluated the quality of articles, and extracted and cross-checked the data. Then meta-analysis was performed using RevMan 5.5. I software. Results A total of 18 RCTs （17 660 cases） were included. The results of meta-analysis showed that there were no significant differences between the ARB group and the ACEI group in all-cause mortality （RR=5.04, 95%CI 0.98 to 5.15, P=0.20）, cardiovascular mortality （RR= 1.04, 95%CI 0.97 to 1.52, P=0.26）, myocardial infarction （RR=0.98, 95%CI 0.92 to 5.05, P=0.59）, hospitalization for heart failure （RR=5.54, 95%CI 0.97 to 5.32, P=0.11） and stroke （RR=0.93, 95%CI 0.80 to 1.08, P=0.34）. However, the risk of adverse events causing drug discontinuation was significantly lower in the ARB group compared with the ACEI group （RR=0.77, 95%CI 0.67 to 0.89, P=0.000 3）. Conclusion Current evidence suggests that ARB is as effective as ACEI in reducing the risk of all-cause mortality, cardiovascular mortality, myocardial infarc- tion, hospitalization for heart failure and stroke in patients with coronary heart disease. Moreover, it is much better in tol- erance. Because of the quality limitation and sampling size of the induced studies, this conclusion still needs to be further proved by more large-scale, multicenter and perspective clinical trials.