两种倾斜试验诊断血管迷走性晕厥的Meta分析

A Meta-analysis on diagnosis of vasovagal syncope with two kinds of tilt table tests

目的系统评价硝酸甘油舌下含服倾斜试验(NUTT)和异丙肾上腺素静滴倾斜试验(IUTT)诊断血管迷走性晕厥的敏感性、特异性及安全性。方法计算机检索PubMed、CENTRAL、EMbase、the ISI Web of Knowledge databases、VIP、CNKI、CBM和WANFANG数据库中关于硝酸甘油舌下含服倾斜试验(NUTT)和异丙肾上腺素静滴倾斜试验(IUTT)诊断血管迷走性晕厥患者的的随机对照实验(RCT),检索时限均为建库至2012年10月。同时手检纳入文献的参考文献。按纳入排除标准由两人独立进行RCT的筛选、资料提取和质量评价后,采用RevMan5.1及Meta-Disc1.4软件进行Meta分析。结果共纳入10篇RCTs,晕厥患者1054例。Meta分析结果示:NUTT诊断血管迷走性晕厥的真阳性(OR=1.16,95%CI:0.90～1.50,P=0.24)、真阴性(OR=1.50,95%CI:0.74～3.03,P=0.26)以及诱发晕厥所需时间(SWD=-0.30,95%CI:-0.78～0.18,P=0.22)与IUTT相似,但可明显降低不良事件发生率(OR=0.31,95%CI:0.18～0.54,P<0.001);NUTT与IUTT的灵敏度分别为0.64(95%CI:0.59～0.69)和0.59(95%CI:0.54～0.64);特异度分别为0.88(95%CI:0.81～0.93)和0.83(95%CI:0.76～0.89);曲线下面积分别为0.84和0.82;SE分别为0.05和0.05。结论 NUTT诊断血管迷走性晕厥的灵敏度、特异度、诱发晕厥所需时间与IUTT相当,但可明显降低试验过程中的不良事件发生率。因本研究纳入的原始文献质量偏低,影响研究结果的论证强度,有待开展更多设计合理、执行严格、多中心大样本的高质量RCT,以求进一步验证NUTT与IUTT诊断血管迷走性晕厥的优劣。

Objective To review systematically the sensibility, specificity and safety of sublingual nitroglycerin provocation head-up tilt table test （ NUTT ） and isoproterenol provocation head-up tilt table test （ IUTT ） in the diagnosis of vasovagal syncope （ VVS ） . Methods The databases of PubMed, Cochrane Central Register of Controlled Trials （ CENTRAL ） , Embase, ISI Web of Knowledge, VIP Database, CNKI, CBM and WanFang Database were retrieved with computer for collecting randomized controlled trials （ RCT ） about NUTT and IUTT in the diagnosis of VVS from the time of database establishment to Oct. 2012. At the same time, the reference materials of included literature were retrieved manually. All data was selected, extracted and given quality evaluation by two independent reviewers according to inclusion and exclusion criterions, and then a Metaanalysis was conducted by using RevMan 5.1 and Meta-Discl.4. Results There were totally 10 RCT included involving 1054 VVS patients. The resuhs of Meta-analysis showed that the true positive （ OR=1.16, 95%CI： 0.90-1.50, P=0.24 ） , true negative （ OR=1.50, 95%CI： 0.74-3.03, P=0.26 ） and required time of inducing VVS （ SWD=-0.30, 95%CI： -0.78-0.18, P=0.22 ） of NUTT in the diagnosis of VVS were similar to those of IUTY, while NUTT decreased significantly the incidence of adverse events （ OR=0.31, 95%CI： 0.18-0.54, P〈0.001）. The sensibility of NUTT and IUTT was, respectively, 0.64 （ 95%CI： 0.59-0.69 ） and 0.59 （ 95%CI： 0.54-0.64 ） , specificity, 0.88 （ 95%CI： 0.81-0.93 ） and 0.83 （ 95%CI： 0.76-0.89 ） , AUC, 0.84 and 0.82, and SE, 0.05 and 0.05. Conclusion The sensibility, specificity and required time of inducing VVS of NUTT are similar to those of IUTT in the diagnosis of VVS, but NUTT can significantly decrease the incidence of adverse events. As the quality of enclosed literature is lower, more reasonable, rigorous, multiple-center and large-sample RCT with higher quality are required for further reviewing the features of NUTT and IUTT in the diagnosis of VVS.