普拉格雷和替格瑞洛治疗急性冠脉综合征的Meta分析

Prasugrel and Ticagrelor for Acute Coronary Syndrome: A Meta-Analysis

目的系统评价新型血小板P2Y12受体抑制剂普拉格雷和替格瑞洛治疗急性冠脉综合征（acute coronary syndrome，ACS）的疗效及安全性。方法计算机检索PubMed（1980～2013．7）、EMbase（1980—2013．5）、TheCochraneLibrary（2013年第7期）、CBM（1990～2013．7）、CNKI（1994～2013．7）、VIP（1989～2013．7）和WanFangData（1980～2013．7），收集普拉格雷或替格瑞洛对比氯吡格雷治疗ACS的随机对照试验（RCT）。由2位评价员按纳入与排除标准独芷筛选文献、提取资料和评价纳入研究的方法学质量后，采用RevMan5．2软件进行Meta分析。结果最终纳人5个RCT，共43452例ACS患者。Meta分析结果显示：与接受标准氯吡格雷治疗相比，新型血小板P2Y12受体抑制剂可有效降低心肌梗死[OR=0．83，95％CI（0．77，0．89），P〈0．00001]、心血管源性死亡[OR=0．86，95％CI（0．78，0．94），P=0．002]和支架内血栓形成[OR=0．61，95％CI（0．38，0．97），P=0．04]的发生率，但不降低卒中[OR=I．06，95％CI（O．88，1．26），P=0．543、颅内出血[OR=I．18，95％CI（0．81，1．71），P=0．39]和心肌梗死溶栓后大出血[OR=I．17，95％CI（0．94，1．47），P=0．16]的发生率。结论新型血小板P2Y12受体抑制剂治疗ACS可有效降低心肌梗死、心血管源性死亡和支架内血栓形成事件的发生率，但与氯吡格雷相比，P2Y12受体抑制剂并不能改善患者卒中和颅内出血的临床结局。此外，新型血小板P2Y。：受体抑制剂显著增加了非CABG相关的出血性并发症的发生率，对高危人群的用药仍需慎重。

Objective To systematically review the therapeutic effects and safety of new platelet inhibition regimens targeting P2Y12-receptors （prasugrel/ticagrelor） in patients with acute coronary syndrome （ACS）. Methods Such data- bases as PubMed （1980 to 2013.7）, EMbase （1980 to 2013.5）, The Cochrane Library （Issue 7, 2013）, CBM （1990 to 2013.7）, CNKI （1994 to 2013.7）, VIP （1989 to 2013.7） and WanFang Data （1980 to 2013.7） were electronically searched to collect the randomized controlled trials （RCTs） about comparing prasugrel/ticagrelor with clopidogrel in treating patients with ACS. Two reviewers screened literature according to the inclusion and exclusion criteria, extracted data, and assessed the methodological quality of the included studies. Then meta-analysis was performed using RevMan 5.2 software. Re- suits Five studies involving 43 452 patients were finally included. The results of meta-analysis showed that： compared with standard clopidogrel, prasugrel/ticagrelor reduced the incidences of myocardial infarction （OR=0.83, 95%CI 0.77 to 0.89, P〈0.000 01）, cardiovascular death （OR=0.86, 95%CI 0.78 to 0.94, P=0.002）, and stent thrombosis （OR=0.61, 95%CI 0.38 to 0.97, P=0.04）; while no advantage was found in reducing the incidences of stroke （OR=1.06, 95%CI 0.88 to 1.26, P=0.54）, intracranial hemorrhage （OR=1.18, 95%CI 0.81 to 1.71, P=0.39）, and severe bleeding after thrombolysis due to myocardial infarction （OR=1.17, 95%CI 0.94 to 1.47, P=0.16）. Conclusion New platelet inhibition regimens targeting P2Y12-receptors for ACS could effectively decrease the incidences of myocardial infarction, cardiovascular death, and stent thrombosis events. However, compared with clopidogrel, it could not improve the clinical outcomes of patients with stroke and intracranial hemorrhage. Additionally, due to the increased risk of non-CABG related bleeding, more attention should be paid to the application of new platelet inhibition regimens.