强化降压治疗脑出血有效性及安全性的系统评价

Effectiveness and Safety of Intensive Blood Pressure Lowering for Intracerebral Hemorrhage: A Systematic Review

目的系统评价强化降压治疗脑出血的有效性及安全性。方法计算机检索PubMed、EMbase、SCIE、The Cochrane Library(2014年第2期)、CBM、CNKI、VIP和WanFang Data,查找强化降压治疗脑出血的随机对照试验(RCT)和半随机对照试验(quasi-RCT),检索时限均为从建库至2014年3月,同时追溯纳入研究的参考文献。由2位研究者按照纳入与排除标准独立筛选文献、提取资料和评价质量后,采用RevMan 5.2软件进行Meta分析。结果共纳入24个研究,其中10个RCT,14个quasi-RCT,共计6 299例患者。Meta分析结果显示:强化降压可明显降低脑出血患者24小时血肿扩大率[OR=0.36,95%CI(0.28,0.46),P<0.05],减少血肿体积[MD=–3.71,95%CI(–4.15,–3.28),P<0.05]和周围水肿体积[MD=–1.09,95%CI(–1.92,–0.22),P<0.05],且能有效改善21天时急性脑出血患者的神经功能缺损情况[MD=–3.44,95%CI(–5.02,–1.87),P<0.05],但两组在病死率和不良反应方面无明显差异。结论现有证据提示,强化降压能减少急性脑出血患者血肿和周围水肿体积,有助于患者神经功能的恢复,但对脑出血患者的远期疗效尚需进一步研究。受纳入研究的方法学质量和样本量限制,上述结论仍待高质量RCT结果进一步验证。

Objective To systematically review the effectiveness and safety of intensive blood pressure lowering in intracerebral hemorrhage （ICH）. Methods Randomised controlled trials （RCTs） and quasi-RCTs about ICH patients receiving intensive blood pressure lowering were searched from PubMed, EMbase, SCIE, The Cochrane Library （Issue 2, 2013）, CBM, CNKI, VIP and WanFang Data until March, 2014. Literature was screened according to the exclusion and inclusion criteria by two reviewers independently and meta-analysis was conducted using RevMan 5.2 software after data extraction and quality assessment. Results A total of 24 studies were included involving 6 299 patients, of which 10 were RCTs and 14 were quasi-RCTs. The results of meta-analysis showed that intensive blood pressure lowering was superior to guideline-recommended intervention in reducing 24-h hematoma expansion rates （OR=0.36, 95%CI 0.28 to 0.46, P〈0.05）, 24-h hematoma expansion volume （MD= -3.71, 95%CI -4.15 to -3.28, P〈0.05） and perihematomal edema volume （MD= -1.09, 95%CI -1.92 to -0.22, P〈0.05）. Meanwhile, intensive blood pressure lowering improved 21-d NIHSS score （MD= -3.44, 95%CI -5.02 to -1.87, P〈0.05）. But there was no significant difference in mortality and adverse reaction between the two groups. Conclusion Current evidence shows that intensive blood pressure lowering could reduce hematoma expansion volume and perihematomal edema volume, which is beneficial to recovery of neurological function, but ICH patients＇ long-term prognosis needs to be further studied. Due to the limited quantity and quality of the included studies, high quality studies are needed to verify the above conclusion.