肢体缺血预处理对择期冠脉支架置入术中患者心脏保护作用的Meta分析

Remote ischemic preconditioning in elective percutaneous coronary intervention: a meta-analysis

目的系统评价肢体缺血预处理减轻择期冠脉支架置入(PCI)患者心脏缺血-再灌注损伤的价值。方法计算机检索Pub Med、EMbase、The Cochrane Library(2015年6期)、Wan Fang Data、CBM和CNKI数据库,查找PCI术前采用肢体缺血预处理的随机对照试验(RCT),检索时限均从建库至2015年6月。由2位评价员按纳入与排除标准独立筛选文献、提取数据并评价纳入研究的偏倚风险后,采用Rev Man 5.3软件进行Meta分析。结果共纳入9个RCT,包括1 099例患者。Meta分析结果显示:肢体缺血预处理组肌钙蛋白I/T水平与对照组差异无统计学意义[SMD=–0.24,95%CI(–0.63,0.16),P=0.24],对应用3×5/5分钟方案的研究进行敏感性分析,也显示肢体缺血预处理组的肌钙蛋白水平与对照组差异无统计学意义[SMD=–0.16,95%CI(–0.36,0.04),P=0.12]。另外,与对照组比较,肢体缺血预处理组PCI后心肌梗死的发生率[RD=–0.14,95%CI(–0.20,–0.08),P<0.000 01]和PCI过程中S-T段升高的发生率[RD=–0.17,95%CI(–0.26,–0.07),P=0.000 6]明显降低,但PCI术后肌酐清除率未见明显降低[SMD=–0.03,95%CI(–0.18,0.12),P=0.71]。结论肢体缺血预处理可以降低择期PCI术后心肌梗死的发生率以及PCI过程中的S-T段升高的发生率。受纳入研究数量和质量限制,上述结论仍需开展更多高质量的RCT加以验证。

Objective To systematically evaluate the clinical value of remote ischemic preconditioning （RIPC） in elective percutaneous coronary intervention （EPCI）. Methods We electronically searched databases including PubMed, EMbase, The Cochrane Library （Issue 6, 2015）, WanFang Data, CBM and CNKI from inception to June 2016, to collect randomized controlled trials （RCTs） about RIPC in EPCI. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed using RevMan 5.3 software. Results Nine RCTs involving 1 099 patients were included. The results of meta-analysis showed that： There were no significant difference in the level of troponin I and T between the RIPC group and the control group （SMD=-0.24, 95%CI -0.63 to 0.16, P=0.24）. Sensitive analysis showed that with 3×5-min remote preconditioning protocol, there was still no significant difference in the level of troponin I and T between the two groups （SMD=-0.16, 95%CI -0.36 to 0.04, P=0.12）. Another, RIPC could significantly reduce the incidence of peri-procedural myocardial infarctions （RD=-0.14, 95%CI -0.20 to -0.08, P〈0.000 01） and the risk of ST-segment deviation in the elective PCI procedure （RD=-0.17, 95%CI -0.26 to -0.07, P=-0.000 6）, but there was no significant difference in postoperative eGFR between both groups （SMD=-0.03, 95%CI -0.18 to 0.12, P=0.71）. Conclusion RIPC can significant reduce the incidence of peri-procedural myocardial infarctions, and the risk of ST-segment deviation in the elective PCI procedure. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify the above conclusion.