合并多支血管病变的ST段抬高型心肌梗死血运重建策略的Meta分析

Meta-analysis of revascularization strategy in st-segment elevation myocardial infarction with multiple vessel disease

目的合并多支冠状动脉血管病变(MVD)的ST段抬高型心肌梗死(STEMI)患者目前最佳的血运重建策略仍存在争议。因此,本研究对不同的血运重建策略进行系统评价。方法计算机检索PubMed、EMbase、Cochrane library、Web of Science、CNKI和CBM,灰色数据库Opengrey和ProQuest(检索年限均从建库至2018年10月)中合并MVD的STEMI患者的不同血运重建策略的随机对照试验(RCT)研究。包括早期完全血运重建(CR)策略和直接经皮冠状动脉介入术(PCI)时仅处理梗死相关血管(IR)策略。分析的结局指标包括:死亡率、主要心血管不良事件(MACE)、再发心肌梗死发生率、再次血运重建率。结果纳入7项RCT研究,共1908例患者。早期CR组与IR组比较,两组死亡率无统计学差异(OR=0.75,95%CI:0.50~1.13;P=0.17);早期CR组与IR组比较,两组再次血运重建率(OR=0.30,95%CI:0.23~0.40;P<0.01);再次心肌梗死率(OR=0.53,95%CI:0.35~0.79;P<0.01)及MACE发生率有统计学差异(OR=0.36,95%CI:0.29~0.46;P<0.01)。结论STEMI患者中早期完全血运重建相比仅处理梗死相关血管组,死亡率无明显差异,但再次血运重建率、再发心肌梗死发生率及MACE发生率明显降低。

Objective The optimal strategy for revascularization in ST-segment elevation myocardial infarction(STEMI)patients with multiple vessel disease(MVD)remains controversial.This study systematically evaluates different strategies of revascularization.Method Randomized controlled trials(RCT)of different revascularization strategies for STEMI patients with MVD were retrieved by computer from PubMed,EMbase,Cochrane Library,Web of Science,CNKI and CBM,and the grey database Opengrey and ProQuest(The search time ranges from the date of database construction to October,2018).It includes the early complete revascularization(Complete revascularization,CR)strageties and the strageties of only dealing with the infarction-related vessels at the primary percutaneous coronary intervention(PCI)(incomplete revascularization;IR).The outcome indicators of analysis include the mortality,major adverse cardiovascular events(MACE),incidence of recurrent myocardial infarction and revascularization.Result Seven RCT studies involving 1908 patients were included.There was no significant difference in mortality between early CR group and IR group(OR=0.75,95%CI:0.50~1.13,P=0.17)when the early CR group is compared with the IR group.There were statistical differences in the rate of revascularization(OR=0.30,95%CI:0.23~0.40,P<0.01);the recurrent myocardial infarction rate(OR=0.53,95%CI:0.35~0.79,P<0.01)and the incidence of MACE(OR=0.36,95%CI:0.29~0.46,P<0.01).Conclusion Compared with the group treated with only infarct-related blood vessels,the mortality rate was not significantly different in STEMI patients in the early and complete revascularization,but the revascularization rate,the incidence of recurrent myocardial infarction,and the incidence of MACE were significantly reduced.