替罗非班与依替巴肽在急性冠脉综合征患者经皮冠状动脉介入治疗中应用效果比较的Meta分析

Comparative Effectiveness of Tirofiban and Eptifibatide in the Treatment of Patients with Acute Coronary Syndrome Underwent Percutaneous Coronary Intervention:a Meta-analysis

背景糖蛋白Ⅱb/Ⅲa受体抑制(GPIs)已被证实在经皮冠状动脉介入治疗(PCI)中可有效抑制血小板聚集、防止血栓并发症、增强心肌早期再灌注,但目前尚缺乏相关研究明确替罗非班与依替巴肽治疗急性冠脉综合征(ACS)的差异。目的比较替罗非班与依替巴肽在ACS患者PCI中应用的有效性及安全性。方法计算机检索PubMed、Web of Science、the Cochrane Library、Ovid、中国知网、万方数据知识服务平台、中国生物医学文献数据库,检索时限为建库至2020年3月。筛选替罗非班与依替巴肽在ACS患者PCI中应用的随机对照试验(RCT)文献,干预措施为试验组给予替罗非班、对照组给予依替巴肽。采用RevMan 5.3统计学软件进行Meta分析,比较两组患者PCI后心肌梗死溶栓试验(TIMI)血流分级、校正的TIMI帧数(CTFC)、TIMI心肌灌注(TMPG)分级、左心室射血分数(LVEF)、血小板聚集抑制率、出血、血小板减少症、主要不良心血管事件(MACE)发生情况。结果最终纳入10篇文献,包含1327例患者。Meta分析结果显示,试验组患者PCI后TIMI血流分级0~2级发生率〔RR=1.08,95%CI(1.01,1.16)〕、CTFC〔MD=-1.08,95%CI(-2.14,-0.02)〕及PCI后18~24 h血小板聚集抑制率〔MD=-2.78,95%CI(-3.94,-1.63)〕低于对照组,TIMI血流分级3级发生率〔RR=0.57,95%CI(0.34,0.94)〕高于对照组(P<0.05)。两组患者PCI后TMPG分级〔TMPG 0~2级:RR=1.15,95%CI(0.95,1.39);TMPG 3级:RR=0.64,95%CI(0.37,1.11)〕、LVEF〔MD=0.60,95%CI(-0.86,2.06)〕、PCI后1 h内血小板聚集抑制率〔MD=-0.31,95%CI(-5.07,4.45)〕、PCI后6~8 h血小板聚集抑制率〔MD=-2.26,95%CI(-20.35,15.82)〕、出血发生率〔轻度出血:RR=0.97,95%CI(0.93,1.02);大出血:RR=1.00,95%CI(0.98,1.01)〕、血小板减少症发生率〔轻度:RR=1.00,95%CI(0.97,1.03);重度:RR=1.01,95%CI(0.98,1.03)〕、MACE发生率〔RR=0.99,95%CI(0.95,1.03)〕比较,差异无统计学意义(P>0.05)。绘制报道出血文献发表偏倚的倒漏斗图发现,分布于直线两侧的散点不对称,提示可能存在发表偏倚。结论与依替巴肽相比,替罗非班可使ACS患者PCI后获得较好的冠状动脉充盈,在改善心肌微循环灌注、心功能、术后8 h内血小板聚集抑制率及安全性方面并无差异。

Background GlycoproteinⅡb/Ⅲa inhibitors(GPIs)have been shown to be effective in inhibiting platelet aggregation,preventing thrombotic complications,and improving myocardial early reperfusion during percutaneous coronary intervention(PCI).However,there is no definitive conclusion to indicate the difference between tirofiban and eptifibatide in the treatment of acute coronary syndrome(ACS).Objective To compare the efficacy and safety of tirofiban and eptifibatide on patients with ACS underwent PCI.Methods PubMed,Web of Science,the Cochrane Library,Ovid,CNKI,Wanfang Data,and China Biomedical Literature Database(CBM)were searched online for randomized controlled trials(RCTs)comparing tirofiban and eptifibatide in patients with ACS undergoing PCI,the retrieval period is from the establishment of the databases to March 2020.The intervention measures were tirofiban in the experimental group and eptifibatide in the control group.The meta-analysis was performed using Rev Man 5.3 statistical software.The outcomes included thrombolysis in myocardial infarction(TIMI),corrected TIMI Frame Count(CTFC),TIMI myocardial perfusion grade(TMPG),left ventricular ejection fraction(LVEF),inhibition of platelet aggregation,bleeding complications,incidence of thrombocytopenia and major adverse cardiac events(MACE)after PCI.Results A total of 10 studies involving 1327 patients were included.The results of Meta-analysis showed that compared with those in control group,patients in experimental group had lower incidence of TIMI flow grade 0-2〔RR=1.08,95%CI(1.01,1.16)〕,CTFC〔MD=-1.08,95%CI(-2.14,-0.02)〕after PCI or inhibition of platelet aggregation at 18-24 hour after PCI〔MD=-2.78,95%CI(-3.94,-1.63)〕,higher incidence of TIMI flow grade 3〔RR=0.57,95%CI(0.34,0.94)〕after PCI(P<0.05).There was no statistically significant difference in TMPG〔TMPG 0-2:RR=1.15,95%CI(0.95,1.39);TMPG 3:RR=0.64,95%CI(0.37,1.11)〕,LVEF〔MD=0.60,95%CI(-0.86,2.06)〕,inhibition of platelet aggregation 1 h after PCI〔MD=-0.31,95%CI(-5.07,4.45)〕,inhibition of platelet aggregation 6-8 h after PCI〔MD=-2.26,95%CI(-20.35,15.82)〕,bleeding incidence〔minor bleeding:RR=0.97,95%CI(0.93,1.02),hemorrhoea:RR=1.00,95%CI(0.98,1.01)〕,incidence of thrombocytopenia〔mild:RR=1.00,95%CI(0.97,1.03);severe:RR=1.01,95%CI(0.98,1.03)〕or MACE〔RR=0.99,95%CI(0.95,1.03)〕between the two groups after PCI(P>0.05).Funnel plots were drawn based on the literatures reporting bleeding complications,which showed asymmetric scattered points on both sides of the line,suggesting the possibility of publication bias.Conclusion Compared with eptifibatide,tirofiban can achieve better coronary artery reperfusion in ACS patients after PCI,and there is no significant difference in improving myocardial microcirculation perfusion,cardiac function,inhibition of platelet aggregation within 8 hour after PCI and the safety.