比较经皮冠状动脉支架植入术后不同抗血小板策略的网状Meta分析

Network meta-analysis comparing different antiplatelet strategies after percutaneous coronary stenting

目的通过网状Meta分析比较支架术后不同抗血小板策略对于临床获益情况。方法计算机检索PubMed、Embase、Web of Science、Cochrane Library,CNKI、WanFang Data、VIP、Sionmed等数据库,筛选出符合标准的文献提取数据后进行网状Meta分析,研究终点包括不良心血管事件,全因死亡,心血管死亡,心肌梗死(MI),支架血栓(ST),卒中,总出血率低及主要出血事件等安全指标。结果共纳入15篇文献,包括52497例经皮冠状动脉介入术(PCI)后患者。网状Meta分析结果表明,双联抗血小板治疗(DAPT)6月+阿司匹林(ASA)组较DAPT 12月组(OR=1.35,95%CI:1.03~1.76)心肌梗死事件发生率高;DAPT 3月+P2Y12组较DAPT 6月+ASA组(OR=0.68,95%CI:0.47~0.99)心肌梗死事件发生率低。与DAPT 12月组比较,DAPT 3月+P2Y12组(OR=0.58,95%CI:0.41~0.81)及DAPT 6月+ASA组(OR=0.65,95%CI:0.44~0.97)总出血事件发生率较低。与DAPT 12月组比较,DAPT 1月+P2Y12组(OR=0.08,95%CI:0.02~0.36)、DAPT 3月+P2Y12组(OR=0.44,95%CI:0.24~0.83)及DAPT 3月+ASA组(OR=0.26,95%CI:0.12~0.59)主要出血事件发生率较低;DAPT 1月+P2Y12组较DAPT 6月+ASA(OR=0.09,95%CI:0.02~0.43)及DAPT 3月+ASA组(OR=0.29,95%CI:0.11~0.78)主要出血事件发生率低。余各种比较,差异均无统计学意义(P>0.05)。结论短时间(1月、3月、6月)DAPT序贯P2Y12抑制剂的策略可显著降低出血风险,而包括ST或MI在内的缺血事件不会增加。而这三组中,3个月的DAPT联合P2Y12在缺血事件和总出血事件方面效果最佳。对于高出血风险患者,3个月的DAPT联合P2Y12可能具有更高的风险获益比。

Objective To compare the clinical benefits of different antiplatelet strategies after PCI through Network Meta-analysis.Methods A computerized search of PubMed,Embase,Web of Science,Cochrane Library,CNKI,WanFang Data,VIP,Sionmed and other databases were conducted.Network meta-analysis was performed after filtering out the literature extraction data that met the criteria,and the study endpoints included adverse cardiovascular events,all-cause death,cardiovascular death,myocardial infarction(MI),stent thrombosis(ST),stroke and other prognosis and major bleeding events and other safety indicators.Results A total of 15 articles were included,including 52497 patients after PCI.Network Meta-analysis results showed that compared with DAPT 12mon group,DAPT 3mon+P2Y12 group(OR=0.58,95%CI:0.41~0.81)and DAPT 6mon+ASA group(OR=0.65,95%CI:0.44~0.97),had lower incidence of bleeding events.The DAPT 6mon+ASA group had a higher incidence of myocardial infarction events than the DAPT 12mon group(OR=1.35,95%CI:1.03~1.76);the DAPT 3mon+P2Y12 group compared to the DAPT 6mon+ASA group(OR=0.68,95%CI:0.47~0.99),had lower incidence of myocardial infarction events.Compared with DAPT 12mon group,DAPT 1mon+P2Y12 group(OR=0.08,95%CI:0.02~0.36),DAPT 3mon+P2Y12 group(OR=0.44,95%CI:0.24~0.83)and DAPT 3mon+ASA group(OR=0.26,95%CI:0.12~0.59),had lower incidence of major bleeding events;DAPT 1mon+P2Y12 group had a lower incidence of major bleeding events than DAPT 6mon+ASA(OR=0.09,95%CI:0.02~0.43)and DAPT 3mon+ASA group(OR=0.29,95%CI:0.11~0.78).For other comparisons,the differences were not statistically significant(P>0.05).Conclusion A strategy of short(1,3,6 months)DAPT with sequential P2Y12 inhibitors resulted in a significant reduction in the risk of bleeding without an increase in ischaemic events including St or MI.And among these three groups,3 months of DAPT combined with P2Y12 had the best effect in terms of ischemic events and total bleeding events.For high bleeding risk patients,3 months of DAPT combined with P2Y12 may have a higher risk benefit ratio.