冠脉内注射肾上腺素防治PCI术后无复流的系统评价和meta分析

Systematic evaluation and meta-analysis of intracoronary injection of epinephrine for preventing no-reflow after PCI

目的系统评价肾上腺素防治经皮冠状动脉介入治疗(PCI)术后无复流的有效性与安全性,为临床治疗进一步提供依据。方法通过检索Cochrane对照试验资料库、PubMed、EMbase、中国生物医学文献数据库、万方数据库以及中国知网这6个数据库自建库以来至2022年7月关于PCI术后无复流、慢血流的相关文献,严格遵循纳入和排除标准,筛选、提取、核对,最后使用RevMan 5.3软件进行meta分析。结果共选中5个研究,合计527例患者。最终分析结果显示:冠脉内注射肾上腺素可明显改善心肌梗死溶栓治疗临床试验(TIMI)血流,减少无复流/慢血流现象的发生率(RR=0.52,95%CI:0.37~0.72,P<0.001);同时,就不良反应而言,肾上腺素可明显降低PCI术中低血压的发生率,且2组差异有统计学意义(P<0.05);但PCI术后TIMI计帧数(CTFC)、心肌显影密度分级(MBG)、住院期间及PCI术后30 d主要不良心脏事件的发生率以及PCI术后左室射血分数(LVEF)的影响,2组差异均无统计学意义(均P>0.05);基于不同对照组对于PCI术后TIMI血流、CTFC进行的亚组分析,结果显示肾上腺素与不同对照组差异的结果与亚组分析之前的结果相似,差异无统计学意义。结论本系统评价结果显示,冠脉内注射肾上腺素可以起到降低PCI术后无复流/慢血流发生率的效果,并且术中低血压发生率低于维拉帕米、硝普钠等药物。但受限于研究的局限性,还需纳入更多样本量的随机对照研究进一步证实。

Objective To systematically evaluate the effectiveness and safety of epinephrine in the prevention and treatment of no-reflow after percutaneous coronary intervention(PCI),and to provide a further basis for clinical management.Methods The Cochrane Controlled Trials Database,PubMed,EMbase,China Biology Medicine disc,Wanfang Database and China National Knowledge Infrastructure were searched for relevant literature on no-reflow and slow flow after PCI since the establishment of the database to July 2022,and the inclusion and exclusion criteria were strictly followed to screen,extract,check and final meta-analysis was performed using RevMan 5.3 software.Results A total of 5 studies were selected,with a combined total of 527 patients.The final analysis showed that intracoronary epinephrine injection significantly improved thrombolysis in myocardial infarction trial(TIMI)flow and reduced the incidence of no/slow flow phenomenon(RR=0.52,95%CI:0.37-0.72,P<0.001).Meanwhile,in terms of adverse effects,epinephrine significantly reduced the incidence of intraoperative hypotension during PCI,and the difference between the two groups was statistically significant(P<0.05).However,for the effects of post-PCI corrected TIMI frame count(CTFC),myocardial blush grade(MBG),incidence of major adverse cardiovascular events(MACEs)during hospitalization and 30 days post-PCI,and post-PCI left ventricular ejection fraction(LVEF),the differences between the two groups were not statistically significant(all P>0.05).A subgroup analysis based on different control groups for TIMI blood flow,CTFC after PCI showed that the results of the difference between epinephrine and different control groups were similar to those before the subgroup analysis and were not statistically significant.Conclusion The results of this systematic evaluation show that intracoronary injection of epinephrine may have the effect of reducing the incidence of no-reflow/slow flow after PCI and that the incidence of intraoperative hypotension is lower than that of drugs such as verapamil and nitroprusside.However,due to the limitations of the study,further confirmation is needed by including randomized controlled trials with larger sample sizes.