高血压合并卒中二级预防降压药物方案选择的网状Meta分析

Comparative efficacy of antihypertensive agents for secondary prevention of hypertension complicated with ischemic stroke:a network Meta-analysis

目的对高血压合并卒中二级预防降压药物方案的选择进行网状Meta分析。方法检索中国知网、维普、万方数据库、CochraneLibrary、PubMed、Embase数据库有关高血压合并卒中二级预防降压药物治疗的随机对照试验(RCTs)。采用Cochrane偏倚风险评估工具5.2评价文献质量和偏倚风险,采用Stata 15.0和RevMan 5.2软件进行网状Meta分析。评价指标为卒中复发率(SRR)或卒中死亡率(SMR)。效应量采用优势比(OR)以及95%置信区间(95%CI)、累积概率排序曲线面积(SUCRA)评价。结果最终纳入文献38篇,共涉及患者44091例,涉及治疗方案13种:安慰剂或常规治疗(Placebo)、血管紧张素转化酶抑制剂(ACEI)、钙通道阻滞剂(CCB)、利尿剂(Diu)、血管紧张素Ⅱ受体拮抗剂(ARB)、β受体阻滞剂(BB)、CCB+Diu、Diu+中枢性降压药(CNS)、ACEI+CCB、ACEI+叶酸(FA)、ARB+Diu、ACEI+Diu、ACEI+BB。所有文献均未描述结果完整性、选择性报告和其他偏倚等。网状Meta分析结果提示,在降低高血压合并卒中患者SRR方面,ARB优于Placebo、Diu、CCB,ACEI+Diu优于ACEI、Diu+CNS,ACEI+CCB优于CCB、ACEI、Diu+CNS;在降低SMR方面,ARB、ACEI优于CCB,ARB、ACEI+CCB优于BB。二级预防降压药物在降低高血压合并卒中患者SRR方面的SUCRA排序为ACEI+CCB>ARB>ACEI+Diu>CCB+Diu>BB>Placebo>ACEI+FA>ACEI+BB>ARB+Diu>Diu>CCB>ACEI>Diu+CNS;在降低高血压合并卒中患者SMR方面的SUCRA排序为ARB>ACEI+CCB>Diu+CNS>ACEI+BB>Placebo>CCB>ACEI>BB。结论高血压合并卒中二级预防降压药物方案选择推荐ACEI+CCB和ARB,但还需要多中心、大样本和高质量RCT,对该结论进行验证。

AIM To explore the efficacy of antihypertensive agents for secondary prevention of hypertension complicated with ischemic stroke.METHODS A literature search was conducted for randomized controlled trials(RCTs)regarding antihypertensive agents for secondary prevention of hypertension complicated with ischemic stroke from databases involving China National Knowledge Infrastructure(CNKI),VIP database,WanFang database,Cochrane Library,PubMed and Embase databases from their inception to 2023.The quality and risk of bias of the literature were assessed by the Cochrane Collaboration's tool(version 5.2).The evaluation indicators were stroke recurrence rate(SRR)or stroke mortality rate(SMR).The effect size was measured using odds ratios(OR)with a 95%confidence interval(95%CI)and the surface under the cumulative ranking curve(SUCRA)for evaluation.RESULTS A total of 38 RCTs included 44091 patients,involving 13 kinds of therapy such as placebo or basic treatment,angiotensin-converting enzyme inhibitor(ACEI),calcium channel blocker(CCB),diuretic(Diu),angiotensinⅡreceptor antagonist(ARB),β-receptor blocker(BB),CCB+Diu,Diu+central nervous system hypotension(CNS),ACEI+CCB,ACEI+folic acid(FA),ARB+Diu,ACEI+Diu,and ACEI+BB.None of the literature described the completeness of the results,selective reporting,or other biases.Network Meta-analysis 95%CI showed,as for SRR,ARB was superior to Placebo,Diu,and CCB,ACEI+Diu was superior to ACEI,Diu+CNS,and ACEI+CCB was superior to CCB,ACEI,Diu+CNS.In reducing SMR,ARB and ACEI were superior to CCB,and ARB and ACEI+CCB were superior to BB.In term of reducing SRR,the SUCRA order of antihypertensive agents for secondary prevention of hypertension complicated with ischemic stroke was as follows:ACEI+CCB>ARB>ACEI+Diu>CCB+Diu>BB>Placebo>ACEI+FA>ACEI+BB>ARB+Diu>Diu>CCB>ACEI>Diu+CNS.In reducing SMR,the SUCRA order was:ARB>ACEI+CCB>Diu+CNS>ACEI+BB>Placebo>CCB>ACEI>BB.CONCLUSION Based on the existing clinical evidence,ACEI+CCB and ARB are recommended for the selection of antihypertensive agents for secondary prevention of hypertension complicated with ischemic stroke.However,further multicenter,large-sample,high-quality RCTs are needed to validate these findings.