Barkat M, Hajibandeh S, Hajibandeh S, Torella F, Antoniou G A
Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK.
Department of General Surgery, Blackpool Victoria Hospital, Blackpool, UK.
Eur J Vasc Endovasc Surg. 2017 Jan;53(1):53-67. doi: 10.1016/j.ejvs.2016.10.011. Epub 2016 Nov 26.
The importance of antiplatelet therapy for the management and prevention of ischaemic stroke cannot be overstated. Despite the established guidelines, there is no clear consensus on how to manage antiplatelet therapy during and after carotid interventions.
The objective was to undertake a systematic literature review and perform a meta-analysis to assess the effects of dual antiplatelet therapy in carotid endarterectomy (CEA) and stenting (CAS).
Electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic reference lists were searched to identify randomised controlled trials (RCTs) and observational studies reporting comparative outcomes of dual versus single antiplatelet therapy in CEA and CAS.
Primary outcomes were mortality and stroke within 30 days of intervention. Secondary outcomes were transient ischaemic attack (TIA), major bleeding, groin or neck haematoma, and myocardial infarction (MI). Dichotomous outcome measures were reported using the risk difference (RD) and 95% confidence interval (CI). Combined overall treatment effects were calculated using fixed-effect or random-effects models.
Three RCTs and seven observational studies were identified reporting a total of 36,881 CEAs and 150 CAS procedures. In CEA, there were no differences in stroke/TIA/death between single and dual antiplatelet therapy, but there was a significant risk of major bleeding (RD, 0.00; 95% CI, 0.00-0.01; p = .0003) and neck haematoma with dual therapy (RD, 0.04; 95% CI, 0.01-0.06; p = .001). In addition, the rate of MI was higher in the dual therapy group than the single therapy group (RD, 0.00; 95% CI, 0.00-0.01; p = .003). In CAS, there was no difference in major bleeding or haematoma formation, but a significant difference in TIA in favour of dual therapy was identified (RD -0.13, 95% CI, -0.22 to -0.05; p = .003).
Dual antiplatelet therapy demonstrates advantages over single therapy only in CAS, as indicated by a reduced risk of TIA. Dual antiplatelet therapy was associated with an increased risk of bleeding complications in patients undergoing CEA.
抗血小板治疗对于缺血性中风的管理和预防至关重要，这一点无论如何强调都不为过。尽管已有既定指南，但对于在颈动脉介入治疗期间及之后如何管理抗血小板治疗，尚无明确的共识。
进行系统的文献综述并开展荟萃分析，以评估双重抗血小板治疗在颈动脉内膜切除术（CEA）和支架置入术（CAS）中的效果。
检索电子信息源（MEDLINE、EMBASE、CINAHL、CENTRAL）及参考文献列表，以识别报告CEA和CAS中双重与单一抗血小板治疗比较结果的随机对照试验（RCT）和观察性研究。
主要结局为干预后30天内的死亡率和中风。次要结局为短暂性脑缺血发作（TIA）、大出血、腹股沟或颈部血肿以及心肌梗死（MI）。二分结局指标采用风险差异（RD）和95%置信区间（CI）报告。使用固定效应或随机效应模型计算综合总体治疗效果。
共识别出3项RCT和7项观察性研究，报告了总共36,881例CEA和150例CAS手术。在CEA中，单一和双重抗血小板治疗在中风/TIA/死亡方面无差异，但双重治疗有大出血（RD，0.00；95%CI，0.00 - 0.01；p = .0003）和颈部血肿的显著风险（RD，0.04；95%CI，0.01 - 0.06；p = .001）。此外，双重治疗组的MI发生率高于单一治疗组（RD，0.00；95%CI，0.00 - 0.01；p = .003）。在CAS中，大出血或血肿形成方面无差异，但在TIA方面发现双重治疗有显著差异（RD -0.13，95%CI，-0.22至-0.05；p = .003）。
如TIA风险降低所示，双重抗血小板治疗仅在CAS中显示出优于单一治疗的优势。双重抗血小板治疗与接受CEA患者的出血并发症风险增加相关。
