慢性肾脏病合并冠状动脉疾病患者使用药物洗脱支架与裸金属支架的比较：系统评价与荟萃分析的见解

Drug-Eluting vs Bare-Metal Stents in Patients With Chronic Kidney Disease and Coronary Artery Disease: Insights From a Systematic Review and Meta-Analysis.

作者信息

Volodarskiy Alexander, Kumar Sunil, Pracon Radoslaw, Sidhu Mandeep, Kretov Evgeny, Mazurek Tomasz, Bockeria Olga, Kaul Upendra, Bangalore Sripal

机构信息

Cardiovascular Outcomes Group, Cardiovascular Clinical Research Center, Associate Professor of Medicine, New York University School of Medicine, The Leon H. Charney Division of Cardiology, New York, NY 10016 USA.

出版信息

J Invasive Cardiol. 2018 Jan;30(1):10-17. Epub 2017 Sep 15.

PMID:28915510

Abstract

BACKGROUND

Most drug-eluting stent (DES) trials have excluded patients with chronic kidney disease (CKD). The efficacy of DES implantation in patients with CKD is therefore not known.

OBJECTIVES

To evaluate the outcomes with DES vs bare-metal stent (BMS) implantation in patients with CKD.

METHODS AND RESULTS

MEDLINE, EMBASE, and CENTRAL were searched for studies including at least 100 patients with CKD (estimated glomerular filtration rate ≤60 mL/min/1.73 m² or on dialysis) treated with DES or BMS and followed for at least 1 month and reporting outcomes of all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), target-vessel revascularization (TVR), and stent thrombosis (ST). Thirty-one studies (5 randomized) with 91,817 participants (49,081 DES and 42,736 BMS) fulfilled the inclusion criteria. DES was associated with lower all-cause mortality (relative risk [RR], 0.77; 95% confidence interval [CI], 0.71-0.84), CV mortality (RR, 0.51; 95% CI, 0.38-0.70), MI (RR, 0.90; 95% CI, 0.86-0.95), TVR (RR, 0.61; 95% CI, 0.47-0.80), and numerically lower ST (RR, 0.75; 95% CI, 0.55-1.01) when compared with BMS. Analysis by study type (RCTs vs non-RCTs) showed similar results for most outcomes (Pinteraction>.05) except all-cause mortality, where there was no difference between DES vs BMS in RCTs (Pinteraction=.04). The effects were greater with 2nd-generation DES vs BMS (for example, ST: RR, 0.38; 95% CI, 0.20-0.72).

CONCLUSIONS

In patients with CKD, the available evidence, largely from observational studies, suggests significantly fewer events with DES vs BMS with even a lower ST rate with 2nd-generation DES. These findings should be tested in large, randomized trials.

摘要

背景

大多数药物洗脱支架（DES）试验排除了慢性肾脏病（CKD）患者。因此，DES植入在CKD患者中的疗效尚不清楚。

目的

评估CKD患者植入DES与裸金属支架（BMS）的结局。

方法与结果

检索MEDLINE、EMBASE和CENTRAL数据库，查找纳入至少100例CKD患者（估计肾小球滤过率≤60 mL/min/1.73 m²或正在接受透析）并接受DES或BMS治疗、随访至少1个月且报告全因死亡率、心血管（CV）死亡率、心肌梗死（MI）、靶血管血运重建（TVR）和支架血栓形成（ST）结局的研究。31项研究（5项随机对照试验）共91,817名参与者（49,081例DES和42,736例BMS）符合纳入标准。与BMS相比，DES与较低的全因死亡率（相对风险[RR]，0.77；95%置信区间[CI]，0.71 - 0.84）、CV死亡率（RR，0.51；95% CI，0.38 - 0.70）、MI（RR，0.90；95% CI，0.86 - 0.95）、TVR（RR，0.61；95% CI，0.47 - 0.80）以及数值上较低的ST（RR，0.75；95% CI，0.55 - 1.01）相关。按研究类型（随机对照试验与非随机对照试验）分析显示，除全因死亡率外，大多数结局的结果相似（交互作用P>.05），在随机对照试验中DES与BMS的全因死亡率无差异（交互作用P = 0.04）。第二代DES与BMS相比效果更佳（例如，ST：RR，0.38；95% CI，0.20 - 0.72）。