First Clinical Medical College, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China.
Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Guangzhou, China.
Eur J Cardiothorac Surg. 2020 May 1;57(5):965-976. doi: 10.1093/ejcts/ezz335.
We sought to determine the optimal antithrombotic therapy after transcatheter aortic valve replacement.
Related scientific databases were searched until December 2018. We conducted a pairwise and a network meta-analysis within a frequentist framework, measuring 30-day bleeding, stroke and all-cause mortality. The surface under the cumulative ranking (SUCRA) curve was estimated to rank the therapies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was performed. The protocol was registered with PROSPERO (CRD42018111163).
Eight studies comprising 2173 patients were analysed. The risk of 30-day bleeding was higher for dual antiplatelet therapy (DAPT) than single antiplatelet therapy (SAPT) [odds ratio (OR) 1.90 (1.10-3.28); P = 0.02], whereas there was no difference in the risk of 30-day stroke [OR 1.27 (0.38-4.20); P = 0.69] and mortality [OR 1.46 (0.67-3.22); P = 0.34] between DAPT and SAPT. In the network meta-analysis, DAPT + oral anticoagulant (OAC) increased the risk of 30-day bleeding compared with SAPT [OR 6.21 (1.74-22.17); P = 0.005], DAPT [OR 3.27 (1.04-10.32); P = 0.043], SAPT + OAC [OR 4.87 (2.51-9.45); P < 0.001] and OAC [OR 14.4 (1.3-154.7); P = 0.028]. Additionally, patients receiving DAPT + OAC had the highest risks for 30-day bleeding (SUCRA 1.0%). OAC seemed to be superior to SAPT and DAPT in terms of 30-day bleeding (SUCRA OAC: 86.3%, SAPT: 72.3%, DAPT: 32.3%) and stroke (SUCRA 54.2%, 47.4%, 40.5%), but not mortality (SUCRA 69.6%, 74.1%, 43.4%).
There is a trend towards less bleeding with the application of SAPT, but no mortality benefit with the application of DAPT is shown. The comparison of SAPT, DAPT and OAC shows that OAC may improve the balance between stroke and bleeding, which can reduce the risk of mortality. In addition, the application of DAPT + OAC was ranked the worst amongst all treatment modalities and should be avoided due to an increased risk of bleeding.
PROSPERO (International Prospective Register of Systematic Reviews, CRD42018111163).
我们旨在确定经导管主动脉瓣置换术后的最佳抗栓治疗策略。
检索相关科学数据库，直至 2018 年 12 月。我们在一个有频率论框架内进行了两两比较和网络荟萃分析，以测量 30 天出血、卒中和全因死亡率。采用累积排序概率曲线（SUCRA）估计值来对治疗方法进行排名。采用推荐评估、制定与评价（GRADE）方法进行评估。该方案已在 PROSPERO（CRD42018111163）注册。
纳入了 8 项共 2173 例患者的研究。双联抗血小板治疗（DAPT）的 30 天出血风险高于单联抗血小板治疗（SAPT）[比值比（OR）1.90（1.10-3.28）；P=0.02]，但 DAPT 与 SAPT 之间 30 天卒中和死亡率并无差异[OR 1.27（0.38-4.20）；P=0.69]和[OR 1.46（0.67-3.22）；P=0.34]。在网络荟萃分析中，DAPT+口服抗凝药（OAC）与 SAPT 相比，30 天出血风险增加[OR 6.21（1.74-22.17）；P=0.005]，与 DAPT [OR 3.27（1.04-10.32）；P=0.043]、SAPT+OAC [OR 4.87（2.51-9.45）；P<0.001]和 OAC [OR 14.4（1.3-154.7）；P=0.028]相比。此外，接受 DAPT+OAC 治疗的患者 30 天出血风险最高（SUCRA 1.0%）。OAC 在 30 天出血（SUCRA OAC：86.3%，SAPT：72.3%，DAPT：32.3%）和卒中等方面似乎优于 SAPT 和 DAPT（SUCRA 54.2%，47.4%，40.5%），但死亡率方面并无优势（SUCRA 69.6%，74.1%，43.4%）。
SAPT 的应用趋势出血减少，但 DAPT 的应用并未显示出死亡率获益。SAPT、DAPT 和 OAC 的比较表明，OAC 可能改善卒中与出血之间的平衡，从而降低死亡率。此外，DAPT+OAC 的应用排名最差，由于出血风险增加，应避免使用。
PROSPERO（国际前瞻性系统评价注册库，CRD42018111163）。
