颅内动脉粥样硬化疾病二级预防中的双重抗血小板治疗：一项网状Meta分析
Dual anti-platelet therapy for secondary prevention in intracranial atherosclerotic disease: a network meta-analysis.
作者信息
Reale Giuseppe, Zauli Aurelia, La Torre Giuseppe, Mannocci Alice, Mazya Michael V, Zedde Marialuisa, Giovannini Silvia, Moci Marco, Iacovelli Chiara, Caliandro Pietro
机构信息
Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy.
出版信息
Ther Adv Neurol Disord. 2022 Aug 5;15:17562864221114716. doi: 10.1177/17562864221114716. eCollection 2022.
BACKGROUND
Intracranial arterial stenosis (ICAS) is a non-marginal cause of stroke/transient ischemic attacks (TIAs) and is associated with high stroke recurrence rate. Some studies have investigated the best secondary prevention ranging from antithrombotic therapy to endovascular treatment (ET). However, no direct comparison between all the possible treatments is currently available especially between single and dual anti-platelet therapies (SAPT and DAPT).
AIM
To establish whether DAPT is more effective than SAPT in preventing the recurrence of ICAS-related stroke, by means of a network meta-analysis (NMA).
DESIGN
Systematic review and NMA in accordance to PRISMA guidelines.
DATA SOURCES AND METHODS
We performed a systematic review of trials investigating secondary prevention (SAPT or DAPT, anticoagulant treatment or ET) in patients with symptomatic ICAS available in MEDLINE, Scopus and Web of Science from January 1989 to May 2021. We defined our primary efficacy outcome as the recurrence of ischemic stroke/TIA. We analysed the extracted data with Bayesian NMA approach.
RESULTS
We identified 815 studies and included 5 trials in the NMA. Sequence generation was adequate in all the selected studies while the allocation concealment method was described in one study. All the included studies reported the pre-specified primary outcomes, and outcome assessment was blinded in all the studies. We used the fixed-effect approach as the heterogeneity was not significant ( > 0.1) according to the Cochran's statistic. DAPT was superior to SAPT and DAPT + ET in preventing stroke/TIA recurrence [respectively, odds ratio (OR), 0.59; confidence interval (CI), 0.39-0.9; and OR, 0.49, CI, 0.26-0.88], while no difference was found between DAPT and oral anticoagulant therapy (OAC). DAPT was safer than OAC (OR, 0.48; CI, 0.26-0.89) and DAPT + ET (OR, 0.50; CI, 0.35-0.71), while no difference was found between DAPT and SAPT.
CONCLUSION
DAPT is more effective than SAPT for secondary stroke prevention in patients with symptomatic ICAS, without increasing the risk of haemorrhage.
REGISTRATION
Prospero/CRD42019140033.
背景
颅内动脉狭窄（ICAS）是卒中/短暂性脑缺血发作（TIA）的重要病因，且与高卒中复发率相关。一些研究探讨了从抗栓治疗到血管内治疗（ET）等最佳二级预防措施。然而，目前尚无所有可能治疗方法之间的直接比较，尤其是单药和双药抗血小板治疗（SAPT和DAPT）之间。
目的
通过网状Meta分析（NMA）确定DAPT在预防ICAS相关卒中复发方面是否比SAPT更有效。
设计
按照PRISMA指南进行系统评价和NMA。
数据来源与方法
我们对1989年1月至2021年5月在MEDLINE、Scopus和Web of Science上检索到的关于症状性ICAS患者二级预防（SAPT或DAPT、抗凝治疗或ET）的试验进行了系统评价。我们将主要疗效结局定义为缺血性卒中/TIA的复发。我们采用贝叶斯NMA方法分析提取的数据。
结果
我们识别出815项研究，纳入NMA的有5项试验。所有入选研究的序列产生均恰当，而分配隐藏方法仅在1项研究中有所描述。所有纳入研究均报告了预先指定的主要结局，且所有研究的结局评估均采用盲法。由于根据Cochran's Q统计量异质性不显著（I²>0.1），我们采用固定效应模型。在预防卒中/TIA复发方面，DAPT优于SAPT和DAPT+ET[比值比（OR）分别为0.59；置信区间（CI）为0.39-0.9；以及OR为0.49，CI为0.26-0.88]，而DAPT与口服抗凝治疗（OAC）之间未发现差异。DAPT比OAC（OR为0.48；CI为0.26-0.89）和DAPT+ET（OR为0.50；CI为0.35-0.71）更安全，而DAPT与SAPT之间未发现差异。
结论
对于症状性ICAS患者，DAPT在二级卒中预防方面比SAPT更有效，且不增加出血风险。
注册信息
Prospero/CRD42019140033
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