抗血栓治疗用于卒中和短暂性脑缺血发作患者的二级预防：一项随机对照试验的多治疗网络荟萃分析。
Antithrombotic therapy for secondary prevention in patients with stroke or transient ischemic attack: A multiple treatment network meta-analysis of randomized controlled trials.
机构信息
Heart Institute, Medical School, University of Pécs, Pécs, Hungary.
Department of Neurology, Medical School, University of Pécs, Pécs, Hungary.
出版信息
PLoS One. 2022 Aug 17;17(8):e0273103. doi: 10.1371/journal.pone.0273103. eCollection 2022.
OBJECTIVE
As stroke represents one of the leading causes of mortality and disability worldwide, we aimed to determine the preventive effect of different antiplatelet therapies after an ischemic stroke or transient ischemic attack.
METHODS
Network meta-analysis evaluating antiplatelet regimes after an ischemic stroke or transient ischemic attack. Searches were conducted in MEDLINE, EMBASE, and Cochrane Library databases until Nov. 23, 2021, for randomized controlled trials. Direct comparisons within trials were combined with indirect evidence from other trials by using a frequentist model. An additive network meta-analysis model was used to evaluate the influence of individual components. The primary efficacy endpoint was a recurrent stroke, the main safety outcomes were the risk of major bleeding and mortality at the longest available follow-up.
RESULTS
58 randomized controlled trials (175,730 patients) were analyzed. The analysis involved 20 antithrombotic strategies including different antiplatelet agents, combinations with aspirin, and anticoagulant therapies. Cilostazol proved to be the most efficacious in reducing stroke recurrence and the risk of bleeding (RR = 0.66, 95%CI = 0.55-0.80 and RR = 0.39, 95%CI = 0.08-2.01) compared to aspirin, respectively. Intensification with combinations of aspirin with ticagrelor or clopidogrel resulted in a lower risk of stroke recurrence (RR = 0.79, 95%CI = 0.67-0.93 and RR = 0.79, 95%CI = 0.72-0.87) but carried a higher bleeding risk (RR = 3.01, 95%CI = 1.65-5.49 and RR = 1.78 95%CI = 1.49-2.13).
CONCLUSION
The prognosis of patients with an ischemic stroke or transient ischemic attack is improved with antiplatelets. Cilostazol showed the best risk-benefit characteristics without trade-off with the risk of major bleeding. Improved stroke recurrence with intensified antiplatelet regimens is counterbalanced with higher bleeding risk, and consequently, mortality remains unaffected. Treatment decisions in stroke survivals should integrate the assessment of bleeding risk for better identification of patients with the highest benefit of treatment intensification.
SYSTEMATIC REVIEW REGISTRATION
Prospero registration number: CRD42020197143, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197143.
目的
由于中风是全球导致死亡和残疾的主要原因之一，我们旨在确定不同抗血小板治疗在缺血性卒中和短暂性脑缺血发作后的预防效果。
方法
对缺血性卒中和短暂性脑缺血发作后抗血小板治疗方案进行网络荟萃分析。检索 MEDLINE、EMBASE 和 Cochrane 图书馆数据库，直到 2021 年 11 月 23 日，以确定随机对照试验。通过使用似然比法，将试验内的直接比较与来自其他试验的间接证据相结合。使用加法网络荟萃分析模型评估单个成分的影响。主要疗效终点为复发性卒中，主要安全性结局为最长随访时的大出血风险和死亡率。
结果
共分析了 58 项随机对照试验（175730 名患者）。该分析涉及 20 种抗血栓形成策略，包括不同的抗血小板药物、阿司匹林联合治疗以及抗凝治疗。与阿司匹林相比，西洛他唑在降低卒中复发和出血风险方面最为有效（RR=0.66，95%CI=0.55-0.80 和 RR=0.39，95%CI=0.08-2.01）。与阿司匹林联合使用替格瑞洛或氯吡格雷强化治疗可降低卒中复发风险（RR=0.79，95%CI=0.67-0.93 和 RR=0.79，95%CI=0.72-0.87），但出血风险增加（RR=3.01，95%CI=1.65-5.49 和 RR=1.78，95%CI=1.49-2.13）。
结论
抗血小板治疗可改善缺血性卒中和短暂性脑缺血发作患者的预后。西洛他唑具有最佳的风险效益特征，且与大出血风险无关。强化抗血小板治疗方案可改善卒中复发，但出血风险增加，因此死亡率不受影响。在卒中幸存者的治疗决策中，应综合评估出血风险，以便更好地识别出获益最大的患者。
系统评价注册
Prospero 注册号：CRD42020197143，https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197143。
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