冠状动脉介入术后基于强效P2Y12拮抗剂的双联抗血小板治疗的减药：随机对照试验的网络荟萃分析
Abatement of potent P2Y12 antagonist-based dual antiplatelet therapy after coronary intervention: A network meta-analysis of randomized controlled trials.
作者信息
El Alaoui El Abdallaoui Oumaima, Tornyos Dániel, Lukács Réka, Komócsi András
机构信息
Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.
Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, Pécs, Hungary.
出版信息
Front Cardiovasc Med. 2023 Jan 12;9:1008914. doi: 10.3389/fcvm.2022.1008914. eCollection 2022.
INTRODUCTION
Dual antiplatelet therapy (DAPT) including prasugrel or ticagrelor is recommended in patients with acute coronary syndromes (ACS) treated with coronary intervention (PCI). Acknowledging the importance of bleeding, multiple trials tested abatement schemes including uniform or guided de-escalation from the potent P2Y12 inhibitor (P2Y12-De) or P2Y12 inhibitor monotherapy (P2Y12-Mo) with heterogeneous results. We aimed to perform a systematic review and network meta-analysis of the impact of DAPT abatement strategies in patients with PCI.
METHODS
Electronic databases were searched for relevant randomized clinical studies evaluating clinical outcomes of patients after PCI. The rate of adverse events was evaluated using a frequentist network metanalysis. The random-effects model was used to combine risk estimates across trials and risk ratio (RR) with 95% confidence intervals (95% CIs) served as summary statistics. The primary endpoints of interest were the rate of major cardiac adverse events (MACE, defined as the composite of cardiovascular mortality, myocardial infarction and stroke) and bleeding.
RESULTS
Ten studies were identified randomizing 42511 patients. 6359 switched to the P2Y12-De and 13062 switched to the P2Y12-Mo. The risk of MACE, reflected a 24% reduction in the P2Y12-De and a 14% in the P2Y12-Mo in comparison with the DAPT strategy using potent P2Y12 inhibitors (RR: 0.76 [0.62, 0.94], and RR: 0.86 [0.75, 0.99], < 0.05 both). A 35% risk reduction of major bleeding was seen with monotherapy (RR: 0.65 [0.46, 0.91],) contrasting the de-escalation trials where this effect was not significant (RR: 0.84 [0.57, 1.22]). All bleeding and minor bleeding events were reduced with both strategies. Indirect P2Y12-Mo versus P2Y12-De comparisons exhibited them as similar alternatives without significant differences.
CONCLUSION
Our analysis suggests that both P2Y12-De and P2Y12-Mo reduce ischemic events and bleeding among PCI-treated ACS patients. Ischemic benefit was more expressed with P2Y12-De, however, reduction of major bleeding was only significant with P2Y12-Mo strategy.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258502, identifier CRD42021258502.
引言
对于接受冠状动脉介入治疗（PCI）的急性冠状动脉综合征（ACS）患者，推荐使用包括普拉格雷或替格瑞洛在内的双联抗血小板治疗（DAPT）。鉴于出血的重要性，多项试验对减药方案进行了测试，包括从强效P2Y12抑制剂进行统一或指导性降阶梯治疗（P2Y12-De）或P2Y12抑制剂单药治疗（P2Y12-Mo），但结果各异。我们旨在对PCI患者中DAPT减药策略的影响进行系统评价和网状荟萃分析。
方法
检索电子数据库，查找评估PCI术后患者临床结局的相关随机临床研究。使用频率学派网状荟萃分析评估不良事件发生率。采用随机效应模型合并各试验的风险估计值，并将风险比（RR）及其95%置信区间（95%CI）作为汇总统计量。主要关注的终点是主要心脏不良事件（MACE，定义为心血管死亡、心肌梗死和中风的复合事件）发生率和出血发生率。
结果
共纳入10项研究，随机分配42511例患者。6359例转为P2Y12-De治疗，13062例转为P2Y12-Mo治疗。与使用强效P2Y12抑制剂的DAPT策略相比，MACE风险方面，P2Y12-De降低了24%，P2Y12-Mo降低了14%（RR分别为0.76[0.62,0.94]和RR为0.86[0.75,0.99]，均P<0.05）。单药治疗时主要出血风险降低了35%（RR：0.65[0.46,0.91]），而在降阶梯治疗试验中这一效果不显著（RR：0.84[0.57,1.22]）。两种策略均使所有出血和轻微出血事件减少。P2Y12-Mo与P2Y12-De的间接比较显示二者为相似的替代方案，无显著差异。
结论
我们的分析表明，P2Y12-De和P2Y12-Mo均可降低接受PCI治疗的ACS患者的缺血事件和出血风险。然而，P2Y12-De的缺血获益更明显，而主要出血的减少仅在P2Y12-Mo策略中显著。
系统评价注册
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258502，标识符CRD42021258502 。
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