Li Chunxing, Ren Zhao, Liu Jia, Liang Shuo, Liu Hua, Wang Dongxiao, Wang Yue, Wang Yumin
Department of Pharmacy, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China.
Zi Zhu Yuan Community Healthcare Center, Aerospace Center Hospital, Beijing, China.
J Evid Based Med. 2024 Dec;17(4):822-832. doi: 10.1111/jebm.12671. Epub 2024 Dec 21.
The optimal low-dose antiplatelet agents in patients with coronary heart disease (CHD) had not been determined. The objective of this study was to compare the impact of different low-dose antiplatelet agents on cardiovascular outcomes and bleeding risks in patients with CHD.
We searched PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, VIP, WanFang Data, and China Biology Medicine. Randomized controlled trials (RCTs) enrolling patients with CHD treated with different low-dose platelet aggregation inhibitors were included. The revised Cochrane Risk of Bias Tool for Randomized Trials Risk was used to assess risk of bias in RCTs. A Bayesian random network meta-analysis (NMA) was conducted, with odds ratios (OR) and 95% confidence intervals (CI) as effect estimates in R 4.2.2 software and Stata 15.0. The quality of evidence was assessed using the Confidence in NMA framework.
Sixteen RCTs involving 6350 patients were included. All participants were treated with a recommended dose of aspirin plus a low or standard dose of P2Y12 receptor antagonist. Low-level evidence indicated the risk of major adverse cardiovascular events (MACE) was similar among low doses of prasugrel, ticagrelor, standard doses of prasugrel, ticagrelor, and clopidogrel. Low- to moderate-level evidence suggested there was no difference in bleeding risk among low dose of prasugrel, ticagrelor, clopidogrel compared to standard dose of prasugrel, ticagrelor, and clopidogrel. NMA showed that low dose of prasugrel had the highest probability of being the best intervention in terms of MACE, myocardial infarction, and bleeding events leading to discontinuation.
Based on low-level evidence, low dose of prasugrel combined with standard dose of aspirin can be recommended for patients with CHD, low dose of ticagrelor was similar in terms of MACE and bleeding compared with standard dose of P2Y12 receptor antagonist. The systematic review was registered in PROSPERO with the registration number CRD42023438376.
冠心病（CHD）患者最佳低剂量抗血小板药物尚未确定。本研究的目的是比较不同低剂量抗血小板药物对CHD患者心血管结局和出血风险的影响。
我们检索了PubMed、Embase、Cochrane图书馆、中国知网、维普、万方数据和中国生物医学数据库。纳入了使用不同低剂量血小板聚集抑制剂治疗CHD患者的随机对照试验（RCT）。使用修订后的Cochrane随机试验偏倚风险工具评估RCT中的偏倚风险。进行贝叶斯随机网络荟萃分析（NMA），在R 4.2.2软件和Stata 15.0中以比值比（OR）和95%置信区间（CI）作为效应估计值。使用NMA框架中的证据置信度评估证据质量。
纳入了16项涉及6350例患者的RCT。所有参与者均接受推荐剂量的阿司匹林加低剂量或标准剂量的P2Y12受体拮抗剂治疗。低质量证据表明，低剂量普拉格雷、替格瑞洛、标准剂量普拉格雷、替格瑞洛和氯吡格雷之间主要不良心血管事件（MACE）风险相似。低至中等质量证据表明，低剂量普拉格雷、替格瑞洛、氯吡格雷与标准剂量普拉格雷、替格瑞洛和氯吡格雷相比，出血风险无差异。NMA显示，就MACE、心肌梗死和导致停药的出血事件而言，低剂量普拉格雷成为最佳干预措施的概率最高。
基于低质量证据，对于CHD患者，可推荐低剂量普拉格雷联合标准剂量阿司匹林，低剂量替格瑞洛在MACE和出血方面与标准剂量P2Y12受体拮抗剂相似。该系统评价已在PROSPERO注册，注册号为CRD42023438376。
