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Int J Cardiol:支架植入后,延长双重抗血小板治疗VS 缩短双重抗血小板治疗

2017-03-21 MedSci MedSci原创

背景:目前的指南推荐药物洗脱支架(DES)植入术后延长双重抗血小板治疗(DAPT)。然而,停用DAPT的最佳时机仍是一个争议。研究者对评价应用DES行经皮冠状动脉介入治疗(PCI)停用DAPT最佳时机的所有随机对照试验(RCT)进行荟萃分析。方法:研究者检索了PubMed、Cochrane图书馆的电子数据库,EMBASE和ClinicalTrials.gov数据库中应用DES患者停用DAPT的不同

背景:目前的指南推荐药物洗脱支架(DES)植入术后延长双重抗血小板治疗(DAPT)。然而,停用DAPT的最佳时机仍是一个争议。研究者对评价应用DES行经皮冠状动脉介入治疗(PCI)停用DAPT最佳时机的所有随机对照试验(RCT)进行荟萃分析。

方法:研究者检索了PubMed、Cochrane图书馆的电子数据库,EMBASE和ClinicalTrials.gov数据库中应用DES患者停用DAPT的不同模式的随机对照试验。主要终点为全因死亡、血管死亡、心肌梗死(MI)和可能或明确的支架内血栓(ST)。次要终点为重复血运重建,卒中、大出血和净不良临床事件(NACE)。

结果: 研究者纳入13项符合标准的随机对照试验,共有36749例。全因死亡率(RR = 0.87, [ 95% CI] [ 0.75,1.01 ],P = 0.07,I2 = 0%),血管死亡(RR = 0.97, [ 95% CI ] [ 0.79,1.19 ],P = 0.76,I2 = 0%),再次血运重建(RR [ 95%CI] = 1.07 [ 0.92,1.25 ],P = 0.36,I2 = 0%)及卒中(RR = 1.01, [95% CI ] [ 0.80,1.28 ],P = 0.94,I2 = 0%)的发生没有显著的差异。与缩短DAPT相比, 较长的DAPT与MI(RR = 1.46, [ 95% CI ] [ 1.26,1.69 ],P<0.00001,I2 = 28%)和ST(RR = 1.93, [95% CI ] [ 1.45,2.58 ],P<0.00001,I2 = 32%)显著降低及大出血的显著增加(RR,0.60 [95% CI ] = [ 0.49,0.74 ],P<0.00001,I2 = 0%)相关。然而,两组间NACE的发生没有差异(RR = 1.03, [ 95% CI ] [ 0.91,1.17 ],P = 0.63,I2 = 0%)。在基于支架类型的亚组分析中,研究显示第一代DES(RR = 2.58, [95% CI ] [ 1.85,3.58 ],I2 = 0%)和依维莫司洗脱支架(EES,RR [ 95%CI] = 1.54 [ 1.12,2.11 ],I2 = 0%)植入后,较长的DAPT与血栓事件发生显著降低相关(MI、ST)。相反,佐他莫司洗脱支架(ZES,RR [ 95%CI] = 1.17 [ 0.83,1.63 ],I2 = 75%)和可生物降解的聚合物DES(BP-DES,RR [ 95%CI] = 1.15 [ 0.74,1.79 ])植入后,患者发生血栓事件无差异。

结论:1)与缩短DAPT相比,延长DAPT与血栓事件(MI、ST)显著降低,大出血发生显著增加相关。2)在血栓形成和出血事件之间进行权衡评估,缩短DAPT非劣于延长DAPT。3)第一代DES和EES支架植入的患者,延长DAPT的获益显著;第二代DES(ZES和BP-DES)支架植入患者延长DAPT的获益减弱。

原文出处:
Wang W, Liu J,et al. The optimal discontinuation of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention with drug-eluting stents: A meta-analysis of randomized trials. Int J Cardiol. 2017 Feb 24.


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