替格瑞洛和氯吡格雷在老年冠心病患者抗血小板治疗中有效性及安全性的Meta分析

doi:10.13481/j.1671-587x.20190123

摘要/Abstract

摘要： 目的：探讨替格瑞洛和氯吡格雷在老年冠心病患者抗血小板治疗中的疗效及安全性，阐明更合理的抗血小板治疗策略。方法：应用计算机检索Cochrane试验资料库、Ovid-Medline全文数据库、EMBase数据库、PubMed数据库、中国学术文献总库（CNKI）、万方数字化期刊库、维普数据库（VIP）及中国生物医学文献数据库（CBM），收集分为替格瑞洛组和氯吡格雷组治疗老年冠心病的随机对照试验（RCT），2组患者分别给予替格瑞洛联合其他药物及氯吡格雷联合其他药物治疗，应用RevMan5.3统计软件进行Meta分析，观察抗血小板治疗有效性相关不良事件[即主要心血管不良事件（MACE）、心肌梗死（MI）、支架内血栓、全因死亡及卒中]和安全性相关不良事件（出血事件）的发生情况。结果：按照纳入和排除标准，共纳入15篇符合入选标准的RCT。Meta分析，与氯吡格雷组比较，替格瑞洛组MACE发生率（RR=0.59，95% CI：0.46~0.76，Z=4.08，P<0.01）、MI发生率（RR=0.48，95% CI：0.28~0.81，Z=2.74，P=0.006）、支架内血栓发生率（RR=0.16，95% CI：0.06~0.48，Z=3.30，P=0.001）和全因死亡发生率（RR=0.52，95% CI：0.30~0.89，Z=2.41，P=0.02）均明显降低，卒中发生率（RR=0.76，95% CI：0.39~1.47，Z=0.81，P=0.42）差异无统计学意义，出血发生率（RR=1.57，95% CI：1.20~2.05，Z=3.28，P=0.001）明显增加。结论：对于老年冠心病患者，替格瑞洛抗血小板治疗的有效性优于氯吡格雷，但可增加出血发生率。

关键词: 替格瑞洛, 氯吡格雷, 老年人, 冠心病, Meta分析

Abstract: Objective: To explore the curative effects and securities of ticagrelor and clopidogrel in the antiplatelet therapy for coronary heart disease in the aged patients, and to provide a more rational strategy for antiplatelet therapy.Methods: Computer search was performed in Cochrane Central Register of Controlled Trial, Ovid-Medline, EMBase, PubMed, CNKI, Wanfang, VIP and CBM,and the randomized controlled trial (RCT) of ticagrelor and clopidogrel in the treatment of coronary heart disease in the old people were collected. The patients in ticagrelor group were given ticagrelor and other drugs,and the patients in clopidogrel group were given clopidogrel and other drugs. RevMan 5.3 software was used to perform Meta-analysis,and the adverse events related to the effectiveness such as the major adverse cardiovascular events(MACE),myocardial infarction(MI),stent thrombosis,death,stroke and the adverse events related to safety (bleeding event) were observed.Results: According to inclusion and exclusion criteria,a total of 15 RCT were included. The results of Meta-analysis showed that the incidences of MACE(RR=0.59,95%CI:0.46-0.76,Z=4.08,P<0.01), MI(RR=0.48,95%CI:0.28-0.81,Z=2.74,P=0.006), stent thrombosis (RR=0.16,95%CI:0.06-0.48,Z=3.30,P=0.0010),and death (RR=0.52,95%CI:0.30-0.89,Z=2.41,P=0.02) in ticagrelor group were decreased compared with clopidogrel group;there was no significant difference in stroke rate (RR=0.76,95%CI:0.39-1.47,Z=0.81,P=0.42)between two groups,and the incidence of bleeding event in ticagrelor group was increased compared with clopidogrel group(RR=1.57,95%CI:1.20-2.05,Z=3.28,P=0.001).Conclusion: For the aged patients with coronary heart disease,ticagrelor is superior to clopidogrel;but the incidence of bleeding is increased.

Key words: ticagrelor, clopidogrel, coronary heart disease, Meta analysis, old people

中图分类号:

R541.4

邢寻静, 秦玲, 唐明龙, 杨硕, 徐国良. 替格瑞洛和氯吡格雷在老年冠心病患者抗血小板治疗中有效性及安全性的Meta分析[J]. 吉林大学学报(医学版), 2019, 45(01): 123-129.

XING Xunjing, QIN Ling, TANG Minglong, YANG Shuo, XU Guoliang. Effectiveness and securities of ticagrelor and clopidogrel in antiplatelet therapy for coronary heart disease in old people: A Meta-analysis[J]. Journal of Jilin University(Medicine Edition), 2019, 45(01): 123-129.

参考文献

[1] NICHOLAS M,TOWNSEND N,SCARBOROUGH P, et al. Cardiovascular disease in Europe 2014:epidemiological update[J]. Eur Heart J, 2014, 35(42):2950-2959.
[2] 张宜春, 徐岩, 辜和平. 脂蛋白(a)水平与VH-IVUS检测冠状动脉粥样硬化斑块成分的关联性分析[J]. 吉林大学学报:医学版, 2016, 42(1):115-119.
[3] 周宏, 刘进才, 罗光华, 等. 冠状动脉疾病报告与数据系统在冠心病患者危险因素分析中的应用[J]. 吉林大学学报:医学版, 2017, 43(3):617-621.
[4] WALLENTIN L,BECKER R C,BUDAJ A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes[J]. N Engl J Med, 2009, 361(11):1045-1057.
[5] JADAD A R,MOORE A,CARROLL D, et al. Assessing the quality of reports of randomized clinical trials:Is blinding necessary?[J]. Control Clin Trials, 1996, 17(1):1-12.
[6] 高燕, 钟萍, 张乃文, 等. 阿司匹林联合替格瑞洛在老年急性冠状动脉综合征非血运重建患者中的临床观察[J]. 中华老年心脑血管病杂志, 2017, 19(11):1149-1152.
[7] 林开敏, 吴雅芳, 谢强. 比较替格瑞洛与氯吡格雷对老年患者支架术后出血的影响[J]. 中国生化药物杂志, 2015, 35(9):152-154.
[8] 许玉娟, 罗芳. 比较替格瑞洛与氯吡格雷在老年人冠脉支架后的抗栓效果[J]. 中国卫生标准管理, 2017, 8(20):101-104.
[9] 李振莲, 王连芹, 任振芳, 等. 替格瑞洛对高龄急性冠脉综合征患者的临床疗效[J]. 热带医学杂志, 2016, 16(10):1303-1305.
[10] 王小东, 庄少伟, 张旭敏, 等. 替格瑞洛对老年急性心肌梗死患者血小板功能及临床预后的影响[J]. 国际心血管病杂志, 2016, 43(3):183-186.
[11] 刘大一, 王智昊, 潘震华, 等. 替格瑞洛对中高危老年非ST段抬高型急性冠脉综合征患者直接冠状动脉介入的有效性及安全性[J]. 中国老年学杂志, 2015, 35(22):6367-6369.
[12] 岑开源, 于海波, 李晶, 等. 替格瑞洛联合阿司匹林对老年急性冠脉综合征伴糖尿病患者纤维蛋白原和高敏C反应蛋白的影响[J]. 解放军医学院学报, 2017, 12:1130-1133.
[13] 纪军, 何胜虎, 陈述, 等. 替格瑞洛在高龄急性非ST段抬高型心肌梗死患者早期介入治疗中的疗效及安全性[J]. 实用临床医药杂志, 2016, 20(24):11-14.
[14] 王莉, 高志胜, 杜雪莲, 等. 替格瑞洛在高龄急性冠脉综合征患者中的应用[J]. 中国医药导刊, 2016, 18(3):282-283.
[15] 刘大一, 王智昊. 替格瑞洛在老年ST段抬高型心肌梗死患者急诊冠状动脉介入治疗中的应用[J]. 中国老年学杂志, 2014, 34(10):2638-2641.
[16] 王宇航, 谷新顺, 王雁博, 等. 替格瑞洛在老年不稳定型心绞痛患者择期行经皮冠状动介入治疗中的疗效及安全性[J]. 中华临床医师杂志:电子版, 2017, 11(4):560-565.
[17] 柳杨, 李运田, 王小东, 等. 替格瑞洛在老年冠脉病变介入治疗中的疗效及安全性分析[J]. 解放军医学院学报, 2017(5):423-425.
[18] 张云梅, 张宏, 赵燕, 等. 替格瑞洛在老年急性冠脉综合征患者中的应用[J]. 中国老年学杂志, 2014, 34(6):1450-1452.
[19] 田彩霞, 薛伟珍, 冯惠芳, 等. 替格瑞洛在老年急性前壁心肌梗死急诊PCI治疗中的早期作用研究[J]. 临床医药实践, 2017, 26(7):550-553.
[20] 阙斌, 聂绍平, 王春梅, 等. 替格瑞洛在老年心肌梗死急诊冠状动脉介入治疗中的作用研究[J]. 中华老年心脑血管病杂志, 2015, 17(10):1013-1016.
[21] 屈虎, 简立国, 李高宇, 等. 替格瑞洛治疗高龄非ST段抬高型急性冠脉综合征患者疗效与安全性[J]. 中国医学工程, 2017, 25(7):7-10.
[22] RAY S. Clopidogrel resistance:the way forward[J]. Indian Heart J, 2014, 66(5):530-534.
[23] MATETZKY S,SHENKMAN B,GUETTA V, et al. Clopidogrel resistance is associated with increased risk of recurrent atherothrombotic events in patients with acute myocardial infarction[J]. Circulation, 2004, 109(25):3171-3175.
[24] JERNBERG T,PAYNE C D,WINTERS K J, et al. Prasugrel achieves greater inhibition of platelet aggregation and a lower rate of non-responders compared with clopidogrel in aspirin-treated patients with stable coronary artery disease[J]. Eur Heart J, 2006, 27(10):1166-1173.
[25] STEG P G,JAMES S K,ATAR D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation[J]. Eur Heart J, 2012, 33(20):2569-2619.
[26] 程龙,李毅,李晶,等.冠心病合并肾功能不全患者两种支架植入的远期预后比较-I-LOVE-IT 2亚组研究[J].解放军医学杂志,2018,43(9):781-788.
[27] TONELLI M R. The limits of evidence based medicine[J].Respir Care, 2001, 46(12):1435-1440.