美国佛罗里达大学医学院Dominick J Angiolillo团队比较了经皮冠状动脉介入治疗患者选择指导性与标准抗血小板治疗对预后的影响。2021年4月17日，该研究发表在《柳叶刀》杂志上。

在接受经皮冠状动脉介入治疗（PCI）的患者中，与标准抗血小板治疗相比，指导性选择抗血小板治疗是否能有效改善预后仍存在争议。研究组评估了在接受PCI的患者中，指导性选择和标准抗血小板治疗的安全性和有效性。

2020年8月20日至10月25日，研究组检索MEDLINE、Cochrane、Embase和Web of Science数据库，查找以任何语言发表的、比较通过血小板功能检测或基因检测指导抗血小板治疗与标准抗血小板治疗PCI患者的随机对照试验和观察性研究，进行系统回顾和荟萃分析。

由两名评审员独立评估研究合格性，提取数据，并评估偏倚风险。主要终点为试验确定的重大心血管不良事件和任何出血。关键次要终点为全因死亡、心血管死亡、心肌梗死、中风、明确或可能的支架血栓形成、大出血和小出血。

研究组共筛选了3656篇潜在相关文章。分析共包括11项随机对照试验和3项观察研究，数据涉及20743名患者。与标准治疗相比，指导性选择抗血小板治疗可显著减少重大心血管不良事件发生率，也可减少出血率，但无统计学意义。

与标准治疗相比，指导性治疗可减少心血管死亡、心肌梗死、支架血栓形成、中风和轻微出血的发生率。在指导性和标准方法中，全因死亡和大出血的风险没有差异。预后根据所使用的策略而有所不同，升级方法显著减少缺血事件而不存在安全性上的权衡，降级方法显著减少出血而不存在有效性上的权衡。

研究结果表明，指导性选择抗血小板治疗改善了综合疗效和个体疗效，具有良好的安全性，主要是减少了小出血率，该结果支持使用血小板功能或基因检测来优化PCI患者的药物选择。

附：英文原文

Title: Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

Author: Mattia Galli, Stefano Benenati, Davide Capodanno, Francesco Franchi, Fabiana Rollini, Domenico DAmario, Italo Porto, Dominick J Angiolillo

Issue&Volume: 2021/04/17

Abstract:

Background

Whether guided selection of antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) is effective in improving outcomes compared with standard antiplatelet therapy remains controversial. We assessed the safety and efficacy of guided versus standard selection of antiplatelet therapy in patients undergoing PCI.

Methods

For this systematic review and meta-analysis, from Aug 20 to Oct 25, 2020, we searched MEDLINE (via PubMed), Cochrane, Embase, and Web of Science databases for randomised controlled trials and observational studies published in any language that compared guided antiplatelet therapy, by means of platelet function testing or genetic testing, versus standard antiplatelet therapy in patients undergoing PCI. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% CIs were used with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Coprimary endpoints were trial-defined primary major adverse cardiovascular events and any bleeding. Key secondary endpoints were all-cause death, cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and major and minor bleeding. This study is registered with PROSPERO (CRD42021215901).

Findings

3656 potentially relevant articles were screened. Our analysis included 11 randomised controlled trials and three observational studies with data for 20743 patients. Compared with standard therapy, guided selection of antiplatelet therapy was associated with a reduction in major adverse cardiovascular events (RR 0·78, 95% CI 0·63–0·95, p=0·015) and reduced bleeding, although not statistically significant (RR 0·88, 0·77–1·01, p=0·069). Cardiovascular death (RR 0·77, 95% CI 0·59–1·00, p=0·049), myocardial infarction (RR 0·76, 0·60–0·96, p=0·021), stent thrombosis (RR 0·64, 0·46–0·89, p=0·011), stroke (RR 0·66, 0·48–0·91, p=0·010), and minor bleeding (RR 0·78, 0·67–0·92, p=0·0030) were reduced with guided therapy compared with standard therapy. Risks of all-cause death and major bleeding did not differ between guided and standard approaches. Outcomes varied according to the strategy used, with an escalation approach associated with a significant reduction in ischaemic events without any trade-off in safety, and a de-escalation approach associated with a significant reduction in bleeding, without any trade-off in efficacy.

Interpretation

Guided selection of antiplatelet therapy improved both composite and individual efficacy outcomes with a favourable safety profile, driven by a reduction in minor bleeding, supporting the use of platelet function or genetic testing to optimise the choice of agent in patients undergoing PCI.

DOI: 10.1016/S0140-6736(21)00533-X

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00533-X/fulltext