长期口服抗凝药患者冠脉介入治疗后抗栓治疗方案的Meta分析

发布时间：2018-01-02 03:28

本文关键词：长期口服抗凝药患者冠脉介入治疗后抗栓治疗方案的Meta分析　出处：《山东大学》2015年硕士论文　论文类型：学位论文

【摘要】：心房颤动(Atrial Fibrillation, AF)(以下简称房颤)作为最常见的心律失常,其发病率随着人群年龄增长而逐渐升高,对于房颤患者来说,适当的抗凝治疗(华法林,Wafarin)可以有效预防卒中(Stroke)等血栓栓塞事件的发生。此外,接受外科手术、心脏瓣膜手术治疗以及长期卧床的患者也常需要长期的口服抗凝药物(Oral Anticoagulant, OAC)治疗以预防深静脉血栓、肺栓塞等血栓栓塞事件的发生。冠心病作为最常见的心血管疾病,其发病率也在逐年上升,因此,临床上正有越来越多的患者在接受长期口服抗凝药物治疗的同时因冠心病而接受冠脉介入治疗(Percutaneous Coronary Intervention, PCI)对于此类患者,在接受冠脉介入治疗后,为预防冠脉血栓及支架内血栓(Stent Thrombosis)等事件的发生,应接受双联抗血小板(Dual Antiplatelet Therapy, DAPT)(阿司匹林联合氯吡格雷)治疗,同时,为了预防卒中、深静脉血栓、肺栓塞等事件的发生,患者仍有接受抗凝药物治疗的指征,此时,联合华法林及双联抗血小板治疗治疗——三联抗栓治疗(Triple Antithrombotic Therapy, TT)——似乎是合理的选择。但是,随着抗栓药物种类的增加患者发生出血事件的几率也可能增加。因此,针对此类患者,临床工作者对于如何平衡栓塞及出血风险以及选择何种抗栓药物治疗方案仍存在较大分歧。研究目的：本研究检索现有的关于长期口服抗凝药患者冠状动脉介入治疗后抗栓治疗方案的临床试验,对其进行整合并进行meta分析,比较三联抗栓治疗(阿司匹林+氯吡格雷+华法林)与另外两种抗栓方案(1.双联抗血小板治疗(阿司匹林+氯吡格雷)；2.华法林联合氯吡格雷(Double Therapy))的安全性和有效性,以期寻找最佳的抗栓治疗方案,并为临床决策的制定提供相应的循证医学证据。研究方法：1.计算机系统检索PubMed和Cochrane Library数据库,检索时间截至2014年11月；2.根据预先设定的纳入标准对文献进行筛选,获得符合纳入标准的临床试验；3采用RevMan 5.2软件进行Meta分析。采用随机效应模型对数据进行合并,抗栓治疗方案的安全性及有效性的效应值用比值比(Odds Ratio, OR)及其95%置信区间(Confidence Interval, CI)表示。试验结果：1.共纳入18个符合标准的临床试验,其中16个实验比较了TT与DAPT的治疗效果,6个实验比较了TT与Double Therapy治疗的效果。2.TT与DAPT相比可以更有效的预防血栓事件的发生。TT有降低患者卒中事件发生率的趋势(OR,0.66; 95% CI,0.41-1.09; p=0.10),亚组分析提示,当将研究局限于非亚洲人群后,TT可以显著降低患者卒中的风险(OR,0.49; 95% CI, 0.35-0.67; p0.00001) 。TT与DAPT治疗组支架内血栓发生率相当(OR,1.07; 95% CI,0.42-2.77; p=0.88).3.TT与DAPT相比导致更多的出血事件。TT与DAPT相比导致的大出血事件(Major Bleeding) (OR,1.54; 95% CI,1.09-2.19; p=0.02)和小出血事件(Minor Bleeding) (OR,1.46; 95% CI,1.07-1.99; p=0.02)更多,但是,当将研究局限于口服抗凝治疗指征仅为房颤的临床试验时,接受TT与DAPT治疗的患者发生大出血的几率相当(OR,1.26; 95% CI,0.89-1.79; p=0.20)。4. TT与Double Therpy的死亡(Death)、卒中、支架内血栓、大出血等事件的发生率相似。结论及意义：1.长期口服抗凝药患者接受冠脉介入治疗后,三联抗栓治疗与双联抗血小板治疗相比可以更有效地预防血栓栓塞事件的发生但是会增加患者出血的风险。2.长期口服抗凝治疗患者接受冠脉介入治疗后,华法林联合氯吡格雷治疗可能成为三联抗栓治疗的替代治疗。
[Abstract]:Atrial fibrillation (Atrial Fibrillation AF) (hereinafter referred to as AF) is the most common arrhythmia, the incidence with age gradually increased, for patients with atrial fibrillation, appropriate anticoagulation (Hua Falin, Wafarin) (Stroke) can be effective for the prevention of stroke and thromboembolic events occurred. In addition, accept surgery, heart valve surgery and long-term bedridden patients often need long-term oral anticoagulation (Oral Anticoagulant, OAC) for prevention of deep vein thrombosis, pulmonary embolism and other thromboembolic events. Coronary heart disease is the most common cardiovascular disease, and its incidence is increasing, therefore, it is clinically more and more patients receiving long-term oral anticoagulant therapy at the same time due to coronary heart disease and undergoing coronary intervention (Percutaneous Coronary, Intervention, PCI) in these patients, in Percutaneous coronary intervention after treatment for prevention of coronary thrombosis and in stent thrombosis (Stent Thrombosis) and other events, should receive dual antiplatelet (Dual Antiplatelet, Therapy, DAPT) (aspirin and clopidogrel) treatment, at the same time, in order to prevent stroke, deep vein thrombosis, pulmonary embolism and other events, there were still receiving anticoagulant drug treatment indications, at this time, with Hua Falin and dual antiplatelet therapy for triple antithrombotic therapy (Triple Antithrombotic, Therapy, TT) - seems to be a reasonable choice. However, with the increase in the types of antithrombotic drugs in patients with probability of bleeding may also increase. Therefore, for these patients, the clinical workers still exist large differences on how to balance the risk of thromboembolism and bleeding as well as the choice of antithrombotic drug treatment. Objective: the purpose of this research on the long-term existing retrieval Clinical trials of antithrombotic therapy for coronary artery in patients with oral anticoagulation after interventional therapy, the integration and meta analysis, comparison of triple antithrombotic therapy (aspirin + clopidogrel + warfarin) and other two kinds of antithrombotic schemes (1. dual antiplatelet therapy (aspirin + clopidogrel A Si); 2. Double (warfarin and clopidogrel Therapy)) the efficacy and safety of antithrombotic therapy, in order to find the optimal solution, and to provide evidence for the clinical decision-making. Methods: 1. computer retrieval system of PubMed and Cochrane Library database, retrieval time as of November 2014 2.; according to the preset inclusion criteria for literature screening. For clinical trials in accordance with the inclusion criteria; 3 RevMan 5.2 software was used for Meta analysis. By using a random effects model is used to merge data, scheme of antithrombotic therapy The effect of the safety and effectiveness of the value of odds ratio (Odds Ratio OR) and its 95% confidence interval (Confidence, Interval, CI). Results: 1. a total of 18 to meet the standards of clinical trials, 16 of which were compared with TT DAPT treatment, 6 experiments have decreased in patients with stroke the incidence trend effects than the.2.TT and DAPT is TT and Double Therapy treatment compared to.TT can more effectively prevent thromboembolic events (OR, 0.66; 95% CI, 0.41-1.09; p=0.10), subgroup analysis suggests that when the research was limited to non Asian group, TT can significantly reduce the risk of stroke patients (OR, 0.49; 95% CI, 0.35-0.67; p0.00001).TT DAPT and the incidence of stent thrombosis in treatment group (OR, 1.07; 95% CI, 0.42-2.77; p=0.88.3.TT) compared with DAPT resulted in more.TT and DAPT than the bleeding bleeding incident (Major Bleeding) (OR, 1.54; 95% CI, 1.09-2.19; p=0.02) and minor bleeding events (Minor Bleeding) (OR, 1.46; 95% CI, 1.07-1.99; p=0.02) more, but when the study is confined to oral anticoagulation therapy indications only clinical trials for atrial fibrillation, TT patients treated with DAPT major a risk of bleeding (OR, 1.26; 95% CI, 0.89-1.79; p=0.20).4. TT and Double Therpy death (Death), stroke, stent thrombosis, bleeding and other events were similar. Conclusion and significance: 1. long-term oral anticoagulants in patients undergoing coronary intervention after treatment with triple antithrombotic therapy dual antiplatelet therapy can be more effective than to prevent occurrence of thromboembolic events but will increase the risk of bleeding in patients with long-term oral anticoagulant therapy in.2. patients undergoing coronary intervention after warfarin combined with clopidogrel in the treatment of replacement therapy may become triple antithrombotic therapy.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R541.4

【共引文献】