Evidence for use of coronary Stents - A hierarchical Bayesian meta-analysis
Evidence for use of coronary Stents - A hierarchical Bayesian meta-analysis
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DOI：
10.7326/0003-4819-138-10-200305200-00005
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发表时间：
2003-05-20
影响因子：
39.2
通讯作者：
Joseph, L
中科院分区：
文献类型：
--
作者：
Brophy, JM;Belisle, P;Joseph, L
背景资料：冠状动脉支架广泛应用于介入性心脏病，但目前对常规冠状动脉支架术与标准经皮腔内冠状动脉成形术（PTCA）和限制性支架术的定量系统综述目的：总结比较常规冠状动脉支架术与标准PTCA的所有随机临床试验的结果。数据来源：使用关键词血管成形术和支架检索电子数据库。还审查了已识别文章的参考文献。此外，我们还检索了几个著名的普通医学和心脏病学期刊，并咨询了一些已知的进行系统评价的机构。研究选择：所有比较性随机临床试验都包括在内，除了那些涉及直接血管成形术治疗急性心肌梗死的试验。数据提取：遵循指定的协议，由两位作者独立提取数据。结果评估总死亡率，心肌梗死，血管造影再狭窄，冠状动脉搭桥手术，重复PTCA，和自由从angina.Data合成：结果合成使用贝叶斯分层随机效应模型。共确定了29项试验，涉及9918例患者。没有证据表明常规冠状动脉支架植入术和标准PTCA在死亡或心肌梗死（比值比，0.90 [95%可信区间[CrI]，0.72 - 1.11]）或需要冠状动脉旁路手术（比值比，1.01 [CrI，0.79 - 1.31]）方面存在差异。冠状动脉支架植入术降低了再狭窄率（比值比，0.52 [CrI，0.37 - 0.69]）和重复PTCA的需要（比值比，0.59 [CrI，0.50 - 0.68]）。这些试验显示了从PTCA到支架植入术的广泛交叉率。通过使用乘法模型，交叉率每增加10%，重复血管成形术的需要减少约8%（比值比乘数，1.08 [CrI，0.98至1.18]）。与经皮腔内冠状动脉成形术联合临时支架植入术相比，常规支架植入术可能使重复血管成形术的需要减少了每100例治疗者不到4至5例。研究不盲目，并建议一个可能高估的benefit.Conclusions：在随机临床试验的对照环境中，常规冠状动脉支架植入术是安全的，但可能不与死亡率，急性心肌梗死，或冠状动脉搭桥手术与标准PTCA临时支架植入术相比，具有重要的降低。冠状动脉支架植入术与血管造影再狭窄率的显著降低和随后重复PTCA的需要相关，尽管由于试验设计，这种获益可能被高估。常规支架植入术减少重复血管成形术的增量受益随着支架植入术与常规PTCA交叉率的增加而减少。
Background: Coronary stents are widely used in interventionall cardiology, but a current quantitative systematic overview comparing routine coronary stenting with standard percutaneous transluminal coronary angioplasty (PTCA) and restricted stenting (provisional stenting) has not been published.Purpose: To summarize results from all randomized clinical trials comparing routine coronary stenting with standard PTCA.Data Sources: Electronic databases were searched by using the key words angioplasty and stent. References from identified articles were also reviewed. In addition, several prominent general medical and cardiology journals were searched and agencies known to perform systematic reviews were consulted.Study Selection: All comparative randomized clinical trials were included, except those involving primary angioplasty for the treatment of acute myocardial infarction.Data Extraction: A specified protocol was followed, and two of the authors independently extracted the data. Outcomes assessed were total mortality, myocardial infarction, angiographic restenosis, coronary artery bypass surgery, repeated PTCA, and freedom from angina.Data Synthesis: The results were synthesized by using a Bayesian hierarchical random-effects model. A total of 29 trials involving 9918 patients were identified. There was no evidence for a difference between routine coronary stenting and standard PTCA in terms of deaths or myocardial infarctions (odds ratio, 0.90 [95% credible interval [CrI], 0.72 to 1.11]) or the need for coronary artery bypass surgery (odds ratio, 1.01 [CrI, 0.79 to 1.31]). Coronary stenting reduced the rate of restenosis (odds ratio, 0.52 [CrI, 0.37 to 0.69]) and the need for repeated PTCA (odds ratio, 0.59 [CrI, 0.50 to 0.68]). The trials showed a wide range of crossover rates from PTCA to stenting. By use of a multiplicative model, each 10% increase in crossover rate decreased the need for repeated angioplasty by approximately 8% (odds ratio multiplying factor, 1.08 [CrI, 0.98 to 1.18]). Routine stenting probably reduces the need for repeated angioplasty by fewer than 4 to 5 per 100 treated persons compared with PTCA with provisional stenting. Studies were not blinded and suggest a bias with a possible overestimation of this benefit.Conclusions: in the controlled environment of randomized clinical trials, routine coronary stenting is safe but probably not associated with important reductions in rates of mortality, acute myocardial infarction, or coronary artery bypass surgery compared with standard PTCA with provisional stenting. Coronary stenting is associated with substantial reductions in angiographic restenosis rates and the subsequent need for repeated PTCA, although this benefit may be overestimated because of trial designs. The incremental benefit of routine stenting for reducing repeated angioplasty diminishes as the crossover rate of stenting with conventional PTCA increases.