Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials.
Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials.
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DOI：
10.1136/bmj.k504
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发表时间：
2018-02-21
期刊：
影响因子：
--
通讯作者：
Windecker S
中科院分区：
文献类型：
--
作者：
Siontis GC;Mavridis D;Greenwood JP;Coles B;Nikolakopoulou A;Jüni P;Salanti G;Windecker S
评估用于检测冠状动脉疾病的非侵入性诊断方法在下游检测、冠状动脉血运重建和临床结果方面的差异。系统回顾和网络荟萃分析。Medline、Medline in Process、Embase、Cochrane临床试验图书馆、PubMed、Web of Science、Scope us、世卫组织国际临床试验注册平台和ClinicalTrials.gov。诊断性随机对照试验，比较出现低风险急性冠状动脉综合征或稳定性冠状动脉疾病症状的患者的非侵入性诊断方法。随机效应网络荟萃分析综合了来自评估非侵入性诊断方式对可疑冠状动脉疾病患者下游检测和以患者为导向的结果的影响的试验的现有证据。方法包括运动心电图、负荷超声心动图、单光子发射计算机断层扫描-心肌灌注成像、实时心肌声学造影、冠状动脉CT血管成像和心血管磁共振。未公布的结果数据来自11项试验。纳入18个低危急性冠脉综合征患者试验(n=11 329)和12个疑似稳定型冠状动脉疾病患者试验(n=22 062)。在低风险急性冠脉综合征患者中，负荷超声心动图、心血管磁共振和运动心动图导致冠状动脉造影术的侵入性转诊比冠状动脉CT血管造影术少(优势比分别为0.28(95%可信区间0.14~0.57)、0.32(0.15~0.71)和0.53(0.28~1.00))。这对随后的心肌梗死风险没有影响，但估计不准确。异质性和不一致性较低。在疑似稳定性冠状动脉疾病的患者中，负荷超声心动图或单光子发射计算机断层扫描-心肌灌注成像的初始诊断策略导致下游试验比冠状动脉CT血管成像少(分别为0.24(0.08~0.74)和0.57(0.37~0.87))。然而，运动心电图的下游检测率最高。在没有明确区分策略的情况下，对死亡和心肌梗死的估计是不准确的。对于低风险急性冠状动脉综合征患者，负荷超声心动图或心血管磁共振的初步诊断策略与非侵入性解剖检查相比，较少转诊有创冠状动脉造影术和血管重建术，对未来的心肌梗死风险没有明显影响。对于可疑的稳定性冠状动脉疾病，对于随后需要进行有创冠状动脉造影术的诊断策略之间没有明显的区别，也不能排除心肌梗死风险的差异。PROSPERO注册号CRD42016049442。
To evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease. Systematic review and network meta-analysis. Medline, Medline in process, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, SCOPUS, WHO International Clinical Trials Registry Platform, and Clinicaltrials.gov. Diagnostic randomised controlled trials comparing non-invasive diagnostic modalities in patients presenting with symptoms suggestive of low risk acute coronary syndrome or stable coronary artery disease. A random effects network meta-analysis synthesised available evidence from trials evaluating the effect of non-invasive diagnostic modalities on downstream testing and patient oriented outcomes in patients with suspected coronary artery disease. Modalities included exercise electrocardiograms, stress echocardiography, single photon emission computed tomography-myocardial perfusion imaging, real time myocardial contrast echocardiography, coronary computed tomographic angiography, and cardiovascular magnetic resonance. Unpublished outcome data were obtained from 11 trials. 18 trials of patients with low risk acute coronary syndrome (n=11 329) and 12 trials of those with suspected stable coronary artery disease (n=22 062) were included. Among patients with low risk acute coronary syndrome, stress echocardiography, cardiovascular magnetic resonance, and exercise electrocardiograms resulted in fewer invasive referrals for coronary angiography than coronary computed tomographic angiography (odds ratio 0.28 (95% confidence interval 0.14 to 0.57), 0.32 (0.15 to 0.71), and 0.53 (0.28 to 1.00), respectively). There was no effect on the subsequent risk of myocardial infarction, but estimates were imprecise. Heterogeneity and inconsistency were low. In patients with suspected stable coronary artery disease, an initial diagnostic strategy of stress echocardiography or single photon emission computed tomography-myocardial perfusion imaging resulted in fewer downstream tests than coronary computed tomographic angiography (0.24 (0.08 to 0.74) and 0.57 (0.37 to 0.87), respectively). However, exercise electrocardiograms yielded the highest downstream testing rate. Estimates for death and myocardial infarction were imprecise without clear discrimination between strategies. For patients with low risk acute coronary syndrome, an initial diagnostic strategy of stress echocardiography or cardiovascular magnetic resonance is associated with fewer referrals for invasive coronary angiography and revascularisation procedures than non-invasive anatomical testing, without apparent impact on the future risk of myocardial infarction. For suspected stable coronary artery disease, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, and differences in the risk of myocardial infarction cannot be ruled out. PROSPERO registry no CRD42016049442.
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为冠状动脉造影术的非ST急性急性冠状动脉综合征的患者选择：荷兰的全国临床小插图研究。
影响因子：
2.9
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2.2
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