本文由小咖机器人翻译整理

期刊来源：Lancet

原文链接：https://doi.org/10.1016/S0140-6736(23)02454-6

摘要内容如下：

背景

先前的荟萃分析显示，与单独的血管造影引导相比，血管内成像引导的经皮冠状动脉介入治疗（PCI）降低了复合不良事件的风险。然而，这些研究不足以显示血管内成像引导是否能减少全因死亡或全因心肌梗死，并且大多数先前的血管内成像研究是使用血管内超声而不是光学相干断层扫描（Oct）（一种较新的成像模式）进行的。我们的目的是评估血管内成像引导的PCI和血管造影引导的PCI与药物洗脱支架的比较性能。

方法

对于本系统回顾和更新的荟萃分析，我们检索了MEDLINE、EMBASE和Cochrane数据库中从开始到2023年8月30日的研究，这些研究将接受药物洗脱支架PCI的患者随机分配到血管内超声或Oct或两者，或单独进行血管造影以指导干预。由两名研究人员独立完成搜索并提取研究水平的数据。主要终点是靶病变失败，定义为心源性死亡、靶血管-心肌梗死（TV-MI）或靶病变血运重建的复合因素，在随机分配接受血管内成像（血管内超声或Oct）与血管造影指导的患者中进行评估。我们进行了一项标准的频率学家荟萃分析以产生直接数据，并进行了一项网络荟萃分析以产生间接数据和总体治疗效果。结果表示为相对风险（RR），在报告的最长随访时间内具有95%的CI。本研究已在国际前瞻性系统评价注册中心（Prospero，编号CRD42023455662）注册。

调查结果

确定了22项试验，其中15964名患者被随机分组并随访，加权平均随访时间为24.7个月（每项研究的最长随访时间为6至60个月）。与血管造影引导的PCI相比，血管内成像引导的PCI降低了靶病变失败的风险（RR 0.71[95%CI 0.63~0.80]；P<0.0001），这是由于心源性死亡风险的降低（RR 0.55[95%CI 0.41-0.75]；P=0.0001），TV-MI（RR 0.82[95%CI 0.68~0.98]；P=0.030）和靶病变血运重建（RR 0.72[95%CI 0.60-0.86]；P=0.0002）。血管内成像引导也降低了支架血栓形成的风险（RR 0.52[95%CI 0.34-0.81]；P=0.0036），所有心肌梗死（RR 0.83[95%CI 0.71~0.99]；P=0.033），全因死亡（RR 0.75[95%CI 0.60-0.93]；P=0.0091）。Oct引导和血管内超声引导PCI的结果相似。

解释

与血管造影引导相比，使用Oct或血管内超声进行冠状动脉支架植入的血管内成像引导增强了PCI的安全性和有效性，降低了死亡、心肌梗死、再次血运重建和支架血栓形成的风险。

英文原文如下：

Abstracts

BACKGROUND  Previous meta-analyses have shown reduced risks of composite adverse events with intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography guidance alone. However, these studies have been insufficiently powered to show whether all-cause death or all myocardial infarction are reduced with intravascular imaging guidance, and most previous intravascular imaging studies were done with intravascular ultrasound rather than optical coherence tomography (OCT), a newer imaging modality. We aimed to assess the comparative performance of intravascular imaging-guided PCI and angiography-guided PCI with drug-eluting stents.

METHODS  For this systematic review and updated meta-analysis, we searched the MEDLINE, Embase, and Cochrane databases from inception to Aug 30, 2023, for studies that randomly assigned patients undergoing PCI with drug-eluting stents either to intravascular ultrasound or OCT, or both, or to angiography alone to guide the intervention. The searches were done and study-level data were extracted independently by two investigators. The primary endpoint was target lesion failure, defined as the composite of cardiac death, target vessel-myocardial infarction (TV-MI), or target lesion revascularisation, assessed in patients randomly assigned to intravascular imaging guidance (intravascular ultrasound or OCT) versus angiography guidance. We did a standard frequentist meta-analysis to generate direct data, and a network meta-analysis to generate indirect data and overall treatment effects. Outcomes were expressed as relative risks (RRs) with 95% CIs at the longest reported follow-up duration. This study was registered with the international prospective register of systematic reviews (PROSPERO, number CRD42023455662).

FINDINGS  22 trials were identified in which 15 964 patients were randomised and followed for a weighted mean duration of 24·7 months (longest duration of follow-up in each study ranging from 6 to 60 months). Compared with angiography-guided PCI, intravascular imaging-guided PCI resulted in a decreased risk of target lesion failure (RR 0·71 [95% CI 0·63-0·80]; p<0·0001), driven by reductions in the risks of cardiac death (RR 0·55 [95% CI 0·41-0·75]; p=0·0001), TV-MI (RR 0·82 [95% CI 0·68-0·98]; p=0·030), and target lesion revascularisation (RR 0·72 [95% CI 0·60-0·86]; p=0·0002). Intravascular imaging guidance also reduced the risks of stent thrombosis (RR 0·52 [95% CI 0·34-0·81]; p=0·0036), all myocardial infarction (RR 0·83 [95% CI 0·71-0·99]; p=0·033), and all-cause death (RR 0·75 [95% CI 0·60-0·93]; p=0·0091). Outcomes were similar for OCT-guided and intravascular ultrasound-guided PCI.

INTERPRETATION  Compared with angiography guidance, intravascular imaging guidance of coronary stent implantation with OCT or intravascular ultrasound enhances both the safety and effectiveness of PCI, reducing the risks of death, myocardial infarction, repeat revascularisation, and stent thrombosis.

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