接受经导管主动脉瓣植入术的重度主动脉瓣狭窄患者的冠状动脉疾病管理：随机对照试验的系统评价与荟萃分析。
完整摘要 · 中文译文
背景：在接受经导管主动脉瓣植入术（TAVI）的重度主动脉瓣狭窄患者中，冠状动脉疾病的最佳管理策略仍不确定。 目的：我们旨在比较接受TAVI的患者中常规冠状动脉血运重建与保守管理的临床结局，并通过荟萃分析随机试验评估各血运重建策略的相对有效性。 方法：我们进行了一项成对荟萃分析，比较经皮冠状动脉介入治疗（PCI）与保守治疗，并进行了一项网络荟萃分析，比较各策略的相对有效性，包括造影指导的PCI和生理学指导的PCI。主要结局为研究定义的复合终点——主要不良心血管事件（MACE）。次要终点包括全因死亡、心血管死亡、心肌梗死、卒中、非计划血运重建和大出血等个体结局。 结果：系统评价纳入五项试验（N=1,644例患者），主要定量合成纳入四项（N=1,476）。与保守治疗相比，常规PCI与较低的MACE风险（风险比[RR] 0.80，95%置信区间[CI]：0.65-0.98）和非计划血运重建风险（RR 0.30，95% CI：0.11-0.83）相关，并与大出血风险增加相关（RR 1.57，95% CI：1.07-2.32）。在网络荟萃分析中，与保守治疗相比，生理学指导的PCI显著降低了MACE、卒中和非计划血运重建。 治疗，并且在血运重建策略中所有缺血性结局方面排名最高。 结论：在接受经导管主动脉瓣植入术（TAVI）转诊的患者中，与保守治疗相比，常规血运重建可降低缺血性结局的风险。在此背景下，生理学指导的经皮冠状动脉介入治疗（PCI）可能在现有策略中具有最有利的疗效特征。（PROSPERO：CRD420261330194）。
完整摘要 · 英文原文
BACKGROUND: The optimal management of coronary artery disease in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains uncertain. AIMS: We aimed to compare clinical outcomes between routine coronary revascularisation and conservative management in patients undergoing TAVI and to assess the relative effectiveness of individual revascularisation strategies by performing a meta-analysis of randomised trials. METHODS: We conducted a pairwise meta-analysis comparing percutaneous coronary intervention (PCI) with conservative treatment and a network meta-analysis comparing the relative effectiveness of individual strategies, including angiography-guided and physiology-guided PCI. The primary outcome was a study-defined composite endpoint of major adverse cardiovascular events (MACE). Secondary endpoints included the individual outcomes of all-cause death, cardiovascular death, myocardial infarction, stroke, unplanned revascularisation, and major bleeding. RESULTS: Five trials (N=1,644 patients) were included in the systematic review, and four were included in the primary quantitative synthesis (N=1,476). Compared with conservative treatment, routine PCI was associated with lower risks of MACE (risk ratio [RR] 0.80, 95% confidence interval [CI]: 0.65-0.98) and unplanned revascularisation (RR 0.30, 95% CI: 0.11-0.83) and an increased risk of major bleeding (RR 1.57, 95% CI: 1.07-2.32). In the network meta-analysis, physiology-guided PCI significantly reduced MACE, stroke, and unplanned revascularisation compared with conservative treatment and ranked highest for all ischaemic outcomes among revascularisation strategies. CONCLUSIONS: Among patients referred for TAVI, routine revascularisation reduces the risk of ischaemic outcomes compared with conservative treatment. In this setting, physiology-guided PCI may be associated with the most favourable efficacy profile across available strategies. (PROSPERO: CRD420261330194).