目的:强化降脂治疗(LLT)对斑块稳定性的决定性影响以及LLT过程中关键标志物与斑块稳定性之间的关系仍未受到质疑。因此,这些荟萃分析和荟萃回归旨在全面评估严格LLT对通过光学相干断层扫描(OCT)识别的最小纤维帽厚度(FCT)和最大脂质弧的影响.这项研究进一步审查了这种影响与高敏C反应蛋白(hs-CRP)变化的相关性。低密度脂蛋白胆固醇(LDL-C),或诊断为冠状动脉疾病(CAD)的患者的其他参数。
方法:在包括PubMed、Embase,和Cochrane图书馆的随机对照试验(RCT)发表至2023年6月1日。该搜索是语言无关性和针对性的RCT,详细阐述了高强度他汀类药物治疗或与其他降脂药物同时使用的他汀类药物与OCT评估的最小FCT和最大脂质弧之间的相关性。采用标准平均差(SMD)算法对连续变量进行随机影响,进行荟萃分析。这些方法与系统和荟萃分析(PRISMA)指南的首选报告项目一致。
结果:确定了涉及972名患者的12个RCTs,并动员了这些分析。荟萃分析结果描绘了强化LLT和增强的最低FCT之间的显著相关性(12项研究,972名参与者;SMD,0.87;95%CI,0.54~1.21;P<0.01),最大脂质弧降低(9项研究,564名参与者;SMD,-0.43;95%CI,-0.58至-0.29;P<0.01)。Meta回归分析确定了最低FCT升高与LDL-C降低的相关性(β,-0.0157;95%CI,-0.0292至-0.0023;P=0.025),总胆固醇(TC)(β,-0.0154;95%CI,-0.0303至-0.0005;P=0.044),和载脂蛋白B(ApoB)(β,-0.0209;95%CI,-0.0361至-0.0057;P=0.022)。然而,相对于hs-CRP/CRP的变化(β,-0.1518;95%CI,-1.3766至-1.0730;P=0.772),甘油三酯(TG)(β,-0.0030;95%CI,-0.0258至-0.0318;P=0.822),和高密度脂蛋白胆固醇(HDL-C)(β,0.0313;95%CI,-0.0965至0.1590;P=0.608)。随后的亚组荟萃分析表明,高强度他汀类药物治疗(5项研究,包括204名参与者;SMD,1.03;95%CI,0.67~1.39;P<0.01),以及包括PCSK9抗体和他汀类药物在内的组合方法(3项研究,522名参与者;SMD,1.17;95%CI,0.62~1.73;P<0.01)有助于最小FCT的增加。同样,高强度他汀类药物治疗(4项研究,183名参与者;SMD,-0.42;95%CI,-0.65至-0.19;P<0.01)或PCSK9抗体和他汀类药物的联合应用(2项研究,222名参与者;SMD,-0.98;95%CI,-1.26至-0.70;P<0.01)被证明降低了最大脂质弧。
结论:密集LLT,主要是高强度他汀类药物治疗和PCSK9抗体联合他汀类药物,在冠心病患者中,OCT对冠状动脉斑块稳定有有益的影响。冠状动脉斑块的稳定主要是由于降脂作用,没有抗炎作用。此外,降脂作用与HDL-C和TG的变化无关,但主要与LDL-C的降低有关,TC,还有ApoB.
OBJECTIVE: The definitive impacts of intensive lipid-lowering therapy (LLT) on plaque stabilization and the relationship between the key markers during LLT and plaque stability remain unquestioned. Thus, these meta-analysis and meta-regression intend to holistically evaluate the influence exerted by rigorous LLT on the minimum fibrous cap thickness (FCT) and maximum lipid arc as discerned through optical coherence tomography (OCT). This study further scrutinizes the correlation of this impact with variations in high-sensitivity C-reactive protein (hs-CRP), low-density lipoprotein cholesterol (LDL-C), or additional parameters within patients diagnosed with coronary artery disease (CAD).
METHODS: Comprehensive searches were conducted on platforms including PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) published until June 1, 2023. The search was language agnostic and targeted RCTs elaborating on the correlation between high-intensity statin therapy or statins used concomitantly with other lipid-lowering medications and the minimum FCT and maximum lipid arc as assessed by OCT. The meta-analyses were executed employing a standard mean difference (SMD) algorithm with random-effects on continuous variables. These methodologies align with the Preferred Reporting Items for Systematic and Meta-analysis (PRISMA) guidelines.
RESULTS: A spectrum of 12 RCTs engaging 972 patients were identified and mobilized for these analyses. Meta-analysis outcomes depicted a conspicuous correlation between intensive LLT and an enhanced minimum FCT (12 studies with 972 participants; SMD, 0.87; 95% CI, 0.54 to 1.21; P < 0.01), reduced maximum lipid arc (9 studies with 564 participants; SMD, -0.43; 95% CI, -0.58 to -0.29; P < 0.01). Meta-regression analysis has determined an association of elevated minimum FCT with decreased LDL-C (β, -0.0157; 95% CI, -0.0292 to -0.0023; P = 0.025), total cholesterol (TC) (β, -0.0154; 95% CI, -0.0303 to -0.0005; P = 0.044), and apolipoprotein B (ApoB) (β, -0.0209; 95% CI, -0.0361 to -0.0057; P = 0.022). However, no significant association was discerned relative to variations in hs-CRP/CRP (β, -0.1518; 95% CI, -1.3766 to -1.0730; P = 0.772), triglyceride (TG) (β, -0.0030; 95% CI, -0.0258 to -0.0318; P = 0.822), and high-density lipoprotein cholesterol (HDL-C) (β, 0.0313; 95% CI, -0.0965 to 0.1590; P = 0.608). Subsequent subgroup meta-analysis demonstrated that high-intensity statin therapy (5 studies with 204 participants; SMD, 1.03; 95% CI, 0.67 to 1.39; P < 0.01), as well as a combinative approach including PCSK9 antibodies and statins (3 studies with 522 participants; SMD, 1.17; 95% CI, 0.62 to 1.73; P < 0.01) contributed to an increase in minimum FCT. Parallelly, high-intensity statin therapy (4 studies with 183 participants; SMD, -0.42; 95% CI, -0.65 to -0.19; P < 0.01) or the combined application of PCSK9 antibodies and statins (2 studies with 222 participants; SMD, -0.98; 95% CI, -1.26 to -0.70; P < 0.01) was evidenced to decrease the maximum lipid arc.
CONCLUSIONS: Intensive LLT, mainly high-intensity statin therapy and combined PCSK9 antibody with statin, has a beneficial effect on coronary plaque stabilization derived from OCT in patients with CAD. Coronary plaque stabilization is primarily due to lipid-lowering effect, not anti-inflammatory effect. Moreover, the lipid-lowering effect has nothing to do with the changes in HDL-C and TG, but is mainly related to the reduction of LDL-C, TC, and ApoB.