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Meta-Analysis
. 2020 Jan;107(1):20-32.
doi: 10.1002/bjs.11384. Epub 2019 Dec 6.

Umbrella review and meta-analysis of antiplatelet therapy for peripheral artery disease

G K Ambler  1   2 , C-A Waldron  3 , U B Contractor  2 , R J Hinchliffe  1   2 , C P Twine  1   2
Affiliations
Meta-Analysis

Umbrella review and meta-analysis of antiplatelet therapy for peripheral artery disease

G K Ambler et al. Br J Surg. 2020 Jan.

Abstract
in English, Spanish

Background: The literature on antiplatelet therapy for peripheral artery disease has historically been summarized inconsistently, leading to conflict between international guidelines. An umbrella review and meta-analysis was performed to summarize the literature, allow assessment of competing safety risks and clinical benefits, and identify weak areas for future research.

Methods: MEDLINE, Embase, DARE, PROSPERO and Cochrane databases were searched from inception until January 2019. All meta-analyses of antiplatelet therapy in peripheral artery disease were included. Quality was assessed using AMSTAR scores, and GRADE analysis was used to quantify the strength of evidence. Data were pooled using random-effects models.

Results: Twenty-eight meta-analyses were included. Thirty-three clinical outcomes and 41 antiplatelet comparisons in 72 181 patients were analysed. High-quality evidence showed that antiplatelet monotherapy reduced non-fatal strokes (3 (95 per cent c.i. 0 to 6) fewer per 1000 patients), In symptomatic patients, it reduced cardiovascular deaths (8 (0 to 16) fewer per 1000 patients), but increased the risk of major bleeding (7 (3 to 14) more events per 1000). In asymptomatic patients, monotherapy reduced non-fatal strokes (5 (0 to 8) fewer per 1000), but had no other clinical benefit. Dual antiplatelet therapy caused more major bleeding after intervention than monotherapy (37 (8 to 102) more events per 1000), with very low-quality evidence of improved endovascular patency (risk ratio 4·00, 95 per cent c.i. 0·91 to 17·68).

Conclusion: Antiplatelet monotherapy has minimal clinical benefit for asymptomatic peripheral artery disease, and limited benefit for symptomatic disease, with a clear risk of major bleeding. There is a lack of evidence to guide antiplatelet prescribing after peripheral endovascular intervention.

Antecedentes: Históricamente, la literatura del tratamiento antiplaquetario en la enfermedad arterial periférica se ha sintetizado inconsistentemente, lo que ha dado lugar a divergencias entre las guías internacionales. Se efectuó una amplia revision con metaanálisis para sintetizar claramente la literatura, permitiendo evaluar los riesgos competitivos de seguridad y los beneficios clínicos, e identificar áreas poco claras susceptibles de futuras investigaciones. MÉTODOS: La búsqueda se realizó en las bases de datos MEDLINE, EMBASE, DARE, PROSPERO y Cochrane desde su inicio hasta enero de 2019. Se incluyeron todos los metaanálisis del tratamiento antiplaquetario en la enfermedad arterial periférica. Se estimó su calidad utilizando la puntuación Amstar y la consistencia de su evidencia mediante el sistema GRADE. Los datos se agruparon utilizando modelos de efectos aleatorios.

Resultados: Se incluyeron 28 metaanálisis. Se analizaron 33 resultados clínicos y 41 comparaciones antiplaquetarias en 72.181 pacientes. Una evidencia de alta calidad demostró que la monoterapia antiplaquetaria reducía los accidentes cerebrovasculares no mortales y la muerte cardiovascular en pacientes sintomáticos (3 y 8 veces menos por 1.000 pacientes, respectivamente, i.c. del 95% 0-6 y 0-16), pero aumentó el riesgo de hemorragia grave (7 veces más por 1.000, i.c. del 95% 3-14). En pacientes asintomáticos, la monoterapia redujo los accidentes cerebrovasculares no mortales (5 veces menos por 1.000, i.c. del 95% 0-8) sin otro beneficio clínico. El doble tratamiento antiplaquetario causó más hemorragias graves después de cualquier intervención que la monoterapia (37 veces más por 1.000, i.c. del 95% 8-102), con una evidencia de muy baja calidad acerca de la mejoría de la permeabilidad endovascular (riesgo relativo 4,00, i.c. del 95% 0,91-17,68). CONCLUSIÓN: La monoterapia antiplaquetaria tiene un beneficio clínico mínimo en la enfermedad arterial periférica asintomática y un beneficio limitado en la sintomática, con un claro riesgo de hemorragia grave. No existe evidencia para recomendar la prescripción de antiagregantes plaquetarios después de una intervención endovascular periférica, situación que debería abordarse en ensayos aleatorizados con una potencia estadística adecuada.

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