Thromboelastography Reliably Monitors The Antiplatelet Drug Effect:A Systematicreview And Meta-Analysis

Objective:Thromboelastography(TEG),as a tool to evaluate bleeding and coagulation function during operation and to guide patients’ blood transfusion,is widely used in heart and liver surgery and trauma first aid,but it is still controversial as an evaluation index of antiplatelet drugs.The purpose of this study is to evaluate the reliability of TEG as an evaluation index for the efficacy of clopidogrel,establish an effective and feasible evaluation system for the efficacy of antiplatelet drugs,and provide a basis for the use of individualized antiplatelet drugs.Methods: The search term was established from the database establishment to October2022.According to the PICOS principle,Pub Med,Em Base,and Cochrane library were searched using a combination of medical free words and subject words for studies using TEG,LTA,Verify Now,and VASP to detect platelet reactivity(PR)and report major cardiovascular adverse events(MACE).Relevant data were extracted from the evaluation literature based on the QUADAS-2 scale,and the risk ratio(RR)and 95%confidence interval(CI)of TEG study endpoints were calculated using the random-effect model or fixed-effect model using stata16 and Revman5.4 software.Diagnostic parameters included sensitivity,specificity,negative and positive likelihood ratios(NLR and PLR),diagnostic ratio ratio(DOR),and AUC of TEG,LTA Verify Now,and VASP.Results:(1)A total of 1,269 records were identified through electronic search,of which1190 records were excluded due to repetitive and unrelated topics.The full texts of the remaining 79 articles were retrieved for further evaluation,of which articles were excluded due to insufficient data(n= 29),reporting of other results(n =5),and reporting of the same study population(n = 4).A total of 41 studies were included,5 of whichmeasured platelet reactivity using two platelet monitoring techniques(PFT)simultaneously,TEG for PR in 15 studies and 5,579 patients,LTA for PR in 9 studies and 6,439 patients,and Verify Now for PR in 14 studies and 14,706 patients.VASP was used to evaluate PR in 8 studies and 3,461 patients were enrolled.(2)In patients diagnosed with high platelet reactivity by TEG,the incidence of MACE increased significantly after administration of clopidogrel(RR: 0.20;95%CI:0.14-0.28;P<0.0001)。TEG-guided antiplatelet therapy reduced the incidence of ischemic events in our patient(RR:0.47;95%CI:0.25-0.88;P=0.019)without increasing the incidence of bleeding events.TEG-guided antiplatelet agents were used to reduce the probability of myocardial infarction in patients after PCI(RR: 0.533;The 95%CI was 0.34-0.85;P <0.05),but there was no difference in all-cause infarction and in-stent thrombosis.(3)The pooled sensitivity and specificity of TEG were 0.61(95% CI: 0.48–0.73)and0.82(95% CI: 0.76–0.87),respectively.The combined PLR and NLR were 3.4(95%CI: 2.7-4.4)and 0.48(95% CI: 0.35-0.64),respectively;The combined DOR was 7(95% CI: 5-11)and AUC was 0.81(95% CI: 0.77-0.84).The pooled sensitivity and specificity for LTA were 0.51(95% CI 0.40-0.62)and 0.71(95% CI 0.65-0.76),respectively.The combined PLR and NLR were 1.7(95% CI,1.5-2.0)and 0.69(95% CI,0.58-0.82),respectively;The combined DOR was 3(95% CI:2-3)and AUC was 0.67(95% CI: 0.67-0.71).The pooled sensitivity and specificity for the VerifyNow assay were 0.66(95% CI:0.54-0.76)and 0.69(95% CI: 0.61-0.76),respectively.The combined PLR and NLR were 2.1(95% CI: 1.6-2.8)and 0.49(95% CI: 0.36-0.68),respectively;The combined DOR was 4(95% CI: 3-7)and AUC was 0.73(95% CI: 0.69-0.77).The pooled sensitivity and specificity for VASP were 0.72(95% CI 0.48-0.87)and 0.53(95% CI 0.41-0.64),respectively.The combined PLR and NLR were 1.5(95% CI:1.2-2.0)and 0.54(95% CI: 0.29-1.00),respectively;The combined DOR was 3(95% CI:1-7)and AUC was 0.63(95% CI: 0.58-0.67).Conclusion: Studies have shown that patients with high platelet reactivity diagnosed by TEG are prone to ischemic events,and the use of clopidogrel guided by TEG can reduce the occurrence of ischemic events without increasing the occurrence of bleeding events.The prediction indexes of TEG(including sensitivity,specificity,PLR,NLR and AUC)are better than the other three methods.Although there is a lack of direct comparison between these four methods,the indirect comparison results show that TEG has the highest accuracy.