Meta-analysis Of Randomized Controlled Trials Of Gualou Xiebai Prescriptions For The Adjuvant Treatment Of Coronary Heart Disease And Its Network Pharmacology Stud

Purpose:1.To evaluate the efficacy and safety of Gualou Xiebai decoctions in the complementary treatment of coronary atherosclerotic heart disease（CHD）via meta-analysis.2.To characterize the common herbs used in conjunction with Gualou and Xiebai via data-mining methods,and to predict its potential underlying pharmacological mechanisms via network pharmacology.Material and method:1.Meta-analysis of randomized controlled trials（RCTs）using Gualou Xiebai decoctions as complementary treatment of CHDRCTs published in CNKI,Wanfang,CQVIP,Pubmed and Cochrane Library databases were searched from 1^st January 2001 to 31^st December 2020.Selection of studies were in strict accordance with the inclusion and exclusion criteria.Primary endpoints included cardiovascular events and echocardiographic evaluation.Secondary endpoints were clinical symptoms improvement,angina reduction,Seattle Angina Questionnaire（SAQ）scores,Canadian Cardiovascular Society Angina Score（CCSAS）scores,electrocardiogram（ECG）assessment,and nitroglycerin usage.Safety profile was assessed through adverse drug events.All included RCTs were evaluated using Cochrane risk-of-bias tool 2.0（Ro B 2）.Results were pooled and analyzed using Rev Man 5.4.1 software,and sensitivity analysis was employed to outcomes with high inter-study heterogeneity.2.Data-mining of common herbs used in conjunction with Gualou and Xiebai in the treatment of CHDUsing the same databases listed above,relevant clinical trials published from 1^st January2001 to 31^st December 2020 were searched.Selection of studies were in strict accordance with the inclusion and exclusion criteria.Relevant herbal formulations were extracted and analyzed to characterize and determine the common herbal combination used in present clinical settings.3.Network pharmacology of the common herbal combinationKnown chemical compounds of the common herbal combination were obtained from Traditional Chinese Medicines Systems Pharmacology Platform（TCMSP）,and selected based on their pharmacological parameters.Selected compounds were imported into BATMAN-TCM database to obtain the corresponding drug targets.On the other hand,Therapeutic Targets Database（TTD）,The Pharmacogenomics Knowledgebase（Pharm GKB）,Drug Bank Online and Dis Ge NET databases were searched to obtain disease targets related to CHD.The drug target and disease target networks were individually imported into STRING and Mentha databases to generate their first-degree protein-protein interaction（PPI）networks.Both PPI networks were then screened for common protein targets via Cytoscape 3.9.1 software,before employing two rounds of topological selection to obtain the core targets with the highest potential of pharmacological activity.Selected core targets were lastly imported into DAVID Bioinformatics Resources 6.8 database for gene ontology（GO）and Kyoto Encyclopedia of Genes and Genomes（KEGG）enrichment analysis to further predict the potential pathways.Results:1.A total of 79 RCTs were included in the meta-analysis,involving 3253 subjects in the intervention group and 3204 subjects in the control group.（1）Ro B 2 assessments suggested that the overall methodological quality of the included studies was low.（2）Pooled analysis of the primary endpoints demonstrated that the intervention group showed a significant reduction in cardiovascular events（RR 0.36,95%CI[0.14,0.94],P=0.04）,and an improvement in left ventricular ejection fraction（WMD 6.63,95%CI[4.68,8.58],P<0.0001）,both of which were statistically superior to that of the control group.（3）Pooled analysis of the secondary endpoints revealed that the intervention group significantly reduced overall clinical symptoms（RR 1.23,95%CI[1.20,1.27],P<0.00001）and angina pain（RR 1.27,95%CI[1.22,1.32],P<0.00001）,lowered recurrent angina attacks（WMD 2.17,95%CI[1.51,2.84],P<0.0001）and duration of each episode（WMD 1.99,95%CI[1.43,2.55],P<0.0001）,as compared to control group.SAQ scores were also improved （WMD 8.86,95%CI[5.59,12.13],P<0.0001）.Electrocardiogram assessment showed improvement in heart functions（RR 1.30,95%CI[1.24,1.36],P<0.00001）.Nitroglycerin usage rate（RR 1.25,95%CI[1.10,1.43],P=0.0009）and dosage（WMD 2.36,95%CI [1.99,2.58],P<0.0001）were reduced as well.All of the results above showed statistical significance,as compared to the control group.（4）Both groups showed no statistical difference in the occurrence of adverse drug events,despite the intervention group suggesting a strong tendency to reduce these adverse reactions（RR 0.61,95%CI[0.37,0.99],P=0.05）.2.A total of 789 herbal formulations comprising of Gualou and Xiebai were collected.（1）Frequency analysis revealed that the top 20 herbs used in the treatment of CHD today are Gualou,Xiebai,Danshen,Banxia,Chuanxiong,Guizhi,Huangqi,Honghua,Danggui,Chishao,Fuling,Yujin,Gancao,Zhishi,Zhigancao,Chenpi,Sanqi,Taoren,Zhiqiao,and Dangshen.（2）Medicinal properties commonly deployed are of warm and pungent nature,supplemented by herbs of neutral,cool,sweet and bitter properties.These herbs show a high attribution to the lung-meridian,followed by the heart-,stomach-,spleen-,and liver-meridians.（3）Gualou-Xiebai is most commonly used in combination with Danshen and Banxia in the management of CHD in present clinical settings.3.Network pharmacology of the above herbal combination predicted 153 potential protein targets.（1）Potential herbal compounds include diosmetin,spinasterol,schottenol,hesperetin,quercetin,naringenin,salvianolic acid,danshenol,tanshindiol B,tanshinone,cavidine,stigmasterol,and baicalein.（2）Top potential protein targets include TP53,AKT1,CTNNB1,SRC,EGFR,JUN,ESR1,HSP90AA1,TNF,INS,SIRT1,HIF1A,PPARG,AR,and VEGFA.（3）GO enrichment analysis suggested that the herbal combination has various biological functions such as regulation of gene expression and transcription,modulation of hypoxic and oxidative stress response,regulation of cell proliferation and apoptotic processes.（4）KEGG enrichment analysis then revealed that the herbal combination exerts its pharmacological effects via several key pathways.Of the highest relevance and importance were fluid shear stress and atherosclerosis pathway,lipid and atherosclerosis pathway,and AGE-RAGE signaling pathway in diabetic complications.Conclusion:1.Gualou Xiebai decoctions were shown to be effective in lowering cardiovascular events,improving heart function,reducing angina pain and associated clinical symptoms,and decreasing nitroglycerin usage,when used in adjunct with standard treatment and care.These herbs also showed a good safety profile.However,due to the low quality of studies available,results should be interpreted with caution and more extensive randomized double-blinded placebo-controlled clinical trials are of interest in future studies.2.Gualou-Xiebai is most commonly coupled with Danshen and Banxia in the treatment of CHD in present clinical settings.This combination contains many bioactive chemical compounds that work synergically to exert its pharmacological effects via numerous protein targets,biological functions and pathways.Although the results obtained are predictive in nature,it presents a potential direction in which future animal and clinical studies can work towards.