Background: Traditional Chinese patent medicines (TCPMs) have been widely used to treat carotid atherosclerotic plaque (CAP) in China. However, systematic evaluation of the clinical efficacy of TCPMs for CAP is still unknown, and the comparative efficacy of different TCPMs is unclear. Objectives: This study aims to compare and rank the effectiveness and safety of different TCPMs in treating CAP using a Bayesian network meta− analysis (NMA). Methods: This NMA was performed according to the Preferred Reporting Items for Systematic Reviews and Meta− Analyses (PRISMA) Extension Statement. Eight databases were searched from their inception to August 2023 for randomized controlled trials (RCTs). The articles regarding eligibility and extracted data were screened independently by two authors. The Cochrane Risk of Bias tool was used to evaluate quality and bias. The change of carotid artery intimal− medial thickness (IMT), carotid maximal plaque area, carotid atherosclerotic plaque Course score, serum lipid levels, CRP, and adverse events rate (AER) were used as outcomes. Data from each RCTs were first pooled using random− effect pairwise meta− analyses and illustrated as odds ratios (ORs) or standardized mean differences (SMDs) with 95% confidence interval (CI). NMAs were performed using Stata17.0 software and the GeMTC package of R software to evaluate the comparative effectiveness of TCPMs, and displayed as ORs or SMDs with 95% CI. A Bayesian hierarchical random− effects model was used to conduct NMAs using the Markov Chain Monte Carlo algorithm. The GRADE partially contextualised framework was applied for NMA result interpretation. Results: NMA included 27 RCT trials with 4131 patients and nine types of TCPMs. Pairwise meta− analyses indicated that Conventional Western medicine (CWM) + TCPM was superior to CWM in reducing the IMT (SMD: − 1.26; 95% CI − 1.59 to − 0.93), the carotid maximal plaque area (SMD − 1.27; 95% CI − 1.71, − 0.82) and the carotid atherosclerotic plaque Course score (SMD − 0.72; 95% CI 95% CI − 1.20, − 0.25). NMAs demonstrated that CWM + Jiangzhiling pill (JZL) with SUCRA 70.6% exhibited the highest effective intervention for reducing IMT. CWM + SXBX (Shexiang baoxin pill) was superior to other TCPMs in reducing the carotid maximal plaque area (83.0%), the atherosclerotic plaque Course score (92.5%), TC (95.6%) and LDL (92.6%) levels. CWM + NXT (Naoxintong capsule), CWM + XS (Xiaoshuang granules/enteric capsule), and CWM + ZBT (Zhibitai) were superior to other CPMs in improving TG (90.1%), HDL (86.1%), and CRP (92.6%), respectively. No serious adverse events were reported. Conclusions: For CAP patients, CWM + XSBX was among the most effective in reducing carotid maximal plaque area, atherosclerotic plaque Course score, TC and LDL levels, and CWM + JZL was the most effective in reducing IMT. Overall, CWM + XSBX may be considered an effective intervention for the treatment of CAP. This study provides reference and evidence for the clinical optimization of TCPM selection in CAP treatment. More adequately powered, well− designed clinical trials to increase the quality of the available evidence are still needed in the future due to several limitations.
Keywords: Traditional Chinese medicine; Chinese patent medicines; Carotid atherosclerotic plaque; Network meta-analysis; Randomized controlled trials
Wenquan Su and Xiaolong Xie contributed equally to this work.
Carotid atherosclerotic plaque (CAP) is an important cause of carotid artery stenosis and has a high global prevalence. CAP global prevalence was approximately 21.1% in 2020, equivalent to 815.76 million people, and carotid artery stenosis global prevalence was approximately 1.5%, equivalent to 57.79 million people between the ages of 30 and 79 [[
Currently, carotid endarterectomy (CEA), carotid stent placement (CAS), and optimal drug therapy (OMT) are the primary treatments for CAP and carotid artery stenosis [[
Traditional Chinese patent medicines (TCPMs) with reliable pharmaceutical ingredients and manufacturing processes have been widely used to treat chronic diseases as an important part of Traditional Chinese medicine (TCM) in China [[
Table 1 Ingredients and traditional effects of the included TCPMs
TCPMs Ingredients (pin yin) Traditional effects Tongxinluo capsule (TXL) Tonifying qi, activating blood, freeing the collateral vessels to relieve pain Xiaoshuang granules/enteric capsule (XS) Tonifying qi, activating blood, freeing the collateral vessels Naoxintong capsule (NXT) Tonifying qi, activating blood, resolving stasis, freeing the collateral vessels Xuesaitong capsule/soft capsule (XST) Notoginseng Total Saponins (Sanqi Zongzaogan) Activating blood, resolving stasis, activating collaterals Jiangzhiling pill (JZL) enriching the kidney, nourishing the liver, tonifying blood Pushen capsule (PS) Activating blood, resolving stasis, enriching yin, resolving turbidity Shexiang baoxin pill (SXBX) Moschus (Rengong Shengxiang), Ginseng extract (Renshen Tiquwu), Bovis calculus artifactus (Rengong Niuhuang)、 Opening the orifices with aroma, tonifying qi Zhibitai (ZBT) Resolving phlegm, resolving stasis, fortifying the spleen, harmonizing the stomach Dengzhan shengmai capsule (DZSM) Tonifying qi, enriching yin, activating blood
This NMA was performed per the Preferred Reporting Items for Systematic Reviews and Meta− Analyses (PRISMA) Extension Statement [[
RCTs published in Chinese or English, regardless of blinding, publication status, were included.
A patient was diagnosed with CAP, including hypertension, coronary atherosclerotic heart disease, and diabetes, using carotid ultrasound [[
The experiment group was administrated TCPMs, regardless of dosage and treatment duration, combined with CWM per guidelines. Patients in the control group received CWM with or without a placebo (PBO) of TCPM or CWM plus another TCPM. Considering that patients with CAP were complicated with hyperlipidemia, hypertension, diabetes, coronary heart disease, cerebral infarction and other underlying diseases, the CWM was primarily used against antihypertensive, hypoglycemic, hypolipidemic, and anti− platelet aggregation.
The primary outcome was the change in indicators of carotid artery IMT at the end of treatment. The additional outcomes were the change in the carotid maximal plaque area, carotid atherosclerotic plaque Course score, serum levels of lipids, CRP, and adverse events rate (AER) at the end of treatment.
Studies that met the following criteria were excluded: (
We searched the following databases from their inception to August 2023. Chinese databases include CNKI, WanFang Data, VIP, and CBM, while English databases include PubMed, Embase, the Cochrane Library, and Web of Science. Additionally, other databases include clinical trial registries (WHO ICTRP, Clinical Trials, and ChiCTR) and Allied and Complementary Medicine Database (AMED). The literature search was constructed around search terms for "Chinese patent medicines", "carotid atherosclerotic plaque", and "randomized controlled trial" and adapted for each database as necessary. Additional file 1 provides a detailed and specific search strategy.
We screened the retrieved articles during the searches and two authors independently conducted a comprehensively assessment of potentially eligible articles according to the inclusion/exclusion criteria. The following data were extracted: author, year of publication, place of conduct, baseline characteristics (sex, age), sample size, intervention(s), comparison(s), course of treatment, and outcome(s). Any disagreement was resolved by discussion until a consensus was reached or by consulting a third author.
All authors received advanced training and used the Cochrane Risk of Bias tool for quality assessment [[
We conducted a head− to− head comparisons pairwise meta− analyses between CWM combined with TCPM and CWM using Review Manager 5.3. We conducted an NMA analysis using Stata17.0 software and the GeMTC package of R software, applying the Markov Chain Monte Carlo algorithm and a Bayesian hierarchical random− effects model [[
Initially, the search strategy yielded 2,159 articles. Duplication resulted in the removal of 1,308 articles. The remaining 851 articles were filtered further and excluded according to the eligibility and exclusion criteria. After rereading the full texts, 27 studies remained for quantitative synthesis [[
Graph: Fig. 1Flowchart of the literature screening process
There were 25 Chinese articles and two English articles involving 11 interventions. All the articles were conducted in China. Overall, 4,131 patients (
Most articles were open− label trials except for two double− blind trials. Both groups were based on CWM, with TCPM addition in the treatment group and PBO addition or blank to the control group, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 6), CWM + XS vs. CWM (n = 2), CWM + NXT vs. CWM (n = 3), CWM + XST vs. CWM (n = 2), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 3), CWM + SXBX vs. CWM (n = 3), CWM + ZBT vs. CWM (n = 3), and CWM + DZSM vs. CWM (n = 2). There were no significant differences in gender and age between the study groups with comparable baselines, and most were middle− aged or elderly. Table 2 presents the details of the included study characteristics.
Table 2 Characteristics of the studies included in this network meta− analysis
Study ID Study design Sample size (T/C) Sex (M/F) Average age Inventions Course Dosage Outcomes [ RCT 1212 (607/605) T: 367/240 C: 355/250 T: 61.4 ± 8.4 C: 61.4 ± 8.2 T: CWM + TXL C: CWM + PBO 24 months 1560 mg bid po 1,2,4,5,6,7,8,9 [ RCT 168 (84/84) T: 56/28 C:55/29 T: 58.6 ± 3.2 C: 59.1 ± 2.7 T: CWM + TXL C: CWM 6 months 1040 mg tid po 1,2,8 [ RCT 64 (32/32) T: 18/14 C:15/17 T: 57.4 ± 6.7 C: 56.8 ± 7.1 T: CWM + TXL C: CWM 6 months 1040 mg tid po 1,2,4,5,6,7,8,9 [ RCT 106 (53/53) T: 33/20 C:31/22 T: 62.5 ± 9.8 C: 63.8 ± 9.4 T: CWM + TXL C: CWM 12 months 780 mg tid po 1,2,3,9 [ RCT 60 (30/30) T: 17/13 C:20/10 T: 58.6 ± 8.3 C: 61.0 ± 7.6 T: CWM + TXL C: CWM 12 months 780 mg tid po 1,3,4,5,6,7,8,9 [ RCT 120 (60/60) T: 33/27 C:29/31 T: 53.4 ± 12.8 C: 55.8 ± 11.7 T: CWM + TXL C: CWM 5 months 780 mg tid po 1,2,4,5,6,7,9 [ RCT 70 (35/35) T: 17/18 C:19/16 T: 61.2 ± 11.5 C: 63.5 ± 10.7 T: CWM + TXL C: CWM 3 months 1040 mg tid po 1,4,5,6,7,8,9 [ RCT 90 (45/45) – – T: CWM + XS C: CWM 3 months 400 mg tid po 1 [ RCT 192 (96/96) T: 58/38 C:56/40 T: 62.1 ± 8.3 C: 61.9 ± 8.1 T: CWM + XS C: CWM 6 months 400 mg tid po 1,4,5,6,7,9 [ RCT 110 (55/55) – – T: CWM + NXT C: CWM 6 months 1200 mg tid po 1 [ RCT 134 (67/67) T: 38/29 C:35/32 T: 58.7 ± 12.4 C: 64.3 ± 13.5 T: CWM + NXT C: CWM 6 months 1200 mg tid po 1,4,5,6,7,8 [ RCT 80 (40/40) – – T: CWM + NXT C: CWM 3 months 1600 mg tid po 1,2,8 [ RCT 71 (36/35) T: 21/15 C:20/15 T: 64.8 ± 12.4 C: 64.3 ± 13.5 T: CWM + XST C: CWM 3 months 100 mg tid po 1,3,9 [ RCT 106 (53/53) T: 30/23 C:31/22 T: 68.0 ± 4.1 C: 68.5 ± 4.3 T: CWM + XST C: CWM 6 months 100 mg tid po 1,2,4,5,6 [ RCT 100 (50/50) T: 25/25 C:23/27 T: 56.0 ± 10.0 C: 55.0 ± 11.0 T: CWM + JZL C: CWM 3 months 8000 mg bid po 1,2,4,5,6,7,9 [ RCT 186 (94/92) T: 54/40 C:52/40 T: 68.1 ± 1.4 C: 67.2 ± 1.1 T: CWM + JZL C: CWM 12 months 1000 mg tid po 1,2,4,5,6,7,9 [ RCT 145 (73/72) T: 45/28 C:45/27 T: 61.1 ± 7.5 C: 61.1 ± 7.5 T: CWM + PS C: CWM 4 months 1000 mg tid po 1,3,4,5,6,7 [ RCT 76 (38/38) T: 25/13 C:26/12 T: 64.1 ± 4.2 C: 63.3 ± 5.2 T: CWM + PS C: CWM 12 months 1000 mg tid po 1,2, 4,5,6,7,8,9 [ RCT 73 (37/36) – – T: CWM + PS C: CWM 6 months 1000 mg tid po 1,2,4,5,6,7,8,9 [ RCT 80 (39/41) T: 24/15 C:25/16 T: 74.2 ± 15.8 C: 72.7 ± 12.4 T: CWM + SXBX C: CWM 6 months 450 mg tid po 1,2,3,4,5,6,7,8,9 [ RCT 116 (58/58) T: 32/26 C:33/25 T: 66.0 ± 8.2 C: 65.2 ± 8.0 T: CWM + SXBX C: CWM 3 months 450 mg tid po 1,2,4,5,6 [ RCT 62 (32/30) T: 19/13 C:18/12 T: 59.0 ± 7.0 C: 58.0 ± 7.5 T: CWM + SXBX C: CWM 12 months 450 mg tid po 1,4,5,6,7,9 [ RCT 180 (90/90) T: 50/40 C:52/38 T: 67.9 ± 4.3 C: 68.7 ± 3.7 T: CWM + ZBT C: CWM 6 months 240 mg bid po 1,3,4,5,6,7,9 [ RCT 124 (62/62) T: 32/30 C:35/27 T: 62.3 ± 7.9 C: 61.6 ± 7.3 T: CWM + ZBT C: CWM 6 months 480 mg bid po 1,2,4,5,6,7,8,9 [ RCT 60 (30/30) T: 17/13 C:15/15 T: 70.3 ± 9.3 C: 70.2 ± 10.2 T: CWM + ZBT C: CWM 3 months 240 mg bid po 1,2,3,4,5,6,7 [ RCT 150 (75/75) T: 34/41 C:42/33 T: 64.4 ± 7.5 C: 64.7 ± 6.9 T: CWM + DZSM C: CWM 12 months 360 mg tid po 1,3,4,5,6,7,9 [ RCT 196 (98/98) T: 47/51 C:50/48 T: 67.8 ± 5.3 C: 68.2 ± 5.4 T: CWM + DZSM C: CWM 0.5 months 360 mg tid po 1,2,4,5,6,7,9
RCT randomized controlled trial, T treatment group, C control group, M male, F female, CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule. 1.carotid artery intimal− medial thickness (IMT), 2. carotid maximal plaque area, 3. carotid atherosclerotic plaque course score, 4. total cholesterol (TC), 5. Triglyceride (TG), 6. low density lipoprotein (LDL), 7. high density lipoprotein (HDL), 8. C− reactive protein (CRP), 9. adverse events rate (AER)
All the included trials reported 'randomly allocating' participants, generating random sequences using random number tables or computer− based or lottery methods, so they were evaluated as "low risk." Two trials reported allocation concealment, evaluated as "low risk," and the other studies did not mention allocation concealment and were evaluated as "uncertain risk." One trial reported double− blind trials were evaluated as "low risk," and the other studies did not mention blinding was evaluated as "high risk" or "uncertain risk". All trials had complete data, no selective reporting or other risk bias, and were all evaluated as "low risk." Fig. 2A depicts the risk bias assessment results. Figure 2B provides the detailed and specific risk of bias assessment.
Graph: Fig. 2Risk of bias graph of the included RCT A: the risk of bias graph; B: the risk of bias summary
We conducted eight pairwise meta− analyses comparing the effects of CWM and CWM combined with TCPM on improving the IMT, the carotid maximal plaque area, the carotid atherosclerotic plaque Course score, blood lipids, and CRP (Fig. 3). We assessed the certainty of the evidence for each outcome under the GRADE framework. The quality of the evidence for all of these comparisons was rated as low. The detailed GRADE assessment was presented in Table 3.
Graph: Fig. 3Forest plot of Pairwise meta-analysis. A: IMT; B: carotid maximal plaque area; C: carotid atherosclerotic plaque course score; D: TC; E: TG; F: LDL; G: HDL; H: CRP; IMT carotid artery intimal- medial thickness, TC total cholesterol, TG Triglyceride, LDL low density lipoprotein, HDL high density lipoprotein, CRP C− reactive protein, AER adverse events rate
Table 3 GRADE assessment
Outcome № of studies Certainty assessment Effect Certainty Study design Risk of bias Inconsistency Indirectness Imprecision Publication bias № of individuals Rate (95% CI) < 6 months of course IMT 10 RCT Serious Not serious Not serious Not serious Strongly suspected 1048 SMD − 1.39 (− 1.96, − 0.82) ⨁⨁◯◯Low Carotid maximal plaque area 6 RCT Serious Not serious Not serious Not serious Strongly suspected 672 SMD − 1.46 (− 2.26, − 0.66) ⨁⨁◯◯Low Carotid atherosclerotic plaque course score 2 RCT Serious Not serious Not serious Not serious Strongly suspected 205 SMD − 0.72 (− 1.05, − 0.39) ⨁⨁◯◯Low TC 7 RCT Serious Not serious Not serious Not serious Strongly suspected 807 SMD − 1.73 (− 2.44, − 1.02) ⨁⨁◯◯Low TG 7 RCT Serious Not serious Not serious Not serious Strongly suspected 807 SMD − 1.37 (− 1.89, − 0.85) ⨁⨁◯◯Low LDL 7 RCT Serious Not serious Not serious Not serious Strongly suspected 807 SMD − 1.13 (− 1.56, − 0.69) ⨁⨁◯◯Low HDL 6 RCT Serious Not serious Not serious Not serious Strongly suspected 691 SMD 1.29 (0.4, 2.18) ⨁⨁◯◯Low CRP 2 RCT Serious Not serious Not serious Not serious Strongly suspected 150 SMD − 1.35 (− 3.01, 0.31) ⨁⨁◯◯Low ≥ 6 months of course IMT 16 RCT Serious Not serious Not serious Not serious Strongly suspected 1871 SMD − 1.19 (− 1.6, − 0.87) ⨁⨁◯◯Low Carotid maximal plaque area 9 RCT Serious Not serious Not serious Not serious Strongly suspected 983 SMD − 1.14 (− 1.71, − 0.58) ⨁⨁◯◯Low Carotid atherosclerotic plaque course score 6 RCT Serious Not serious Not serious Not serious Strongly suspected 647 SMD − 0.71 (− 1.35, − 0.07) ⨁⨁◯◯Low TC 13 RCT Serious Not serious Not serious Not serious Strongly suspected 1487 SMD − 1.01 (− 1.49, − 0.54) ⨁⨁◯◯Low TG 13 RCT Serious Not serious Not serious Not serious Strongly suspected 1487 SMD − 1.06 (− 1.55, − 0.57) ⨁⨁◯◯Low LDL 13 RCT Serious Not serious Not serious Not serious Strongly suspected 1487 SMD − 1.25 (− 1.75, − 0.75) ⨁⨁◯◯Low HDL 12 RCT Serious Not serious Not serious Not serious Strongly suspected 1381 SMD 0.56 (0.12, 0.99) ⨁⨁◯◯Low CRP 8 RCT Serious Not serious Not serious Not serious Strongly suspected 779 SMD − 0.80 (− 0.95, − 0.66) ⨁⨁◯◯Low
RCT randomized controlled trial
Compared to CWM, CWM combined with TCPM had a stronger effect in reducing the IMT [26 RCTs; SMD − 1.26 (95% CI − 1.59, − 0.93); p < 0.00001; I
We conducted sensitivity analysis comparing pooled results from " < 6 months of course" and " ≥ 6 months of course" is illustrated in Fig. 3. There was no significant subgroup difference between the two groups, implying that the difference in length of course did not influence the pooled results on improving the IMT, the carotid maximal plaque area, the carotid atherosclerotic plaque Course score, blood lipids, and CRP.
A total of 27 RCTs referred to the IMT of nine types of TCPMs and 11 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 6), CWM + XS vs. CWM (n = 2), CWM + NXT vs. CWM (n = 3), CWM + XST vs. CWM (n = 2), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 3), CWM + SXBX vs. CWM (n = 3), CWM + ZBT vs. CWM (n = 3), and CWM + DZSM vs. CWM (n = 2) (Table 2). Figure 4A presents the network evidence plot.
Graph: Fig. 4Network diagrams for different outcomes. A: IMT; B: carotid maximal plaque area; C: carotid atherosclerotic plaque course score; D: TC; E: TG; F: LDL; G: HDL; H: CRP; I: AER; CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule, IMT carotid artery intimal- medial thickness, TC total cholesterol, TG Triglyceride, LDL low density lipoprotein, HDL high density lipoprotein, CRP C-reactive protein, AER adverse events rate. The width of the lines represents the proportion of the number of trials for each comparison with the total number of trials, and the size of the nodes represents the proportion of the number of randomized patients (sample sizes)
Compared to CWM, except for CWM + NXT [MD − 0.18 (95% CI − 0.39, 0.03)], CWM + XST [MD − 0.18 (95% CI − 0.43, 0.08)], CWM + PS [MD − 0.17 (95% CI: − 0.39, 0.04)] and CWM + DZSM [MD − 0.09 (95% CI − 0.34, 0.17)], other five TCPMs demonstrated a statistically significant effect in reducing the IMT. Accordingly, other interventions had no statistically significant difference. The details were shown in Table 4.
Table 4 Pairwise league table of IMT (lower− left quadrant) and carotid maximal plaque area (upper− right quadrant)
Carotid maximal plaque area − 0.16 (− 12.71, 12.42) 0.95 (− 11.56, 13.52) 5.29 (− 5.13, 16.75) − 1.37 (− 11.09, 8.39) 4.78 (− 4.72, 15.09) 0.50 (− 9.21, 10.22) − 0.33 (− 12.91, 12.17) − 2.31 (− 13.55, 9.05) − 2.06 (− 7.67, 3.52) 0.05 (− 0.25, 0.34) − 0.04 (− 0.30, 0.22) − 0.09 (− 0.41, 0.24) 1.12 (− 14.84, 16.91) 5.46 (− 8.71, 20.63) − 1.21 (− 15.02, 12.58) 4.928 (− 8.56, 19.24) 0.68 (− 13.13, 14.38) − 0.18 (− 16.041, 15.61) − 2.16 (− 19.05, 14.76) − 1.88 (− 13.15, 9.27) − 0.04 (− 0.33, 0.25) − 0.09 (− 0.44, 0.27) 0.00 (− 0.33, 0.33) 4.33 (− 9.76, 19.57) − 2.31 (− 16.16, 11.51) 3.82 (− 9.57, 18.19) − 0.44 (− 14.27, 13.28) − 1.28 (− 17.18, 14.58) − 3.25 (− 20.25, 13.63) − 3.00 (− 14.23, 8.23) 0.06 (− 0.24, 0.35) 0.01 (− 0.35, 0.37) 0.10 (− 0.23, 0.43) 0.10 (− 0.26, 0.45) − 6.65 (− 19.49, 5.06) − 0.50 (− 13.00, 11.75) − 4.78 (− 17.63, 7.03) − 5.61 (− 20.86, 8.43) − 7.58 (− 23.82, 7.55) − 7.36 (− 17.27, 1.61) − 0.04 (− 0.30, 0.22) − 0.09 (− 0.42, 0.24) − 0.01 (− 0.30, 0.30) − 0.01 (− 0.34, 0.33) − 0.10 (− 0.43, 0.23) 6.15 (− 4.80, 17.95) 1.87 (− 9.39, 13.18) 1.04 (− 12.69, 14.79) − 0.94 (− 15.89, 13.95) − 0.68 (− 8.66, 7.26) 0.05 (− 0.21, 0.31) 0.01 (− 0.33, 0.34) 0.09 (− 0.21, 0.40) 0.09 (− 0.24, 0.42) − 0.01 (− 0.34, 0.32) 0.09 (− 0.21, 0.40) − 4.27 (− 16.10, 6.66) − 5.12 (− 19.38, 8.27) − 7.07 (− 22.47, 7.46) − 6.83 (− 15.37, 0.91) − 0.01(− 0.26, 0.26) − 0.05 (− 0.38, 0.28) 0.03 (− 0.26, 0.34) 0.03 (− 0.29, 0.37) − 0.06 (− 0.39, 0.27) 0.04 (− 0.26, 0.34) − 0.06 (− 0.35, 0.25) − 0.83 (− 14.55, 12.86) − 2.82 (− 17.69, 12.05) − 2.56 (− 10.51, 5.44) − 0.13 (− 0.43, 0.17) − 0.18 (− 0.54, 0.18) − 0.09 (− 0.42, 0.24) − 0.09 (− 0.45, 0.27) − 0.19 (− 0.55, 0.17) − 0.09 (− 0.43, 0.25) − 0.18 (− 0.52, 0.16) − 0.13 (− 0.47, 0.20) − 1.99 (− 18.76, 14.96) − 1.72 (− 12.99, 9.48) − 0.02 (− 0.37, 0.34) − 0.06 (− 0.52, 0.39) 0.02 (− 0.41, 0.46) 0.02 (− 0.44, 0.48) − 0.08 (− 0.54, 0.38) 0.03 (− 0.41, 0.47) − 0.07 (− 0.50, 0.37) − 0.01 (− 0.46, 0.42) 0.11 (− 0.35, 0.58) 0.27 (− 12.33, 12.80) − − − 0.18 (− 0.39, 0.03) − 0.18 (− 0.43, 0.08) − 0.17 (− 0.39, 0.04) − 0.09 (− 0.34, 0.17) − 0.20 (− 0.58, 0.19)
IMT carotid artery medial-intimal thickness, CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule.Data of comparisons for IMT and carotid maximal plaque area are SMD (95% CI). The 95% CI which don't range across 0 favors the column–defining treatment and are showed in bold
According to the SUCRA probability results (Fig. 5A), CWM + JZL was likely the best intervention for reducing the IMT. Table 5 illustrates the detailed SUCRA and ranking probability. The interventions were ranked as follows: CWM + JZL (70.6%) > CWM + SXBX (70.5%) > CWM + XS (68.6%) > CWM + TXL (57.8%) > CWM + ZBT (56.5%) > CWM + PBO (51.7%) > CWM + XST (48.0%) > CWM + NXT (46.8%) > CWM + PS (46.8%) > CWM + DZSM (27.2%) > > CWM (5.4%).
Graph: Fig. 5Surface under the cumulative ranking curve (SUCRA) plots for different outcomes. The vertical axis represents cumulative probabilities and the horizontal axis represents rank. A: IMT; B: carotid maximal plaque area; C: carotid atherosclerotic plaque course score; D: TC; E: TG; F: LDL; G: HDL; H: CRP; I: AER; CWM conventional western medicine, PBO placebo; TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule, IMT carotid artery intimal-medial thickness, TC total cholesterol, TG Triglyceride, LDL low density lipoprotein, HDL high density lipoprotein, CRP C− reactive protein
Table 5 Pairwise league table of TC (lower− left quadrant) and carotid atherosclerotic plaque course score (upper− right quadrant)
Carotid atherosclerotic plaque course score − − − 1.47 (− 4.12, 1.20) − − 1.69 (− 3.84, 0.47) − 0.87 (− 3.51, 1.76) − 1.00 (− 3.15, 1.16) − 1.91 (− 4.56, 0.75) − − 1.45 (− 2.99, 0.09) 0.31 (− 0.89, 1.52) − 0.28 (− 1.53, 0.97) − 0.59 (− 2.15, 0.96) − 0.55 (− 1.78, 0.68) − 0.86 (− 2.40, 0.67) − 0.27 (− 1.85, 1.29) − − 0.22 (− 2.87, 2.42) 0.60 (− 2.47, 3.60) 0.47 (− 2.20, 3.09) − 0.44 (− 3.50, 2.60) − 0.02 (− 2.17, 2.18) − 0.01 (− 0.94, 0.94) − 0.32 (− 1.64, 1.01) 0.28 (− 1.08, 1.64) 0.55 (− 0.79, 1.90) 0.01 (− 0.84, 0.84) − 0.31 (− 1.57, 0.93) 0.28 (− 1.02, 1.57) 0.56 (− 0.73, 1.82) 0.01 (− 1.01, 1.00) 0.82 (− 1.81, 3.41) 0.69 (− 1.47, 2.81) − 0.23 (− 2.86, 2.45) − 0.24 (− 1.28, 1.74) 0.75 (− 0.08, 1.58) 0.43 (− 0.80, 1.67) 1.02 (− 0.26, 2.31) 0.75 (− 0.25, 1.73) 0.74 (− 0.14, 1.64) − 0.13 (− 2.75, 2.49) − 1.03 (− 4.07, 2.03) − − 0.58 (− 2.71, 1.57) 0.11 (− 0.72, 0.95) − 0.21 (− 1.44, 1.04) 0.38 (− 0.89, 1.68) 0.66 (− 0.60, 1.93) 0.11 (− 0.88, 1.10) 0.10 (− 0.78, 1.01) − 0.64 (− 1.52, 0.25) − 0.91 (− 3.56, 1.75) − − 0.45 (− 1.95, 1.08) − 0.45 (− 1.40, 0.48) − 0.77 (− 2.09, 0.54) − 0.17 (− 1.53, 1.17) 0.10 (− 1.25, 1.44) − 0.45 (− 1.55, 0.61) − 0.46 (− 1.45, 0.54) − 1.20 (− 2.19, − 0.23) − 0.56 (− 1.56, 0.41) 0.46 (− 1.72, 2.62) − 0.13 (− 1.21, 0.94) − 0.45 (− 2.06, 1.17) 0.15 (− 1.50, 1.79) 0.42 (− 1.22, 2.05) − 0.13 (− 1.56, 1.30) − 0.14 (− 1.49, 1.23) − 0.88 (− 2.23, 0.48) − 0.24 (− 1.61, 1.12) 0.32 (− 1.10, 1.75) − 0.90 (− 1.97, 0.17) − 0.30 (− 1.43, 0.82) − 0.03 (− 1.13, 1.07) − 0.58 (− 1.35, 0.18) − 0.59 (− 1.22, 0.06) − 0.13 (− 0.88, 0.64) − 0.45 (− 1.66, 0.75)
TC total cholesterol, CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule.Data of comparisons for TC and carotid atherosclerotic plaque course score are SMD (95% CI). The 95% CI which don't range across 0 favors the column-defining treatment and are showed in bold
A total of 16 RCTs referred to the carotid maximal plaque area of eight types of TCPMs and 10 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 4), CWM + NXT vs. CWM (n = 1), CWM + XST vs. CWM (n = 1), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 2), CWM + SXBX vs. CWM (n = 2), CWM + ZBT vs. CWM (n = 2), and CWM + DZSM vs. CWM (n = 1) (Table 2). Figure 4B presents the network evidence plot. All interventions had no statistically significant difference. The details were shown in Table 4.
According to the SUCRA probability results (Fig. 5B), CWM + SXBX was the most likely the best intervention for reducing the carotid maximal plaque area. Table 8 presents the detailed SUCRA and ranking probability. The ranking of interventions was as follows: CWM + SXBX (83.0%) > CWM + JZL (82.7%) > CWM + XST (53.1%) > CWM + ZBT (52.0%) > CWM + TXL (48.4%) > CWM + NXT (45.3%) > CWM + DZSM (44.7%) > CWM + PS (35.0%) > CWM + PBO (31.1%) > CWM (24.8%).
Eight RCTs referred to the carotid atherosclerotic plaque Course score of six types of TCPMs and seven types of interventions, including CWM + TXL vs. CWM (n = 2), CWM + XST vs. CWM (n = 1), CWM + PS vs. CWM (n = 1), CWM + SXBX vs. CWM (n = 1), CWM + ZBT vs. CWM (n = 2), and CWM + DZSM vs. CWM (n = 1). (Table 2). Figure 4C presents the network evidence plot. All interventions had no statistically significant differences. The details were shown in Table 5.
According to the SUCRA probability results (Fig. 5C), CWM + XSBX was the most likely the best intervention for lowering the carotid atherosclerotic plaque Course score. Table 8 depicts the detailed SUCRA and ranking probability. The interventions were ranked as follows: CWM + SXBX (92.5%) > CWM + TXL (85.9%) > CWM + ZBT (61.0%) > CWM + PS (55.0%) > CWM (23.2%) > CWM + XST (22.7%) > CWM + DZSM (9.7%).
A total of 21 RCTs referred to the TC of nine types of TCPMs and 11 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 4), CWM + XS vs. CWM (n = 1), CWM + NXT vs. CWM (n = 1), CWM + XST vs. CWM (n = 1), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 3), CWM + SXBX vs. CWM (n = 3), CWM + ZBT vs. CWM (n = 3), and CWM + DZSM vs. CWM (n = 2). (Table 2). Figure 4D presents the network evidence plot.
CWM + TXL [MD − 0.58 (95% CI − 1.14, − 0.03)], CWM + SXBX [MD − 1.33 (95% CI − 1.95, − 0.70)], and CWM + ZBT [MD − 0.69 (95% CI − 1.32, − 0.07)] had a statistically significant effect on lowering TC compared to CWM. CWM + SXBX [MD − 1.30 (95% CI − 2.57, − 0.03)] had a statistically significant effect on lowering TC compared to CWM + XST. Accordingly, other interventions had no statistically significant differences. The details were shown in Table 5.
According to the SUCRA probability results (Fig. 5D), CWM + XSBX was the most likely the best intervention for lowering TC. Table 8 indicates the detailed SUCRA and ranking probability. The 11 types of interventions were ranked as follows: CWM + SXBX (95.6%) > CWM + XS (73.6%) > CWM + ZBT (63.8%) > CWM + JZL (57.1%) > CWM + TXL (57.0%) > CWM + PS (56.3%) > CWM + PBO (46.9%) > CWM + NXT (37.9%) > CWM + DZSM (24.6%) > CWM + XST (23.2%) > CWM (14.0%).
A total of 21 RCTs referred to the TG of nine types of TCPMs and 11 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 4), CWM + XS vs. CWM (n = 1), CWM + NXT vs. CWM (n = 1), CWM + XST vs. CWM (n = 1), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 3), CWM + SXBX vs. CWM (n = 3), CWM + ZBT vs. CWM (n = 3), and CWM + DZSM vs. CWM (n = 2) (Table 2). Figure 4E presents the network evidence plot.
CWM + NXT [MD − 0.76 (95% CI − 1.35, − 0.17)], CWM + JZL [MD − 0.52 (95% CI − 0.94, − 0.10)] and CWM + SXBX [MD − 0.59 (95% CI − 0.95, − 0.23)] had a statistically significant effect on lowering TG compared to CWM. Consequently, other interventions had no statistically significant differences. The details were shown in Table 6.
Table 6 Pairwise league table of LDL (lower− left quadrant) and TG (upper− right quadrant)
0.17 (− 0.48, 0.83) 0.46 (− 0.20, 1.12) − 0.25 (− 0.93, 0.43) 0.22 (− 0.30, 0.74) 0.04 (− 0.41, 0.50) 0.29 (− 0.17, 0.76) − 0.05 (− 0.50, 0.41) − 0.21 (− 0.72, 0.30) − 0.02 (− 0.61, 0.57) − 0.30 (− 0.60, 0.01) 0.31 (− 0.60, 1.22) 0.29 (− 0.54, 1.12) − 0.42 (− 1.27, 0.43) 0.05 (− 0.67, 0.77) − 0.13 (− 0.81, 0.55) 0.12 (− 0.57, 0.80) − 0.22 (− 0.90, 0.46) − 0.39 (− 1.10, 0.33) − 0.19 (− 1.08, 0.69) − 0.47 (− 1.05, 0.11) − 0.20 (− 1.11, 0.71) − 0.51 (− 1.66, 0.64) − 0.71 (− 1.56, 0.14) − 0.24 (− 0.97, 0.49) − 0.42 (− 1.10, 0.27) − 0.17 (− 0.86, 0.52) − 0.51 (− 1.19, 0.17) − 0.67 (− 1.40, 0.05) − 0.48 (− 1.37, 0.40) − 0.36 (− 1.30, 0.58) − 0.67 (− 1.84, 0.49) − 0.16 (− 1.33, 1.02) 0.47 (− 0.28, 1.21) 0.29 (− 0.42, 1.00) 0.54 (− 0.17, 1.25) 0.20 (− 0.51, 0.90) 0.03 (− 0.71, 0.78) 0.23 (− 0.68, 1.13) − 0.05 (− 0.66, 0.56) 0.20 (− 0.52, 0.93) − 0.11 (− 1.10, 0.90) 0.40 (− 0.60, 1.41) 0.56 (− 0.46, 1.60) − 0.18 (− 0.72, 0.37) 0.07 (− 0.49, 0.62) − 0.27 (− 0.82, 0.28) − 0.43 (− 1.03, 0.16) − 0.24 (− 1.03, 0.54) − 0.04 (− 0.66, 0.60) − 0.34 (− 1.28, 0.60) 0.17 (− 0.78, 1.10) 0.33 (− 0.64, 1.29) − 0.23 (− 0.99, 0.51) 0.25 (− 0.25, 0.75) − 0.09 (− 0.58, 0.40) − 0.26 (− 0.80, 0.29) − 0.06 (− 0.82, 0.68) − 0.34 (− 0.69, 0.01) 0.53 (− 0.11, 1.16) 0.22 (− 0.72, 1.16) 0.73 (− 0.22, 1.67) 0.90 (− 0.09, 1.85) 0.33 (− 0.44, 1.08) 0.57 (− 0.11, 1.24) − 0.34 (− 0.84, 0.16) − 0.50 (− 1.05, 0.04) − 0.31 (− 1.07, 0.44) 0.12 (− 0.49, 0.76) − 0.19 (− 1.11, 0.76) 0.32 (− 0.61, 1.28) 0.49 (− 0.47, 1.47) − 0.07 (− 0.83, 0.69) 0.16 (− 0.50, 0.84) − 0.41 (− 1.07, 0.29) − 0.16 (− 0.70, 0.37) 0.03 (− 0.72, 0.77) − 0.25 (− 0.60, 0.09) − 0.33 (− 1.03, 0.38) − 0.64 (− 1.62, 0.35) − 0.13 (− 1.12, 0.87) 0.04 (− 0.98, 1.05) − 0.53 (− 1.35, 0.29) − 0.29 (− 1.03, 0.45) − 0.45 (− 1.20, 0.27) 0.19 (− 0.59, 0.97) − 0.09 (− 0.50 0.33) − 0.07 (− 0.88, 0.73) − 0.38 (− 1.59, 0.83) 0.13 (− 1.10, 1.35) 0.29 (− 0.95, 1.52) − 0.27 (− 1.36, 0.80) − 0.04 (− 1.07, 0.98) − 0.61 (− 1.63, 0.42) − 0.20 (− 1.23, 0.81) 0.26 (− 0.82, 1.31) − 0.28 (− 0.94, 0.39) − 0.74 (− 1.54, 0.07) − 0.23 (− 1.05, 0.58) − 0.07 (− 0.91, 0.77) − 0.40 (− 0.87, 0.08) − 0.10 (− 0.67, 0.46) − 0.36 (− 1.26, 0.55)
LDL low density lipoprotein, TG riglyceride, CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule. Data of comparisons for LDL and TG are SMD (95% CI). The 95% CI which don't range across 0 favors the column-defining treatment and are showed in bold
According to the SUCRA probability results (Fig. 5E), CWM + NXT was the most likely the best intervention for lowering the TG. Table 8 presents the detailed SUCRA and ranking probability. The interventions were ranked as follows: CWM + NXT (90.1%) > CWM + SXBX (81.1%) > CWM + JZL (72.7%) > CWM + XS (66.1%) > CWM + PS (52.5%) > CWM + TXL (47.0%) > CWM + PBO (44.7%) > CWM + ZBT (41.6%) > CWM + DZSM (22.2%) > CWM + XST (21.9%) > CWM (10.0%).
A total of 21 RCTs referred to the LDL of nine types of TCPMs and 11 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 4), CWM + XS vs. CWM (n = 1), CWM + NXT vs. CWM (n = 1), CWM + XST vs. CWM (n = 1), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 3), CWM + SXBX vs. CWM (n = 3), CWM + ZBT vs. CWM (n = 3), and CWM + DZSM vs. CWM (n = 2). (Table 2). Figure 4F presents the network evidence plot.
CWM + TXL [MD − 0.43 (95% CI − 0.84, − 0.02)], CWM + JZL [MD − 0.63 (95% CI − 1.22, − 0.05)], CWM + SXBX [MD − 0.96 (95% CI − 1.44, − 0.48)], and CWM + ZBT [MD − 0.56 (95% CI − 1.04, − 0.09)] has a statistically significant effect on lowering LDL compared to CWM. CWM + SXBX [MD − 0.86 (95% CI − 1.60, − 0.11)] had a statistically significant effect on lowering LDL compared to CWM + DZSM. Therefore, other interventions had no statistically significant difference. The details were shown in Table 6.
According to the SUCRA probability results (Fig. 5F), CWM + SXBX was the most likely the best intervention for lowering the LDL. Table 8 depicts the detailed SUCRA and ranking probability. The interventions were ranked as follows: CWM + SXBX (92.6%) > CWM + XS (76.9%) > CWM + JZL (69.9%) > CWM + ZBT (64.4%) > CWM + TXL (53.5%) > CWM + PS (49.1%) > CWM + PBO (47.0%) > CWM + NXT (35.9%) > CWM + XST (24.9%) > CWM + DZSM (23.5%) > CWM (12.3%).
A total of 19 RCTs referred to the HDL of eight types of TCPMs and 10 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 4), CWM + XS vs. CWM (n = 1), CWM + NXT vs. CWM (n = 1), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 3), CWM + SXBX vs. CWM (n = 2), CWM + ZBT vs. CWM (n = 3), and CWM + DZSM vs. CWM (n = 2). (Table 2). Figure 4G presents the network evidence plot.
CWM + TXL [MD 0.34 (95% CI: 0.05, 0.64)] had a statistically significant effect on raising HDL compared to CWM. Thus, no statistically significant difference existed between the other interventions. The details were shown in Table 7.
Table 7 Pairwise league table of HDL (lower-left quadrant) and CRP (upper-right quadrant)
CRP HDL – 0.19 (− 1.14, 1.48) – – 0.23 (− 1.11, 1.51) − 0.10 (− 1.81, 1.54) 0.31 (− 1.39, 1.94) – − 0.14 (− 1.60, 1.32) − 0.67 (− 1.45, 0.04) − 0.18 (− 0.81, 0.46) − – – – – – – – – 0.18 (− 0.47, 0.83) 0.36 (− 0.44, 1.17) – – 0.04 (− 1.49, 1.57) − 0.30 (− 2.15, 1.55) 0.11 (− 1.73, 1.96) – − 0.33 (− 2.26, 1.66) − 0.87 (− 1.95, 0.21) – – – – – – – – − − − 0.02 (− 0.55, 0.48) 0.16 (− 0.56, 0.84) − 0.20 (− 0.93, 0.49) – – – – – − − 0.18 (− 0.27, 0.62) 0.36 (− 0.30, 1.01) − 0.01 (− 0.67, 0.66) – 0.20 (− 0.32, 0.75) − 0.34 (− 2.20, 1.51) 0.07 (− 1.78, 1.91) – − 0.37 (− 2.31, 1.61) − 0.91 (− 1.99, 0.18) 0.30 (− 0.20, 0.80) 0.48 (− 0.22, 1.17) 0.12 (− 0.58, 0.82) – 0.32 (− 0.25, 0.92) 0.12 (− 0.40, 0.64) 0.41 (− 1.70, 2.53) – − 0.04 (− 2.21, 2.23) − 0.57 (− 2.07, 0.94) 0.29 (− 0.16, 0.73) 0.46 (− 0.20, 1.12) 0.10 (− 0.56, 0.76) – 0.31 (− 0.21, 0.86) 0.10 (− 0.36, 0.58) − 0.02 (− 0.54, 0.51) – − 0.44 (− 2.62, 1.79) − 0.98 (− 2.47, 0.51) 0.19 (− 0.31, 0.69) 0.37 (− 0.32, 1.06) 0.01 (− 0.69, 0.71) – 0.21 (− 0.35, 0.81) 0.01 (− 0.51, 0.53) − 0.11 (− 0.68, 0.46) − 0.09 (− 0.61, 0.43) – – 0.04 (− 0.52, 0.61) 0.22 (− 0.63, 1.07) − 0.14 (− 0.99, 0.72) – 0.06 (− 0.68, 0.84) − 0.14 (− 0.85, 0.58) − 0.26 (− 1.01, 0.50) − 0.24 (− 0.96, 0.48) − 0.15 (− 0.90, 0.60) − 0.53 (− 2.21, 1.07) 0.52 (− 0.05, 1.08) 0.16 (− 0.41, 0.73) – 0.36 (− 0.04, 0.80) 0.16 (− 0.17, 0.50) 0.04 (− 0.36, 0.44) 0.06 (− 0.28, 0.39) 0.15 (− 0.25, 0.55) 0.30 (− 0.34, 0.93)
HDL high density lipoprotein, CRP C-reactive protein, CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule. Data of comparisons for HDL and CRP are SMD (95% CI). The 95% CI which don't range across 0 favors the column− defining treatment and are showed in bold
According to the SUCRA probability results (Fig. 5G), CWM + XS was the most likely the best intervention for improving HDL. Table 8 illustrates the detailed SUCRA and ranking probability. The interventions were ranked as follows: CWM + XS (86.1%) > CWM + JZL (72.9%) > CWM + TXL (72.9%) > CWM + PBO (62.4%) > CWM + PS (45.6%) > CWM + NXT (45.2%) > CWM + DZSM (43.1%) > CWM + ZBT (28.6%) > CWM + SXBX (26.8%) > CWM (16.4%).
Table 8 Surface under the cumulative ranking curve and ranking probability of different Chinese patent medicines on each outcome
Treatment IMT Carotid maximal plaque area Carotid atherosclerotic plaque course score TC TG LDL HDL CRP SUCRA Rank SUCRA Rank SUCRA Rank SUCRA Rank SUCRA Rank SUCRA Rank SUCRA Rank SUCRA Rank CWM 5.40% 11 24.80% 10 23.20% 5 14.00% 11 10.00% 11 12.30% 11 16.40% 10 6.00% 7 CWM + PBO 51.70% 6 31.10% 9 – – 46.90% 7 44.70% 7 47.00% 7 62.40% 4 42.80% 6 CWM + TXL 57.80% 4 48.40% 5 57.00% 5 47.00% 6 53.50% 5 72.90% 3 52.30% 4 CWM + XS 68.60% 3 – – – – 73.60% 2 66.10% 4 76.90% 2 – – CWM + NXT 46.80% 8 45.30% 6 – – 37.90% 8 35.90% 8 45.20% 6 64.90% 3 CWM + XST 48.00% 7 53.10% 3 22.70% 6 23.20% 10 21.90% 10 24.90% 9 − − − − CWM + JZL 82.70% 2 – – 57.10% 4 72.70% 3 69.90% 3 72.90% 2 − CWM + PS 46.80% 9 35.00% 8 55.00% 4 56.30% 6 52.50% 5 49.10% 6 45.60% 5 67.00% 2 CWM + SXBX 70.50% 2 92.50% 1 81.10% 2 26.80% 9 45.70% 5 CWM + ZBT 56.50% 5 52.00% 4 61.00% 3 63.80% 3 41.60% 8 64.40% 4 28.60% 8 CWM + DZSM 27.20% 10 44.70% 7 9.70% 7 24.60% 9 22.20% 9 23.50% 10 43.10% 7 – –
CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule, IMT carotid artery intimal-medial thickness, TC total cholesterol, TG Triglyceride, LDL low density lipoprotein, HDL high density lipoprotein, CRP C-reactive protein
A total of 11 RCTs referred to the CRP of five types of TCPMs and seven types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 5), CWM + NXT vs. CWM (n = 2), CWM + PS vs. CWM (n = 2), CWM + SXBX vs. CWM (n = 1), and CWM + ZBT vs. CWM (n = 1). (Table 2). Figure 4H presents the network evidence plot. All interventions had no statistically significant difference. The details were shown in Table 7.
According to the SUCRA probability results (Fig. 5H), CWM + ZBT was the most likely the best intervention for lowering the CRP. Table 8 presents the detailed SUCRA and ranking probability. The interventions were ranked as follows: CWM + ZBT (71.3%) > CWM + PS (67.0%) > CWM + NXT (64.9%) > CWM + TXL (52.3%) > CWM + SXBX (45.7%) > CWM + PBO (42.8%) > CWM (6.0%).
A total of 18 RCTs reported the number of the AER of eight types of TCPMs and 10 types of interventions, including CWM + TXL vs. CWM + PBO (n = 1), CWM + TXL vs. CWM (n = 5), CWM + XS vs. CWM (n = 1), CWM + XST vs. CWM (n = 1), CWM + JZL vs. CWM (n = 2), CWM + PS vs. CWM (n = 2), CWM + SXBX vs. CWM (n = 2), CWM + ZBT vs. CWM (n = 2), and CWM + DZSM vs. CWM (n = 2) (Table 2). Figure 4I presents the network evidence plot.
Four studies reported no adverse reactions in the experimental and control groups, while the remaining 14 studies reported 204 cases of adverse reactions. Adverse events included gastrointestinal reactions, such as nausea, discomfort, indigestion, abdominal distension, pain, and diarrhea. Autonomic nervous dysfunction symptoms had dizziness, headache, rash, myalgia, mild hepatic or renal insufficiency, bleeding, and delayed PT. However, most resolved spontaneously without special treatment. The detailed list of adverse reactions was shown in Table 9.
Table 9 Occurrence of adverse reactions
Treatment Study ID AEs Adverse reactions Response Treatment group Control group CWM + TXL vs. CWM + PBO 100 Hepatic insufficiency (seven cases), renal insufficiency (one case), headache (10 cases), stomach discomfort (24 cases), abdominal pain and diarrhea (four cases), bleeding or delayed PT (eight cases), allergic rash or asthma (one case) Hepatic insufficiency (five cases), renal insufficiency (two cases), headache (11 cases), stomach discomfort (14 cases), abdominal pain and diarrhea (six cases), bleeding or delayed PT (two cases), allergic rash or asthma (one case), mental disorders (one case), insomnia (three cases) – CWM + TXL vs. CWM 7 Gastrointestinal reactions (two cases) Gastrointestinal reactions (three cases) and mild liver function abnormalities (two cases) – 0 0 0 – 1 Mild nausea (one case) 0 – 13 Nausea and abdominal pain (five cases), dizziness and headache (two cases), skin itch (one case) Gastrointestinal discomfort (two cases), dizziness, and headache (three cases) – 1 0 Mild liver function abnormalities (one case) After liver protection and other symptomatic treatment, liver function returned to normal CWM + XS vs. CWM 3 Mild liver function abnormalities (one case) Mild liver function abnormalities (two cases) – CWM + XST vs. CWM 1 0 Mild liver function abnormalities (one case) – CWM + JZL vs. CWM 6 Mild liver function abnormalities (four cases) Mild liver function abnormalities (two cases) – 0 0 0 – CWM + PS vs. CWM 0 0 0 – 11 Gastrointestinal discomfort (two cases), myalgia (one case), and mild liver function abnormalities (two cases) Skin itch (one case), gastrointestinal discomfort (one case), myalgia (two cases), and mild liver function abnormalities (two cases) Two groups of patients with myalgia and mild liver function abnormalities requested a change of medication and abandoned treatment CWM + SXBX vs. CWM 2 Mild liver function abnormalities (two cases) After liver protection and other symptomatic treatment, liver function returned to normal 2 0 Mild upper abdominal discomfort (two cases) – CWM + ZBT vs. CWM 23 Abdominal pain and distention (three cases), myalgia (one case), mild liver function abnormalities (one case) Abdominal pain and distention (five cases), headache (three cases), myalgia (three cases), mild liver function abnormalities (four cases), myocardial enzyme injury (two cases), rash (one case) – 2 Gastrointestinal discomfort (two cases) It resolved spontaneously without special treatment CWM + DZSM vs. CWM 32 Gastrointestinal discomfort (four cases), tumor (one case), skin rash (one case), myalgia (four cases), herpes zoster (one case) Bleeding event (four cases), gastrointestinal discomfort (12 cases), tumor (one case), myalgia (three cases), acute cholecystitis (one case) – 0 0 0
CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, DZSM Dengzhan shengmai capsule
No closed loops were found in the NMA due to the lack of direct comparison of TCPMs. The inconsistency test could not be carried out. Hence, the results were analyzed using a consistency model.
IMT is the leading indicator for publishing the results of the evaluation applications. The comparison− adjusted funnel plots were plotted to test the publication bias of IMT. When the points in the funnel chart are symmetrical based on the position of the centerline, presenting that there is no publication bias. Figure 6 depicts that the points in the funnel chart are asymmetrical along the center line, indicating the potential presence of publication bias favoring CWM + TCPMs in reducing IMT, as compared to CWM and CWM + PBO.
Graph: Fig. 6Funnel plot of IMT. CWM conventional western medicine, PBO placebo, TXL Tongxinluo capsule, XS Xiaoshuang granules/enteric capsule, NXT Naoxintong capsule, XST Xuesaitong capsule/soft capsule, JZL Jiangzhiling pill, PS Pushen capsule, SXBX Shexiang baoxin pill, ZBT Zhibitai, Dengzhan shengmai capsule
OMT, a pharmacotherapy regimen based on statins, is an important non− invasive treatment for CAP. The clinical efficacy of OMT can be improved by adding complementary and alternative medicines [[
Numerous pharmacological studies have also found that TCPMs could improve CAP through multiple targets and signaling pathways. JZL, which traditionally removes dampness and dissolves phlegm, was the best intervention for reducing IMT in this study. Crataegus pinnatifida Bunge, the essential herb of JZL, has anti− atherosclerotic effects by lowering blood lipids, inhibiting oxidative and inflammation, and protecting vascular endothelium [[
This NMA study had several strengths. First, this study was the first to evaluate the comparative efficacy and safety of TCPMs for CAP and to guide optimal medication in a clinical setting. Second, this study set strict inclusion criteria and excluded RCTs with incorrect randomization methods, ensuring methodological quality. Finally, the ranking of TCPMs contributed to the formulation of clinical medication plans.
However, this study still has some limitations. First, the overall quality of the studies included was limited because most studies did not report the allocation concealment and blinding in detail. Additionally, clinical heterogeneity may have occurred due to the diversity of CWM and the various TCPMs dosage and duration, and these results should be interpreted with caution. Finally, assuming that the studies included were mainly conducted among Chinese populations, the external adaptability of the results would be restricted when applied for reference in populations of different countries and regions.
This study aims to evaluate the efficacy of TCPMs in treating CAP based on the characteristics of carotid plaque, blood lipids, inflammatory markers, and adverse reactions to guide the clinical medication of CAP more accurately. CWM + JZL was the most effective in reducing IMT. CWM + SXBX was the most effective in reducing carotid maximal plaque area, and atherosclerotic plaque Course score. CWM + XSBX also significantly reduced TC and LDL levels and outperformed other CPMs. CWM + XSBX may be considered an effective intervention for the treatment of CAP. However, further direct comparisons are warranted. This study provides a more accurate selection of TCPMs in CAP therapy, which may help improve drug regimens of OMT by supplementing complementary and alternative drugs. More adequately powered, well− designed clinical trials to increase the quality of the available evidence are still needed in the future due to several limitations.
Not applicable.
WS: formal analysis, data curation, investigation, and writing− original draft; XX: data curation, formal analysis, validation, and writing− original draft; JZ: methodology, investigation, and formal analysis; QF: formal analysis and data curation; ND: formal analysis and data curation; QL: formal analysis and data curation; YD: supervision, conceptualization, and formal analysis; SW: conceptualization, methodology, funding acquisition, and formal analysis.
This work was supported by the National Natural Science Foundation of China (No. 82174340).
All data supporting this systematic review and meta− analysis are from previously reported studies and datasets, which have been cited.
Not applicable.
Not applicable.
The authors declare no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Graph: Additional file 1. Searching strategies.
• AER
- Adverse events rate
• CAP
- Carotid atherosclerotic plaque
• CAS
- Carotid stent placement
• CEA
- Carotid endarterectomy
• CRP
- C− reactive protein
• CWM
- Conventional western medicine
• DZSM
- Dengzhan shengmai capsule
• HDL
- High density lipoprotein
• IMT
- Carotid artery intimal-medial thickness
• JZL
- Jiangzhiling pill
• LDL
- Low density lipoprotein
• NMA
- Network meta-analysis
• NXT
- Naoxintong capsule
• OMT
- Optimal drug therapy
• PBO
• Placebo
• PS
- Pushen capsule
• RCTs
- Randomized controlled trials
• SUCRA
- Surface under the cumulative ranking
• SXBX
- Shexiang baoxin pill
• TC
- Total cholesterol
• TCM
- Traditional Chinese medicine
• TCPMs
- Traditional Chinese patent medicine
• TG
- Triglyceride
• TXL
- Tongxinluo capsule
• XS
- Xiaoshuang granules/enteric capsule
• XST
- Xuesaitong capsule/soft capsule
• ZBT
- Zhibitai
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By Wenquan Su; Xiaolong Xie; Jiping Zhao; Qinhua Fan; Naijia Dong; Qingxiao Li; Yawei Du and Shengxian Wu
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