年龄校正的D-二聚体联合简化Geneva评分对老年急性肺栓塞的诊断价值
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摘要
目的分析年龄校正的D-二聚体联合简化Geneva评分对老年急性肺栓塞(APE)的诊断价值。方法选取2013年9月—2017年9月河南科技大学第一附属医院呼吸与危重症医学科收治的疑似老年APE患者313例,检测其D-二聚体水平并计算年龄校正的D-二聚体、进行简化Geneva评分。以CT肺动脉造影(CTPA)为"金标准",分析年龄校正的D-二聚体、简化Geneva评分及二者联合对老年APE的诊断价值。结果 (1)年龄校正的D-二聚体诊断老年APE的灵敏度为93%,特异度为55%,阳性预测值为75%,阴性预测值为84%,Youden指数为0.48。(2)简化Geneva评分诊断老年APE的灵敏度为77%,特异度为71%,阳性预测值为80%,阴性预测值为68%,Youden指数为0.48。(3)年龄校正的D-二聚体联合简化Geneva评分诊断老年APE的灵敏度为97%,特异度为44%,阳性预测值为72%,阴性预测值为90%,Youden指数为0.41,Kappa值为0.445;年龄校正的D-二聚体联合简化Geneva评分排除诊断老年APE的灵敏度为90%,特异度为82%,阳性预测值为88%,阴性预测值为85%,Youden指数为0.72,Kappa值为0.538。(4)ROC曲线显示,年龄校正的D-二聚体诊断老年APE的曲线下面积(AUC)为0.881[95%CI(0.841,0.921),P<0.01],简化Geneva评分诊断老年APE的AUC为0.827[95%CI(0.779,0.875),P<0.01],年龄校正的D-二聚体联合简化Geneva评分诊断老年APE的AUC为0.920[95%CI(0.887,0.953),P<0.01]。结论年龄校正的D-二聚体联合简化Geneva评分对老年APE的诊断价值较高,有利于提高老年APE筛查效果,可作为缺乏CTPA、肺通气灌注扫描等医疗设备的医院或存在血流动力学改变的疑似老年APE患者的诊断/排除诊断指标。
Objective To analyze the diagnostic value of age-adjusted D-dimer combined with simplified Geneva score on acute pulmonary embolism(APE)in the aged.Methods From September 2013 to September 2017,a total of 313 suspected elderly patients with APE were selected in the Department of Respiratory and Critical Care Medicine,the First Affiliated Hospital of Henan University of Science and Technology,the D-dimer was detected and age-adjusted D-dimer was calculated,meanwhile simplified Geneva score was conducted.Taking CTPA as golden standard,diagnostic value of age-adjusted D-dimer,simplified Geneva score and combination of the above two on APE in the aged was analyzed respectively.Results(1)The sensitivity of age-adjusted D-dimer in diagnosing APE in the aged was 93%,the specificity was 55%,the positive predictive value was 75%,the negative predictive value was 84%,the Youden index was 0.48.(2)The sensitivity of simplified Geneva score in diagnosing APE in the aged was 77%,the specificity was 71%,the positive predictive value was 80%,the negative predictive value was 68%,the Youden index was 0.48.(3)The sensitivity of age-adjusted D-dimer combined with simplified Geneva score in diagnosing APE in the aged was 97%,the specificity was 44%,the positive predictivevalue was 72%,the negative predictive value was 90%,the Youden index was 0.41,the Kappa value was 0.445;the sensitivity of age-adjusted D-dimer combined with simplified Geneva score for excluded diagnosis of APE in the aged was 90%,the specificity was 82%,the positive predictive value was 88%,the negative predictive value was 85%,the Youden index was 0.72,the Kappa value was 0.538.(4)ROC curve showed that,AUC of age-adjusted D-dimer in diagnosing APE in the aged was 0.881[95%CI(0.841,0.921),P<0.01],that of simplified Geneva score was 0.827[95%CI(0.779,0.875),P<0.01],and that of D-dimer combined with simplified Geneva score was 0.920[95%CI(0.887,0.953),P<0.01].Conclusion Diagnostic value of age-adjusted D-dimer combined with simplified Geneva score is relatively high in diagnosing APE in the aged,which is helpful to improve the screening efficiency,may be a diagnostic/excluded diagnostic indicator for suspected elderly APE patients with hemodynamic change and in those hospitals lacking of CTPA or pulmonary ventilation perfusion scan equipment.
Objective To analyze the diagnostic value of age-adjusted D-dimer combined with simplified Geneva score on acute pulmonary embolism(APE)in the aged.Methods From September 2013 to September 2017,a total of 313 suspected elderly patients with APE were selected in the Department of Respiratory and Critical Care Medicine,the First Affiliated Hospital of Henan University of Science and Technology,the D-dimer was detected and age-adjusted D-dimer was calculated,meanwhile simplified Geneva score was conducted.Taking CTPA as golden standard,diagnostic value of age-adjusted D-dimer,simplified Geneva score and combination of the above two on APE in the aged was analyzed respectively.Results(1)The sensitivity of age-adjusted D-dimer in diagnosing APE in the aged was 93%,the specificity was 55%,the positive predictive value was 75%,the negative predictive value was 84%,the Youden index was 0.48.(2)The sensitivity of simplified Geneva score in diagnosing APE in the aged was 77%,the specificity was 71%,the positive predictive value was 80%,the negative predictive value was 68%,the Youden index was 0.48.(3)The sensitivity of age-adjusted D-dimer combined with simplified Geneva score in diagnosing APE in the aged was 97%,the specificity was 44%,the positive predictivevalue was 72%,the negative predictive value was 90%,the Youden index was 0.41,the Kappa value was 0.445;the sensitivity of age-adjusted D-dimer combined with simplified Geneva score for excluded diagnosis of APE in the aged was 90%,the specificity was 82%,the positive predictive value was 88%,the negative predictive value was 85%,the Youden index was 0.72,the Kappa value was 0.538.(4)ROC curve showed that,AUC of age-adjusted D-dimer in diagnosing APE in the aged was 0.881[95%CI(0.841,0.921),P<0.01],that of simplified Geneva score was 0.827[95%CI(0.779,0.875),P<0.01],and that of D-dimer combined with simplified Geneva score was 0.920[95%CI(0.887,0.953),P<0.01].Conclusion Diagnostic value of age-adjusted D-dimer combined with simplified Geneva score is relatively high in diagnosing APE in the aged,which is helpful to improve the screening efficiency,may be a diagnostic/excluded diagnostic indicator for suspected elderly APE patients with hemodynamic change and in those hospitals lacking of CTPA or pulmonary ventilation perfusion scan equipment.
引文
[1]POLO FRIZ H,PASCIUTI L,MELONI D F,et al.A higher d-dimer threshold safely rules-out pulmonary embolism in very elderly emergency department patients[J].Thromb Res,2014,133(3):380-383.DOI:10.1016/j.thromres.2013.12.045.
[2]WELLS P S,ANDERSON D R,RODGER M,et al.Derivation of a simple clinical model to categorize patients probability of pulmonary embolism:increasing the models utility with the SimpliRED D-dimer[J].Thromb Haemost,2000,83(3):416-420.
[3]LE GAL G,RIGHINI M,ROY P M,et al.Prediction of pulmonary embolism in the emergency department:the revised Geneva score[J].Ann Intern Med,2006,144(3):165-171.DOI:10.7326/0003-4819-144-3-200602070-00004.
[4]赵梦华,宋文奇,徐宝元,等.GRACE评分用于急性肺栓塞危险分层的研究[J].中国急救医学,2014,34(4):338-341.DOI:10.3969/j.issn.1002-1949.2014.04.012.
[5]徐希奇,荆志成.《2014年ESC急性肺栓塞诊治指南》解读[J].中国循环杂志,2014(z2):67-71.DOI:10.3969/j.issn.1000-3614.2014.z2.017.
[6]SOARES T H,DE BASTOS M,DE CARVALHO B V,et al.Prognostic value of computed tomographic pulmonary angiography and the pulmonary embolism severity index in patients with acute pulmonary embolism[J].Blood Coagul Fibrinolysis,2013,24(1):64-70.DOI:10.1097/MBC.0b013e32835a72c2.
[7]STEIN P D,FOWLER S E,GOODMAN L R,et al.Multidetector computed tomography for acute pulmonary embolism[J].N Eng JMed,2006,354(22):2317-2327.
[8]中华医学会呼吸病学分会肺栓塞与肺血管病学组,中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会,全国肺栓塞与肺血管病防治协作组.肺血栓栓塞症诊治与预防指南[J].中华医学杂志,2018,98(14):1060-1087.DOI:10.3760/cma.j.issn.0376-2491.2018.14.007.
[9]中华医学会心血管病学分会肺血管病学组,中国医师协会心血管内科医师分会.急性肺血栓栓塞症诊断治疗中国专家共识[J].中华内科杂志,2010,49(1):74-81.DOI:10.3760/cma.j.issn.0578-1426.2010.01.026.
[10]POLO FRIZ H,MOLTENI M,DEL SORBO D,et al.Mortality at 30 and 90 days in elderly patients with pulmonary embolism:a retrospective cohort study[J].Inter Emerg Med,2015,10(4):431-436.DOI:10.1007/s11739-014-1179-z.
[11]WEBEROVA D,WEBER P,MELUZINOVA H,et al.Deceased elderly in-patients with pulmonary embolism[J].Bratisl Lek Listy,2014,115(12):786-790.
[12]刘晓婷,林光柱,赵学忠.303例住院肺栓塞患者危险因素分析[J].中华流行病学杂志,2011,32(12):1275-1277.DOI:10.3760/cma.j.issn.0254-6450.2011.12.021.
[13]张金彪,代荣琴.D-二聚体检测的研究进展及其临床价值[J].国际检验医学杂志,2014,35(9):1152-1153.DOI:10.3969/j.issn.1673-4130.2014.09.027.
[14]GUPTA A,RAJA A S,IP I K,et al.Assessing 2 D-dimer ageadjustment strategies to optimize computed tomographic use in EDevaluation of pulmonary embolism[J].Am J Emerg Med,2014,32(12):1499-1502.DOI:10.1016/j.ajem.2014.09.027.
[15]SCHOUTEN H J,GEERSING G J,KOEK H L,et al.Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis[J].BMJ,2013,346:f2492.DOI:10.1136/bmj.f2492.
[16]陶琳,杨毅.心肌型脂肪酸结合蛋白联合血浆D-二聚体对肺栓塞预后评估的临床意义[J].中华临床医师杂志(电子版),2015,9(15):2836-2839.DOI:10.3877/cma.j.issn.1674-0785.2015.15.013.
[17]RIGHINI M,VAN ES J,DEN EXTER P L,et al.Age-Adjusted D-Dimer cutoff levels to rule out pulmonary embolism:the ADJUST-PE study[J].JAMA,2014,311(11):1117-1124.DOI:10.1001/jama.2014.2135.
[18]WONG D D,RAMASESHAN G,MENDELSON R M.Comparison of the Wells and Revised Geneva Scores for the diagnosis of pulmonary embolism:an Australian experience[J].Intern Med J,2011,41(3):258-263.DOI:10.1111/j.1445-5994.2010.02204.x.
[19]MOS I C,DOUMA R A,ERKENS P M,et al.Reliability of clinical decision rules in diagnosing acute pulmonary embolism[J].Ned Tijdschr Geneeskd,2012,156(34):A4216.
[20]叶艳平,李艳彦,陈谨,等.Wells评分和修改的Geneva评分对急性肺栓塞的预测价值[J].中华内科杂志,2012,51(8):626-629.DOI:10.3760/cma.j.issn.0578-1426.2012.08.013.2019-01-172019-05-13
[2]WELLS P S,ANDERSON D R,RODGER M,et al.Derivation of a simple clinical model to categorize patients probability of pulmonary embolism:increasing the models utility with the SimpliRED D-dimer[J].Thromb Haemost,2000,83(3):416-420.
[3]LE GAL G,RIGHINI M,ROY P M,et al.Prediction of pulmonary embolism in the emergency department:the revised Geneva score[J].Ann Intern Med,2006,144(3):165-171.DOI:10.7326/0003-4819-144-3-200602070-00004.
[4]赵梦华,宋文奇,徐宝元,等.GRACE评分用于急性肺栓塞危险分层的研究[J].中国急救医学,2014,34(4):338-341.DOI:10.3969/j.issn.1002-1949.2014.04.012.
[5]徐希奇,荆志成.《2014年ESC急性肺栓塞诊治指南》解读[J].中国循环杂志,2014(z2):67-71.DOI:10.3969/j.issn.1000-3614.2014.z2.017.
[6]SOARES T H,DE BASTOS M,DE CARVALHO B V,et al.Prognostic value of computed tomographic pulmonary angiography and the pulmonary embolism severity index in patients with acute pulmonary embolism[J].Blood Coagul Fibrinolysis,2013,24(1):64-70.DOI:10.1097/MBC.0b013e32835a72c2.
[7]STEIN P D,FOWLER S E,GOODMAN L R,et al.Multidetector computed tomography for acute pulmonary embolism[J].N Eng JMed,2006,354(22):2317-2327.
[8]中华医学会呼吸病学分会肺栓塞与肺血管病学组,中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会,全国肺栓塞与肺血管病防治协作组.肺血栓栓塞症诊治与预防指南[J].中华医学杂志,2018,98(14):1060-1087.DOI:10.3760/cma.j.issn.0376-2491.2018.14.007.
[9]中华医学会心血管病学分会肺血管病学组,中国医师协会心血管内科医师分会.急性肺血栓栓塞症诊断治疗中国专家共识[J].中华内科杂志,2010,49(1):74-81.DOI:10.3760/cma.j.issn.0578-1426.2010.01.026.
[10]POLO FRIZ H,MOLTENI M,DEL SORBO D,et al.Mortality at 30 and 90 days in elderly patients with pulmonary embolism:a retrospective cohort study[J].Inter Emerg Med,2015,10(4):431-436.DOI:10.1007/s11739-014-1179-z.
[11]WEBEROVA D,WEBER P,MELUZINOVA H,et al.Deceased elderly in-patients with pulmonary embolism[J].Bratisl Lek Listy,2014,115(12):786-790.
[12]刘晓婷,林光柱,赵学忠.303例住院肺栓塞患者危险因素分析[J].中华流行病学杂志,2011,32(12):1275-1277.DOI:10.3760/cma.j.issn.0254-6450.2011.12.021.
[13]张金彪,代荣琴.D-二聚体检测的研究进展及其临床价值[J].国际检验医学杂志,2014,35(9):1152-1153.DOI:10.3969/j.issn.1673-4130.2014.09.027.
[14]GUPTA A,RAJA A S,IP I K,et al.Assessing 2 D-dimer ageadjustment strategies to optimize computed tomographic use in EDevaluation of pulmonary embolism[J].Am J Emerg Med,2014,32(12):1499-1502.DOI:10.1016/j.ajem.2014.09.027.
[15]SCHOUTEN H J,GEERSING G J,KOEK H L,et al.Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism:systematic review and meta-analysis[J].BMJ,2013,346:f2492.DOI:10.1136/bmj.f2492.
[16]陶琳,杨毅.心肌型脂肪酸结合蛋白联合血浆D-二聚体对肺栓塞预后评估的临床意义[J].中华临床医师杂志(电子版),2015,9(15):2836-2839.DOI:10.3877/cma.j.issn.1674-0785.2015.15.013.
[17]RIGHINI M,VAN ES J,DEN EXTER P L,et al.Age-Adjusted D-Dimer cutoff levels to rule out pulmonary embolism:the ADJUST-PE study[J].JAMA,2014,311(11):1117-1124.DOI:10.1001/jama.2014.2135.
[18]WONG D D,RAMASESHAN G,MENDELSON R M.Comparison of the Wells and Revised Geneva Scores for the diagnosis of pulmonary embolism:an Australian experience[J].Intern Med J,2011,41(3):258-263.DOI:10.1111/j.1445-5994.2010.02204.x.
[19]MOS I C,DOUMA R A,ERKENS P M,et al.Reliability of clinical decision rules in diagnosing acute pulmonary embolism[J].Ned Tijdschr Geneeskd,2012,156(34):A4216.
[20]叶艳平,李艳彦,陈谨,等.Wells评分和修改的Geneva评分对急性肺栓塞的预测价值[J].中华内科杂志,2012,51(8):626-629.DOI:10.3760/cma.j.issn.0578-1426.2012.08.013.2019-01-172019-05-13