血浆D-二聚体临界值联合Wells量表对可疑肺栓塞的除外价值
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摘要
目的:评价传统和按年龄校正的血浆D-二聚体临界值分别联合二分类Wells量表对可疑肺栓塞的除外价值。方法:入选北京大学人民医院2013年9月至2015年1月因胸痛、呼吸困难等症状怀疑肺栓塞的患者335例,其中复选年龄>50岁的患者274例;应用二分类Wells量表进行临床肺栓塞可能性评估,选择Wells量表评分≤4分患者,分别联合血浆D-二聚体传统临界值(500μg/L)和按年龄校正的临界值(年龄>50岁患者为:年龄×10μg/L),以CT肺动脉造影为确诊肺栓塞的金标准,比较两种临界值对可疑肺栓塞的除外价值。结果:(1)传统和按年龄校正的血浆D-二聚体临界值分别联合二分类Wells量表诊断肺栓塞的ROC曲线下面积为0.764(95%CI:0.703~0.818)和0.814(95%CI:0.756~0.863),差异无统计学意义(Z=0.05,P=0.121);(2)传统血浆D-二聚体临界值联合二分类Wells量表诊断肺栓塞的敏感性、特异性、阳性预测值、阴性预测值、约登指数分别为100%、48.9%、28.8%、100%,0.49;按年龄校正的血浆D-二聚体临界值联合二分类Wells量表诊断肺栓塞的敏感性、特异性、阳性预测值、阴性预测值、约登指数分别为97.4%、62.3%、35.5%、99.1%,0.60。与传统临界值相比,按年龄校正的血浆D-二聚体临界值联合二分类Wells量表,诊断肺栓塞的特异性(传统临界值组48.9%,年龄校正临界值组62.3%)明显提高,敏感性(传统临界值组100%,年龄校正临界值组99.1%)无明显降低;(3)222例二分类Wells量表评分≤4分患者中,90例(40.5%)患者血浆D-二聚体<传统临界值(500μg/L),25例(11.3%)患者血浆D-二聚体介于传统临界值(500μg/L)与年龄校正临界值(年龄×10μg/L)之间。结论:应用按年龄校正的血浆D-二聚体临界值联合二分类Wells量表可提高50岁以上肺栓塞患者诊断的特异性,未明显降低敏感性,可用于可疑肺栓塞的排除诊断。
Objective: To evaluate the value of conventional and age-adjusted D-dimer cut-off value combined with 2-level Wells score for diagnosis of suspected pulmonary embolism. Methods: In the study,335 patients with suspected pulmonary embolism who visited Peking University People 's Hospital were enrolled retrospectively,then 274 patients with age over fifty years were chosen. The 2-level Wells score was applied to evaluate the clinical probability of pulmonary embolism,the diagnostic value of traditional D-dimer cut-off value( 500 μg/L) and age adjusted D-dimer cut-off value( age × 10 μg/L above50 years) combined with Wells score no greater than 4 were compared. Computed tomography pulmonary arteriography( CTPA) was considered as the gold standard for diagnosis of pulmonary embolism. Results:( 1) The area under a receiver operating characteristic( ROC) curve( AUC) in analysis of the combination of Wells score no greater than 4 and traditional D-dimer cut-off value was 0. 764( 95% CI: 0. 703-0. 818). On the other hand,the AUC in a ROC analysisof the combination of Wells Score no greater than4 and age-adjusted D-dimer cut-off value was 0. 814( 95% CI: 0. 756-0. 863). These two results did not differ statistically( Z = 0. 05,P = 0. 121).( 2) The sensitivity,specificity,positive predictive value,negative predictive value and Youden index of the diagnosis of pulmonary embolism of the combination of traditional D-dimer cut-off value and 2-level Wells Score were 100%,48. 9%,28. 8%,100%,and0. 49,respectively. Meanwhile,the sensitivity,specificity,positive predictive value,negative predictive value and Youden index of the diagnosis of pulmonary embolism of the combination of age-adjusted Ddimer cut-off value and 2-level Wells Score were 97. 4%,62. 3%,35. 5% 99. 1%,and 0. 60,respectively. Compared with using traditional D-dimer cut-off value,using age-adjusted D-dimer cut-off value could improve the diagnosis specificity( traditional D-dimer cut-off value group: 48. 9%,age-adjusted Ddimer cut-off value group: 62. 3%) of pulmonary embolism without reducing the sensitivity( traditional D-dimer cut-off value group: 100%,age-adjusted D-dimer cut-off value group: 99. 1%).( 3) Among the 222 patients with Wells Score no greater than 4,90 patients were with D-dimer less than traditional cut-off value( 500 μg/L),and 25 patients( account for 11. 3% of all 222 patients) were with D-dimer between traditional cut-off value and age-adjusted cut-off value. Conclusion: The application of age-adjusted D-dimer cut-off value can improve the diagnostic specificity of pulmonary embolism in patients over 50 years,without reducing the sensitivity. It can be used for ruling out suspected pulmonary embolism safely.
Objective: To evaluate the value of conventional and age-adjusted D-dimer cut-off value combined with 2-level Wells score for diagnosis of suspected pulmonary embolism. Methods: In the study,335 patients with suspected pulmonary embolism who visited Peking University People 's Hospital were enrolled retrospectively,then 274 patients with age over fifty years were chosen. The 2-level Wells score was applied to evaluate the clinical probability of pulmonary embolism,the diagnostic value of traditional D-dimer cut-off value( 500 μg/L) and age adjusted D-dimer cut-off value( age × 10 μg/L above50 years) combined with Wells score no greater than 4 were compared. Computed tomography pulmonary arteriography( CTPA) was considered as the gold standard for diagnosis of pulmonary embolism. Results:( 1) The area under a receiver operating characteristic( ROC) curve( AUC) in analysis of the combination of Wells score no greater than 4 and traditional D-dimer cut-off value was 0. 764( 95% CI: 0. 703-0. 818). On the other hand,the AUC in a ROC analysisof the combination of Wells Score no greater than4 and age-adjusted D-dimer cut-off value was 0. 814( 95% CI: 0. 756-0. 863). These two results did not differ statistically( Z = 0. 05,P = 0. 121).( 2) The sensitivity,specificity,positive predictive value,negative predictive value and Youden index of the diagnosis of pulmonary embolism of the combination of traditional D-dimer cut-off value and 2-level Wells Score were 100%,48. 9%,28. 8%,100%,and0. 49,respectively. Meanwhile,the sensitivity,specificity,positive predictive value,negative predictive value and Youden index of the diagnosis of pulmonary embolism of the combination of age-adjusted Ddimer cut-off value and 2-level Wells Score were 97. 4%,62. 3%,35. 5% 99. 1%,and 0. 60,respectively. Compared with using traditional D-dimer cut-off value,using age-adjusted D-dimer cut-off value could improve the diagnosis specificity( traditional D-dimer cut-off value group: 48. 9%,age-adjusted Ddimer cut-off value group: 62. 3%) of pulmonary embolism without reducing the sensitivity( traditional D-dimer cut-off value group: 100%,age-adjusted D-dimer cut-off value group: 99. 1%).( 3) Among the 222 patients with Wells Score no greater than 4,90 patients were with D-dimer less than traditional cut-off value( 500 μg/L),and 25 patients( account for 11. 3% of all 222 patients) were with D-dimer between traditional cut-off value and age-adjusted cut-off value. Conclusion: The application of age-adjusted D-dimer cut-off value can improve the diagnostic specificity of pulmonary embolism in patients over 50 years,without reducing the sensitivity. It can be used for ruling out suspected pulmonary embolism safely.
引文
[1]Konstantinides SV,Torbicki A,Agnelli G,et al.The task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology.2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism[J].Eur Heart,2014,35(43):3033-3069.
[2]Lucassen W,Geersing GJ,Erkens PM,et al.Clinical decision rules for excluding pulmonary embolism:a meta-analysis[J].Ann Intern Med,2011,155:448-460.
[3]Douma RA,le Gal G,Sohne M,et al.Potential of an age adjusted d-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients:a retrospective analysis of three large cohorts[J].BMJ,2010,340:c1475.
[4]Leeflang MM,Bossuyt PM,Irwig L.Diagnostic test accuracy may vary with prevalence:implications for evidence-based diagnosis[J].Clin Epidemiol,2009,62(1):5-12.
[5]Legnani C,Palareti G,Cosmi B,et al.Different cut-off values of quantitative D-dimer methods to predict the risk of venous thromboembolism recurrence:A post-hoc analysis of the PROLONG study[J].Haematologica,2008,93(6):900-907.
[6]Wells PS,Anderson DR,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.
[7]Puurunen MK,Gona PN,Larson MG,et al.Epidemiology of venous thromboembolism in the Framingham Heart Study[J].Thromb Res,2016,29(6):14527-14533
[8]van Es J,Mos I,Douma R,et al.The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded[J].Thromb Haemost,2012,107(1):167-171.
[9]Duru S,Ergün R,Dilli A,et al.Clinical,laboratory and computed tomography pulmonary angiography results in pulmonary embolism:retrospective evaluation of 205 patients[J].Anadolu Kardiyol Derg,2012,12(2):142-149.
[10]Klok FA,Zidane M,Djurabi RK,et al.The physician’s estimation alternative diagnosis is less likely than pulmonary embolism in the Wells rule is dependent on the presence of other required items[J].Thromb Haemost,2008,99(1):244-245.
[11]Runyon MS,Webb WB,Jones AE,et al.Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule:a prospective observational study[J].Acad Emerg Med,2005,12(7):587-593.
[12]Penaloza A,Roy PM,Kline J,et al.Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism[J].J Thromb Haemost,2012,10(7):1291-1296.
[2]Lucassen W,Geersing GJ,Erkens PM,et al.Clinical decision rules for excluding pulmonary embolism:a meta-analysis[J].Ann Intern Med,2011,155:448-460.
[3]Douma RA,le Gal G,Sohne M,et al.Potential of an age adjusted d-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients:a retrospective analysis of three large cohorts[J].BMJ,2010,340:c1475.
[4]Leeflang MM,Bossuyt PM,Irwig L.Diagnostic test accuracy may vary with prevalence:implications for evidence-based diagnosis[J].Clin Epidemiol,2009,62(1):5-12.
[5]Legnani C,Palareti G,Cosmi B,et al.Different cut-off values of quantitative D-dimer methods to predict the risk of venous thromboembolism recurrence:A post-hoc analysis of the PROLONG study[J].Haematologica,2008,93(6):900-907.
[6]Wells PS,Anderson DR,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.
[7]Puurunen MK,Gona PN,Larson MG,et al.Epidemiology of venous thromboembolism in the Framingham Heart Study[J].Thromb Res,2016,29(6):14527-14533
[8]van Es J,Mos I,Douma R,et al.The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded[J].Thromb Haemost,2012,107(1):167-171.
[9]Duru S,Ergün R,Dilli A,et al.Clinical,laboratory and computed tomography pulmonary angiography results in pulmonary embolism:retrospective evaluation of 205 patients[J].Anadolu Kardiyol Derg,2012,12(2):142-149.
[10]Klok FA,Zidane M,Djurabi RK,et al.The physician’s estimation alternative diagnosis is less likely than pulmonary embolism in the Wells rule is dependent on the presence of other required items[J].Thromb Haemost,2008,99(1):244-245.
[11]Runyon MS,Webb WB,Jones AE,et al.Comparison of the unstructured clinician estimate of pretest probability for pulmonary embolism to the Canadian score and the Charlotte rule:a prospective observational study[J].Acad Emerg Med,2005,12(7):587-593.
[12]Penaloza A,Roy PM,Kline J,et al.Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism[J].J Thromb Haemost,2012,10(7):1291-1296.