风险评分结合D-二聚体在急性主动脉综合征诊断中的意义
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摘要
目的评估主动脉夹层风险评分(ADD-RS)结合D-二聚体(DD)在急性主动脉综合征(AAS)标准化的诊断策略的准确性和有效性。方法前瞻性分析惠州市3家三级甲等医院急诊内科2014年1月至2017年8月收治的3 330例拟诊断为急性主动脉综合征患者的临床资料,其中男性2 132例,女性1 198例;年龄50～72岁,平均(52.68±4.9岁)。采用验前概率标准化工具ADD-RS联合血清DD进行AAS的筛查和诊断,DD>0.5μg/mL记为DD~+。最终的诊断依据影像学、尸检、手术或14 d随访结果确定。评估在ADD-RS=0/DD~-或ADD-RS≤1/DD~-的患者中排除AAS的漏诊率和有效性。结果 766例(23%)患者ADD-RS=0,1 732例(52%)患者ADD-RS=1,为非高风险组;832例(25%)患者ADD-RS>1,为高风险组。DD~+的患者为1 335例(40.1%)。通过影像学、尸检、手术或14 d随访结果最终确诊AAS患者434例(13%),其中DD~+ 417例(96%),诊断灵敏度为95.2%(95%CI:92.7%～97%),特异度为62%(95%CI:60.3%～64.1%)。DD~-17例(3.9%)。在ADD-RS=0/DD~-的529例患者中,2例(0.4%)确诊为AAS,ADD-RS联合DD诊断策略的漏诊率为0.3%(95%CI为0.1～1.7%),排除AAS的有效率为15.3%(95%CI:14.6～17.2%)。在1 663例ADD-RS≤1/DD~-患者中,6例确诊AAS,ADD-RS联合DD漏诊率为0.4%(95%CI为0.2%～1.1%)有效率为51.2%(95%CI 48.1～53.6%)。结论以ADD-RS≤1结合DD~-的诊断新策略,确诊AAS的有效率较高,漏诊率较低。
Objective To assess the safety and efficiency of such diagnostic strategy of aortic dissection score combined D-dimer for acute aortic syndromes(AAS). Methods In a multicenter prospective observational study involving 3 hospitals from 2014 to 2017,3330 patients were analyzed. Among them, 2132 were males and 1198 were females,aged from 50 to 72 years,with an average age of(52.68±4.9) years. The tool for PPA was the aortic dissection detection risk score(ADD-RS) per current guidelines. DD was considered negative(DD-) if >0.5 cu/mL. Final case adjudication was based on conclusive diagnostic imaging,autopsy,surgery or on 14-day follow-up. The outcomes were the failure rate and efficiency of a diagnostic strategy ruling-out AAS in patients with ADD-RS=0/DD~- or ADD-RS≤D/DD~-. Results 766(23%) patients had ADD-RS=0, 1732(52%) patients had ADD-RS=1, and 832(25%) had ADD-RS>1. 434(13%) patients had AAS. A positive DD test result had an overall sensitivity of 95.2%(95% CI 92.7-97%) and a specificity of 62%(95% CI 60.3-64.1%) for diagnosis of AAS; 17 patients with AAS had DD~-. Within 529 patients with ADD-RS=0/DD~-, 2 cases of AAS were observed. This yielded a failure rate of 0.4%(95% CI 0.1-1.9%) and efficiency of 15.3%(95% CI 14.6-17.2%) for the ADD-RS=0/DD~- strategy. Within 1 663 patients with ADD-RS ≤s/DD~-, 6 cases of AAS were observed. This yielded a failure rate of 0.4%(95% CI 0.2-1.1%) and efficiency of 51.2%(95% CI 48.1-53.6%) for the ADD-RS≤f/DD~-strategy. Conclusions Integration of ADD-RS(both =0 or ≤o)with DD may be considered to standardize diagnostic rule-out of AAS.
Objective To assess the safety and efficiency of such diagnostic strategy of aortic dissection score combined D-dimer for acute aortic syndromes(AAS). Methods In a multicenter prospective observational study involving 3 hospitals from 2014 to 2017,3330 patients were analyzed. Among them, 2132 were males and 1198 were females,aged from 50 to 72 years,with an average age of(52.68±4.9) years. The tool for PPA was the aortic dissection detection risk score(ADD-RS) per current guidelines. DD was considered negative(DD-) if >0.5 cu/mL. Final case adjudication was based on conclusive diagnostic imaging,autopsy,surgery or on 14-day follow-up. The outcomes were the failure rate and efficiency of a diagnostic strategy ruling-out AAS in patients with ADD-RS=0/DD~- or ADD-RS≤D/DD~-. Results 766(23%) patients had ADD-RS=0, 1732(52%) patients had ADD-RS=1, and 832(25%) had ADD-RS>1. 434(13%) patients had AAS. A positive DD test result had an overall sensitivity of 95.2%(95% CI 92.7-97%) and a specificity of 62%(95% CI 60.3-64.1%) for diagnosis of AAS; 17 patients with AAS had DD~-. Within 529 patients with ADD-RS=0/DD~-, 2 cases of AAS were observed. This yielded a failure rate of 0.4%(95% CI 0.1-1.9%) and efficiency of 15.3%(95% CI 14.6-17.2%) for the ADD-RS=0/DD~- strategy. Within 1 663 patients with ADD-RS ≤s/DD~-, 6 cases of AAS were observed. This yielded a failure rate of 0.4%(95% CI 0.2-1.1%) and efficiency of 51.2%(95% CI 48.1-53.6%) for the ADD-RS≤f/DD~-strategy. Conclusions Integration of ADD-RS(both =0 or ≤o)with DD may be considered to standardize diagnostic rule-out of AAS.
引文
1 刘洋,冯飞,吕广欣.联合检测血浆D- 二聚体和基质金属蛋白酶- 9对急性主动脉夹层的诊断及预后判断价值[J].中国心血管病研究,2019,17(2):147- 150.
2 Howard DP,Banerjee A,Fairhead JF,et al.Population- based study of incidence,risk factors,outcome,and prognosis of ischemic peripheral arterial events:Implications for prevention[J].Circulation,2015,132(19):1805- 1815.
3 Klompas M.Does this patient have an acute thoracic aortic dissection?[J].JAMA,2002,287(17):2262- 2272.
4 Owens PL,Barrett ML,Gibson TB,et al.Emergency department care in the united states:A profile of national data sources[J].Ann Emerg Med,2010,56(2):150- 165.
5 Hansen MS,Nogareda GJ,Hutchison SJ.Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection[J].Am J Cardiol,2007,99(6):852- 856.
6 Kurabayashi M,Miwa N,Ueshima D,et al.Factors leading to failure to diagnose acute aortic dissection in the emergency room[J].J Cardiol,2011,58(3):287- 293.
7 Zhan S,Hong S,Shan- Shan L,et al.Misdiagnosis of aortic dissection:Experience of 361 patients[J].J Clin Hypertens(Greenwich),2012,14(4):256- 260.
8 Mettler FA Jr,Huda W,Yoshizumi TT,et al.Effective doses in radiology and diagnostic nuclear medicine:A catalog[J].Radiology,2008,248(1):254- 263.
9 Smith- Bindman R,Lipson J,Marcus R,et al.Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer[J].Arch Intern Med,2009,169(22):2078- 2086.
10 Lovy AJ,Bellin E,Levsky JM,et al.Preliminary development of a clinical decision rule for acute aortic syndromes[J].Am J Emerg Med,2013,31(11):1546- 1550.
11 Fang Z,Zhu XH,Wei X,et al.The diagnostic value of combined D- dimer with other indicators in suspected acute aortic dissection patients[J].Int J Cardiol,2018,268:215.
12 Erbel R,Aboyans V,Boileau C,et al.2014 ESD guidelines on the diagnosis and treatment of aortic diseases:document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult.The task force for the diagnosis and treatment of aortic diseases of the european society of cardiology(ESC)[J].Eur Heart J,2014,35(41):2873- 2926.
13 Righini M,Van Es J,Den Exter PL,et al.Age- adjusted d- dimer cutoff levels to rule out pulmonary embolism:The ADJUST- PE study[J].JAMA,2014,311(11):1117- 1124.
14 Konstantinides SV,Torbicki A,Agnelli G,et al.Corrigendum to:2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism[J].Eur Heart J,2015,36(39):2642
15 Watanabe H,Horita N,Shibata Y,et al.Diagnostic test accuracy of d- dimer for acute aortic syndrome:Systematic review and meta- analysis of 22studies with 5000 subjects[J].Sci Rep,2016,6:26893.
16 Asha SE,Miers JW.A systematic review and meta- analysis of d- dimer as a rule- out test for suspected acute aortic dissection[J].Ann Emerg Med,2015,66(4):368- 378.
17 American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thoracic Aortic Dissection,Diercks DB,Promes SB,et al.Clinical policy:critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection[J].Ann Emerg Med,2015,65(1):32- 42.
18 Baez AA,Cochon L.Improved rule- out diagnostic gain with a combined aortic dissection detection risk score and d- dimer bayesian decision support scheme[J].J Crit Care,2017,37:56- 59.
19 Nazerian P,Morello F,Vanni S,et al.Combined use of aortic dissection detection risk score and d- dimer in the diagnostic workup of suspected acute aortic dissection[J].Int J Cardiol,2014,175(1):78- 82.
20 Gorla R,Erbel R,Kahlert P,et al.Accuracy of a diagnostic strategy combining aortic dissection detection risk score and d- dimer levels in patients with suspected acute aortic syndrome[J].Eur Heart J Acute Cardiovasc Care,2017,6(5):371- 378.
21 冯小鹏,叶自力,余名华.风险评分结合D- 二聚体在主动脉夹层急诊早期诊断中的意义[J].岭南急诊医学杂志,2016,106(6):562- 563
22 Nazerian P,Mueller C,Soeiro AM,et al.Diagnostic accuracy of the aortic dissection detection risk score plus D- Dimer for acute aortic syndromes:the ADvISED prospective multicenter study[J].Circulation,2018,137(3):250- 258.
23 Sarasin FP,Louis- Simonet M,Gaspoz JM,et al.Detecting acute thoracic aortic dissection in the emergency department:Time constraints and choice of the optimal diagnostic test[J].Ann Emerg Med,1996,28(3):278- 288.
24 van Belle A,Büller HR,Huisman MV,et al.Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability,d- dimer testing,and computed tomography[J].JAMA,2006,295(2):172- 179.
2 Howard DP,Banerjee A,Fairhead JF,et al.Population- based study of incidence,risk factors,outcome,and prognosis of ischemic peripheral arterial events:Implications for prevention[J].Circulation,2015,132(19):1805- 1815.
3 Klompas M.Does this patient have an acute thoracic aortic dissection?[J].JAMA,2002,287(17):2262- 2272.
4 Owens PL,Barrett ML,Gibson TB,et al.Emergency department care in the united states:A profile of national data sources[J].Ann Emerg Med,2010,56(2):150- 165.
5 Hansen MS,Nogareda GJ,Hutchison SJ.Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection[J].Am J Cardiol,2007,99(6):852- 856.
6 Kurabayashi M,Miwa N,Ueshima D,et al.Factors leading to failure to diagnose acute aortic dissection in the emergency room[J].J Cardiol,2011,58(3):287- 293.
7 Zhan S,Hong S,Shan- Shan L,et al.Misdiagnosis of aortic dissection:Experience of 361 patients[J].J Clin Hypertens(Greenwich),2012,14(4):256- 260.
8 Mettler FA Jr,Huda W,Yoshizumi TT,et al.Effective doses in radiology and diagnostic nuclear medicine:A catalog[J].Radiology,2008,248(1):254- 263.
9 Smith- Bindman R,Lipson J,Marcus R,et al.Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer[J].Arch Intern Med,2009,169(22):2078- 2086.
10 Lovy AJ,Bellin E,Levsky JM,et al.Preliminary development of a clinical decision rule for acute aortic syndromes[J].Am J Emerg Med,2013,31(11):1546- 1550.
11 Fang Z,Zhu XH,Wei X,et al.The diagnostic value of combined D- dimer with other indicators in suspected acute aortic dissection patients[J].Int J Cardiol,2018,268:215.
12 Erbel R,Aboyans V,Boileau C,et al.2014 ESD guidelines on the diagnosis and treatment of aortic diseases:document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult.The task force for the diagnosis and treatment of aortic diseases of the european society of cardiology(ESC)[J].Eur Heart J,2014,35(41):2873- 2926.
13 Righini M,Van Es J,Den Exter PL,et al.Age- adjusted d- dimer cutoff levels to rule out pulmonary embolism:The ADJUST- PE study[J].JAMA,2014,311(11):1117- 1124.
14 Konstantinides SV,Torbicki A,Agnelli G,et al.Corrigendum to:2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism[J].Eur Heart J,2015,36(39):2642
15 Watanabe H,Horita N,Shibata Y,et al.Diagnostic test accuracy of d- dimer for acute aortic syndrome:Systematic review and meta- analysis of 22studies with 5000 subjects[J].Sci Rep,2016,6:26893.
16 Asha SE,Miers JW.A systematic review and meta- analysis of d- dimer as a rule- out test for suspected acute aortic dissection[J].Ann Emerg Med,2015,66(4):368- 378.
17 American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thoracic Aortic Dissection,Diercks DB,Promes SB,et al.Clinical policy:critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection[J].Ann Emerg Med,2015,65(1):32- 42.
18 Baez AA,Cochon L.Improved rule- out diagnostic gain with a combined aortic dissection detection risk score and d- dimer bayesian decision support scheme[J].J Crit Care,2017,37:56- 59.
19 Nazerian P,Morello F,Vanni S,et al.Combined use of aortic dissection detection risk score and d- dimer in the diagnostic workup of suspected acute aortic dissection[J].Int J Cardiol,2014,175(1):78- 82.
20 Gorla R,Erbel R,Kahlert P,et al.Accuracy of a diagnostic strategy combining aortic dissection detection risk score and d- dimer levels in patients with suspected acute aortic syndrome[J].Eur Heart J Acute Cardiovasc Care,2017,6(5):371- 378.
21 冯小鹏,叶自力,余名华.风险评分结合D- 二聚体在主动脉夹层急诊早期诊断中的意义[J].岭南急诊医学杂志,2016,106(6):562- 563
22 Nazerian P,Mueller C,Soeiro AM,et al.Diagnostic accuracy of the aortic dissection detection risk score plus D- Dimer for acute aortic syndromes:the ADvISED prospective multicenter study[J].Circulation,2018,137(3):250- 258.
23 Sarasin FP,Louis- Simonet M,Gaspoz JM,et al.Detecting acute thoracic aortic dissection in the emergency department:Time constraints and choice of the optimal diagnostic test[J].Ann Emerg Med,1996,28(3):278- 288.
24 van Belle A,Büller HR,Huisman MV,et al.Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability,d- dimer testing,and computed tomography[J].JAMA,2006,295(2):172- 179.