Hull R D, Pineo G F, Stein P D, Mah A F, Butcher M S
Thrombosis Research Unit, Foothills Hospital, Calgary, Alberta, Canada.
Semin Thromb Hemost. 2001;27(1):15-23. doi: 10.1055/s-2001-12843.
Improvements in the methods of clinical trials combined with the use of objective tests to detect venous thrombosis have enhanced the clinician's ability to diagnose pulmonary embolism and venous thrombosis (venous thromboembolism). The authors updated a previous cost-effectiveness analysis of the commonly recommended strategies for pulmonary embolism diagnosis and management to reflect current clinical practice. Two criteria of effectiveness were used: correct identification of venous thromboembolism and correct identification of venous thromboembolism and correct identification of patients for whom treatment was unnecessary. The cost of each diagnostic alternative was defined as the direct cost of administering the diagnostic tests plus the treatment costs associated with a positive test result. A strategy based on the combined use ofventilation-perfusion lung scanning, serial ultrasonography, cardiorespiratory evaluation, and pulmonary angiography was the most cost-effective. This strategy also necessitated pulmonary angiography in the fewest number of patients. The safety of this strategy relates to two important biologic concepts: 1) local extension of submassive pulmonary embolism in the lung is not an important cause of morbidity or mortality in patients with adequate cardiorespiratory reserve, and 2) in most patients, proximal vein thrombi of the lower extremities are the source of recurrent pulmonary embolism.
临床试验方法的改进，再加上使用客观检测手段来发现静脉血栓形成，提高了临床医生诊断肺栓塞和静脉血栓形成（静脉血栓栓塞症）的能力。作者更新了之前关于肺栓塞诊断和管理常用推荐策略的成本效益分析，以反映当前的临床实践。使用了两个有效性标准：正确识别静脉血栓栓塞症以及正确识别无需治疗的患者。每种诊断方法的成本定义为进行诊断检测的直接成本加上与阳性检测结果相关的治疗成本。基于通气-灌注肺扫描、系列超声检查、心肺评估和肺血管造影联合使用的策略是最具成本效益的。该策略还使需要进行肺血管造影的患者数量最少。该策略的安全性涉及两个重要的生物学概念：1）在心肺储备充足的患者中，肺内亚大块肺栓塞的局部扩展并非发病或死亡的重要原因；2）在大多数患者中，下肢近端静脉血栓是复发性肺栓塞的来源。
