Wolf Stephen J, McCubbin Tracy R, Feldhaus Kim M, Faragher Jeffrey P, Adcock Dorothy M
Department of Emergency Medicine, Denver Health Medical Center, Denver, CO 80204, USA.
Ann Emerg Med. 2004 Nov;44(5):503-10. doi: 10.1016/j.annemergmed.2004.04.002.
The literature suggests that the d -dimer is useful in patients suspected of having pulmonary embolism and who have a low pretest probability of disease. A previously defined clinical decision rule, the Wells Criteria, may provide a reliable and reproducible means of determining this pretest probability. We evaluate the interrater agreement and external validity of Wells Criteria in determining pretest probability in patients suspected of having pulmonary embolism.
This was a prospective observational study. Trained research assistants enrolled patients during 120 random 8-hour shifts. Patients who underwent imaging for pulmonary embolism after a medical history, physical examination, and chest radiograph were enrolled. Treating providers and research assistants determined pretest probability according to Wells Criteria in a blinded fashion. Two d -dimer assays were run. Three-month follow-up for the diagnosis of pulmonary embolism was performed. Interrater agreement tables were created. kappa Values, sensitivities, and specificities were determined.
Of the 153 eligible patients, 3 patients were missed, 16 patients declined, and 134 (88%) patients were enrolled. Sixteen (12%) patients were diagnosed with pulmonary embolism. The kappa values for Wells Criteria were 0.54 and 0.72 for the trichotomized and dichotomized scorings, respectively. When Wells Criteria were trichotomized into low pretest probability (n=59, 44%), moderate pretest probability (n=61, 46%), or high pretest probability (n=14, 10%), the pulmonary embolism prevalence was 2%, 15%, and 43%, respectively. When Wells Criteria were dichotomized into pulmonary embolism-unlikely (n=88, 66%) or pulmonary embolism-likely (n=46, 34%), the prevalence was 3% and 28%, respectively. The immunoturbidimetric and rapid enzyme-linked immunosorbent assay d -dimer assays had similar sensitivities (94%) and specificities (45% versus 46%).
Wells Criteria have a moderate to substantial interrater agreement and reliably risk stratify pretest probability in patients with suspected pulmonary embolism.
文献表明，D-二聚体对疑似肺栓塞且疾病预测试验前概率较低的患者有用。先前定义的临床决策规则——Wells标准，可能提供一种可靠且可重复的方法来确定这种预测试验前概率。我们评估Wells标准在确定疑似肺栓塞患者预测试验前概率方面的评分者间一致性和外部效度。
这是一项前瞻性观察性研究。经过培训的研究助理在120个随机的8小时轮班期间招募患者。在进行病史采集、体格检查和胸部X线检查后接受肺栓塞成像检查的患者被纳入研究。治疗提供者和研究助理以盲法根据Wells标准确定预测试验前概率。进行了两种D-二聚体检测。对肺栓塞诊断进行了为期三个月的随访。创建了评分者间一致性表格。确定了kappa值、敏感性和特异性。
在153名符合条件的患者中，3名患者被遗漏，16名患者拒绝参与，134名（88%）患者被纳入研究。16名（12%）患者被诊断为肺栓塞。Wells标准的kappa值，三分法评分和二分法评分分别为0.54和0.72。当Wells标准被分为预测试验前概率低（n = 59，44%）、预测试验前概率中等（n = 61，46%）或预测试验前概率高（n = 14，10%）时，肺栓塞患病率分别为2%、15%和43%。当Wells标准被分为肺栓塞可能性不大（n = 88，66%）或肺栓塞可能性大（n = 4,6，34%）时，患病率分别为3%和28%。免疫比浊法和快速酶联免疫吸附试验D-二聚体检测具有相似的敏感性（94%）和特异性（分别为45%和46%）。
Wells标准具有中等至较高的评分者间一致性，并能可靠地对疑似肺栓塞患者的预测试验前概率进行风险分层。
