Kline J A, Courtney D M, Kabrhel C, Moore C L, Smithline H A, Plewa M C, Richman P B, O'Neil B J, Nordenholz K
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28323-2861, USA.
J Thromb Haemost. 2008 May;6(5):772-80. doi: 10.1111/j.1538-7836.2008.02944.x. Epub 2008 Mar 3.
Over-investigation of low-risk patients with suspected pulmonary embolism (PE) represents a growing problem. The combination of gestalt estimate of low suspicion for PE, together with the PE rule-out criteria [PERC(-): age < 50 years, pulse < 100 beats min(-1), SaO(2) >or= 95%, no hemoptysis, no estrogen use, no surgery/trauma requiring hospitalization within 4 weeks, no prior venous thromboembolism (VTE), and no unilateral leg swelling], may reduce speculative testing for PE. We hypothesized that low suspicion and PERC(-) would predict a post-test probability of VTE(+) or death below 2.0%.
We enrolled outpatients with suspected PE in 13 emergency departments. Clinicians completed a 72-field, web-based data form at the time of test order. Low suspicion required a gestalt pretest probability estimate of <15%. The main outcome was the composite of image-proven VTE(+) or death from any cause within 45 days.
We enrolled 8138 patients, 85% of whom had a chief complaint of either dyspnea or chest pain. Clinicians reported a low suspicion for PE, together with PERC(-), in 1666 patients (20%). At initial testing and within 45 days, 561 patients (6.9%, 95% confidence interval 6.5-7.6) were VTE(+), and 56 others died. Among the low suspicion and PERC(-) patients, 15 were VTE(+) and one other patient died, yielding a false-negative rate of 16/1666 (1.0%, 0.6-1.6%). As a diagnostic test, low suspicion and PERC(-) had a sensitivity of 97.4% (95.8-98.5%) and a specificity of 21.9% (21.0-22.9%).
The combination of gestalt estimate of low suspicion for PE and PERC(-) reduces the probability of VTE to below 2% in about 20% of outpatients with suspected PE.
对疑似肺栓塞（PE）的低风险患者进行过度检查是一个日益严重的问题。结合对PE低怀疑度的整体评估以及PE排除标准[PERC（-）：年龄<50岁、脉搏<100次/分钟、SaO₂≥95%、无咯血、未使用雌激素、4周内无需要住院治疗的手术/外伤、无既往静脉血栓栓塞症（VTE）且无单侧下肢肿胀]，可能会减少对PE的推测性检查。我们假设低怀疑度和PERC（-）可预测VTE（+）或死亡的检测后概率低于2.0%。
我们在13个急诊科纳入了疑似PE的门诊患者。临床医生在下达检查医嘱时填写一份72项的基于网络的数据表。低怀疑度要求整体预测试概率估计<15%。主要结局是45天内影像学证实的VTE（+）或任何原因导致的死亡。
我们纳入了8138例患者，其中85%的主要诉求为呼吸困难或胸痛。临床医生报告1666例患者（20%）对PE低怀疑度且符合PERC（-）。在初次检查时及45天内，561例患者（6.9%，95%置信区间6.5 - 7.6）为VTE（+），另有56例死亡。在低怀疑度且符合PERC（-）的患者中，15例为VTE（+），1例死亡，假阴性率为16/1666（1.0%，0.6 - 1.6%）。作为一种诊断试验，低怀疑度和PERC（-）的敏感性为97.4%（95.8 - 98.5%），特异性为21.9%（21.0 - 22.9%）。
对PE低怀疑度的整体评估与PERC（-）相结合，可使约20%疑似PE的门诊患者VTE概率降至2%以下。
