Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, IL.
Boston University School of Medicine, Department of Emergency Medicine, Boston, MA.
Ann Emerg Med. 2014 Jan;63(1):16-24. doi: 10.1016/j.annemergmed.2013.08.016. Epub 2013 Sep 27.
The objective of this study was to determine the diagnostic performance of right ventricular dilatation identified by emergency physicians on bedside echocardiography in patients with a suspected or confirmed pulmonary embolism. The secondary objective included an exploratory analysis of the predictive value of a subgroup of findings associated with advanced right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, McConnell's sign).
This was a prospective observational study using a convenience sample of patients with suspected (moderate to high pretest probability) or confirmed pulmonary embolism. Participants had bedside echocardiography evaluating for right ventricular dilatation (defined as right ventricular to left ventricular ratio greater than 1:1) and right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, or McConnell's sign). The patient's medical records were reviewed for the final reading on all imaging, disposition, hospital length of stay, 30-day inhospital mortality, and discharge diagnosis.
Thirty of 146 patients had a pulmonary embolism. Right ventricular dilatation on echocardiography had a sensitivity of 50% (95% confidence interval [CI] 32% to 68%), a specificity of 98% (95% CI 95% to 100%), a positive predictive value of 88% (95% CI 66% to 100%), and a negative predictive value of 88% (95% CI 83% to 94%). Positive and negative likelihood ratios were determined to be 29 (95% CI 6.1% to 64%) and 0.51 (95% CI 0.4% to 0.7%), respectively. Ten of 11 patients with right ventricular hypokinesis had a pulmonary embolism. All 6 patients with McConnell's sign and all 8 patients with paradoxical septal motion had a diagnosis of pulmonary embolism. There was a 96% observed agreement between coinvestigators and principal investigator interpretation of images obtained and recorded.
Right ventricular dilatation and right ventricular dysfunction identified on emergency physician performed echocardiography were found to be highly specific for pulmonary embolism but had poor sensitivity. Bedside echocardiography is a useful tool that can be incorporated into the algorithm of patients with a moderate to high pretest probability of pulmonary embolism.
本研究旨在确定急诊医师在疑似或确诊肺栓塞患者床边超声心动图中识别的右心室扩张的诊断性能。次要目标包括对与右心室功能障碍（右心室运动减退、矛盾性室间隔运动、McConnell 征）相关的亚组发现的预测价值进行探索性分析。
这是一项前瞻性观察性研究，使用疑似（中高度预测试验概率）或确诊肺栓塞患者的便利样本。参与者接受了床边超声心动图检查，以评估右心室扩张（定义为右心室与左心室比值大于 1:1）和右心室功能障碍（右心室运动减退、矛盾性室间隔运动或 McConnell 征）。回顾患者的病历记录，以获取所有影像学检查、处置、住院时间、30 天院内死亡率和出院诊断的最终结果。
146 例患者中有 30 例患有肺栓塞。超声心动图上的右心室扩张的敏感性为 50%（95%置信区间[CI]为 32%至 68%），特异性为 98%（95%CI 为 95%至 100%），阳性预测值为 88%（95%CI 为 66%至 100%），阴性预测值为 88%（95%CI 为 83%至 94%）。阳性和阴性似然比分别为 29（95%CI 为 6.1%至 64%）和 0.51（95%CI 为 0.4%至 0.7%）。11 例右心室运动减退患者中有 10 例患有肺栓塞。所有 6 例 McConnell 征患者和所有 8 例矛盾性室间隔运动患者均被诊断为肺栓塞。两位研究者对所获得和记录的图像的解释存在 96%的一致性。
急诊医师进行的超声心动图中识别的右心室扩张和右心室功能障碍对肺栓塞具有高度特异性，但敏感性较低。床边超声心动图是一种有用的工具，可以纳入中高度预测试验概率肺栓塞患者的算法中。
