急诊科应用肺部超声诊断急性失代偿性心力衰竭：一项SIMEU多中心研究
Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study.
作者信息
Pivetta Emanuele, Goffi Alberto, Lupia Enrico, Tizzani Maria, Porrino Giulio, Ferreri Enrico, Volpicelli Giovanni, Balzaretti Paolo, Banderali Alessandra, Iacobucci Antonello, Locatelli Stefania, Casoli Giovanna, Stone Michael B, Maule Milena M, Baldi Ileana, Merletti Franco, Cibinel Gian Alfonso, Baron Paolo, Battista Stefania, Buonafede Giuseppina, Busso Valeria, Conterno Andrea, Del Rizzo Paola, Ferrera Patrizia, Pecetto Paolo Fascio, Moiraghi Corrado, Morello Fulvio, Steri Fabio, Ciccone Giovannino, Calasso Cosimo, Caserta Mimma A, Civita Marina, Condo' Carmen, D'Alessandro Vittorio, Del Colle Sara, Ferrero Stefania, Griot Giulietta, Laurita Emanuela, Lazzero Alberto, Lo Curto Francesca, Michelazzo Marianna, Nicosia Vincenza, Palmari Nicola, Ricchiardi Alberto, Rolfo Andrea, Rostagno Roberto, Bar Fabrizio, Boero Enrico, Frascisco Mauro, Micossi Ilaria, Mussa Alessandro, Stefanone Valerio, Agricola Renzo, Cordero Gabriele, Corradi Federica, Runzo Cristina, Soragna Aldo, Sciullo Daniela, Vercillo Domenico, Allione Attilio, Artana Nicoletta, Corsini Fabrizio, Dutto Luca, Lauria Giuseppe, Morgillo Teresa, Tartaglino Bruno, Bergandi Daniela, Cassetta Ilaria, Masera Clotilde, Garrone Mario, Ghiselli Gianluca, Ausiello Livia, Barutta Letizia, Bernardi Emanuele, Bono Alessia, Forno Daniela, Lamorte Alessandro, Lison Davide, Lorenzati Bartolomeo, Maggio Elena, Masi Ilaria, Maggiorotto Matteo, Novelli Giulia, Panero Francesco, Perotto Massimo, Ravazzoli Marco, Saglio Elisa, Soardo Flavia, Tizzani Alessandra, Tizzani Pietro, Tullio Mattia, Ulla Marco, Romagnoli Elisa
出版信息
Chest. 2015 Jul;148(1):202-210. doi: 10.1378/chest.14-2608.
BACKGROUND
Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.
METHODS
We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.
RESULTS
The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.
CONCLUSIONS
The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.
TRIAL REGISTRY
Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.
背景
肺部超声检查（LUS）已成为一种用于肺部疾病鉴别诊断的非侵入性工具。然而，其用于急性失代偿性心力衰竭（ADHF）的诊断仍存在一些问题。我们检验了这样一个假设，即在急诊科将LUS与临床评估相结合的综合方法在区分ADHF与非心源性呼吸困难方面比标准检查具有更高的诊断准确性。
方法
我们在意大利的7个急诊科进行了一项多中心前瞻性队列研究。对于出现急性呼吸困难的患者，要求急诊医生在（1）初始临床评估后以及（2）进行LUS检查后（“LUS实施”诊断）将诊断分类为ADHF或非心源性呼吸困难。所有患者还接受了胸部X线检查。出院后，通过独立查阅完整病历确定每位患者呼吸困难的原因。然后比较不同方法的诊断准确性。
结果
该研究纳入了1005例患者。与初始临床检查（敏感性85.3% [95% CI，81.8% - 88.4%]；特异性90% [95% CI，87.2% - 92.4%]）、单独的胸部X线检查（敏感性69.5% [95% CI，65.1% - 73.7%]；特异性82.1% [95% CI，78.6% - 85.2%]）以及利钠肽（敏感性85% [95% CI，80.3% - 89%]；特异性61.7% [95% CI，54.6% - 68.3%]；n = 486）相比，LUS实施方法在区分ADHF与急性呼吸困难的非心脏原因方面具有显著更高的准确性（敏感性97% [95% CI，95% - 98.3%]；特异性97.4% [95% CI，95.7% - 98.6%]）。与标准检查相比，LUS实施方法的净重新分类指数为19.1%。
结论
在急诊科就诊的患者中，将LUS与临床评估相结合可能会提高ADHF诊断的准确性。
试验注册
Clinicaltrials.gov；编号：NCT01287429；网址：www.clinicaltrials.gov。
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