Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA ; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Pulm Circ. 2015 Mar;5(1):171-83. doi: 10.1086/679723.
Many dyspneic patients who undergo computerized tomographic pulmonary angiography (CTPA) for presumed acute pulmonary embolism (PE) have no identified cause for their dyspnea yet have persistent symptoms, leading to more CTPA scanning. Right ventricular (RV) dysfunction or overload can signal treatable causes of dyspnea. We report the rate of isolated RV dysfunction or overload after negative CTPA and derive a clinical decision rule (CDR). We performed secondary analysis of a multicenter study of diagnostic accuracy for PE. Inclusion required persistent dyspnea and no PE. Echocardiography was ordered at clinician discretion. A characterization of isolated RV dysfunction or overload required normal left ventricular function and RV hypokinesis, or estimated RV systolic pressure of at least 40 mmHg. The CDR was derived from bivariate analysis of 97 candidate variables, followed by multivariate logistic regression. Of 647 patients, 431 had no PE and persistent dyspnea, and 184 (43%) of these 431 had echocardiography ordered. Of these, 64 patients (35% [95% confidence interval (CI): 28%-42%]) had isolated RV dysfunction or overload, and these patients were significantly more likely to have a repeat CTPA within 90 days (P = .02, [Formula: see text] test). From univariate analysis, 4 variables predicted isolated RV dysfunction: complete right bundle branch block, normal CTPA scan, active malignancy, and CTPA with infiltrate, the last negatively. Logistic regression found only normal CTPA scanning significant. The final rule (persistent dyspnea + normal CTPA scan) had a positive predictive value of 53% (95% CI: 37%-69%). We conclude that a simple CDR consisting of persistent dyspnea plus a normal CTPA scan predicts a high probability of isolated RV dysfunction or overload on echocardiography.
许多因疑似急性肺栓塞（PE）而行计算机断层肺动脉造影（CTPA）的呼吸困难患者，其呼吸困难没有明确的病因，但症状持续存在，导致更多的 CTPA 扫描。右心室（RV）功能障碍或负荷过重可能提示可治疗的呼吸困难原因。我们报告了阴性 CTPA 后孤立性 RV 功能障碍或负荷过重的发生率，并得出了临床决策规则（CDR）。我们对一项多中心 PE 诊断准确性研究进行了二次分析。纳入标准为持续呼吸困难且无 PE。超声心动图由临床医生决定是否进行。孤立性 RV 功能障碍或负荷过重的特征需要正常的左心室功能和 RV 运动不良，或估计 RV 收缩压至少为 40mmHg。CDR 是通过对 97 个候选变量进行双变量分析，然后进行多变量逻辑回归得出的。在 647 名患者中，431 名患者无 PE 且持续呼吸困难，其中 184 名（43%）患者行超声心动图检查。其中，64 名患者（35% [95%置信区间：28%-42%]）有孤立性 RV 功能障碍或负荷过重，这些患者在 90 天内再次进行 CTPA 的可能性显著更高（P=0.02，[Formula: see text]检验）。单变量分析显示，4 个变量可预测孤立性 RV 功能障碍：完全性右束支传导阻滞、正常 CTPA 扫描、活动性恶性肿瘤和 CTPA 伴有浸润，后者为阴性。逻辑回归发现仅正常 CTPA 扫描具有显著意义。最终规则（持续呼吸困难+正常 CTPA 扫描）的阳性预测值为 53%（95%CI：37%-69%）。我们得出结论，由持续呼吸困难加正常 CTPA 扫描组成的简单 CDR 可预测超声心动图上孤立性 RV 功能障碍或负荷过重的可能性较高。
