Weekes Anthony J, Thacker Gregory, Troha Daniel, Johnson Angela K, Chanler-Berat Jordan, Norton H James, Runyon Michael
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
Ann Emerg Med. 2016 Sep;68(3):277-91. doi: 10.1016/j.annemergmed.2016.01.027. Epub 2016 Mar 11.
We determine the diagnostic accuracy of goal-directed echocardiography, cardiac biomarkers, and computed tomography (CT) in early identification of severe right ventricular dysfunction in normotensive emergency department patients with pulmonary embolism compared with comprehensive echocardiography.
This was a prospective observational study of consecutive normotensive patients with confirmed pulmonary embolism. Investigators, blinded to clot burden and biomarkers, performed qualitative goal-directed echocardiography for right ventricular dysfunction: right ventricular enlargement (diameter greater than or equal to that of the left ventricle), severe right ventricular systolic dysfunction, and septal bowing. Brain natriuretic peptide and troponin cutoffs of greater than or equal to 90 pg/mL and greater than or equal to 0.07 ng/mL and CT right ventricular:left ventricular diameter ratio greater than or equal to 1.0 were also compared with comprehensive echocardiography.
One hundred sixteen normotensive pulmonary embolism patients (111 confirmed by CT, 5 by ventilation-perfusion scan) were enrolled. Twenty-six of 116 patients (22%) had right ventricular dysfunction on comprehensive echocardiography. Goal-directed echocardiography had a sensitivity of 100% (95% confidence interval [CI] 87% to 100%), specificity of 99% (95% CI 94% to 100%), positive likelihood ratio (+LR) of 90.0 (95% CI 16.3 to 499.8), and negative likelihood ratio (-LR) of 0 (95% CI 0 to 0.13). Brain natriuretic peptide had a sensitivity of 88% (95% CI 70% to 98%), specificity of 68% (95% CI 57% to 78%), +LR of 2.8 (95% CI 2.0 to 3.9), and -LR of 0.17 (95% CI 0.06 to 0.43). Troponin had a sensitivity of 62% (95% CI 41% to 80%), specificity of 93% (95% CI 86% to 98%), +LR of 9.2 (95% CI 4.1 to 20.9), and -LR of 0.41 (95% CI 0.24 to 0.62). CT had a sensitivity of 91% (95% CI 72% to 99%), specificity of 79% (95% CI 69% to 87%), +LR of 4.3 (95% CI 2.8 to 6.7), and -LR of 0.11 (95% CI 0.03 to 0.34).
Goal-directed echocardiography was highly accurate for early severe right ventricular dysfunction identification and pulmonary embolism risk-stratification. Brain natriuretic peptide was sensitive but less specific, whereas troponin had lower sensitivity but higher specificity. CT had good sensitivity and moderate specificity.
与全面超声心动图相比，我们确定目标导向超声心动图、心脏生物标志物和计算机断层扫描（CT）在早期识别血压正常的急诊科肺栓塞患者严重右心室功能障碍方面的诊断准确性。
这是一项对连续确诊的血压正常的肺栓塞患者进行的前瞻性观察性研究。研究人员在不知道血栓负荷和生物标志物的情况下，对右心室功能障碍进行定性目标导向超声心动图检查：右心室扩大（直径大于或等于左心室）、严重右心室收缩功能障碍和室间隔弯曲。还将脑钠肽和肌钙蛋白的临界值分别大于或等于90 pg/mL和大于或等于0.07 ng/mL以及CT右心室与左心室直径比大于或等于1.0与全面超声心动图进行比较。
纳入了116例血压正常的肺栓塞患者（111例经CT确诊，5例经通气灌注扫描确诊）。116例患者中有26例（22%）在全面超声心动图检查中存在右心室功能障碍。目标导向超声心动图的敏感性为100%（95%置信区间[CI]87%至100%），特异性为99%（95%CI 94%至100%），阳性似然比（+LR）为90.0（95%CI 16.3至499.8），阴性似然比（-LR）为0（95%CI 0至0.13）。脑钠肽的敏感性为88%（95%CI 70%至98%），特异性为68%（95%CI 57%至78%），+LR为2.8（95%CI 2.0至3.9），-LR为0.17（95%CI 0.06至0.43）。肌钙蛋白的敏感性为62%（95%CI 41%至80%），特异性为93%（95%CI 86%至98%），+LR为9.2（95%CI 4.1至20.9），-LR为0.41（95%CI 0.24至0.62）。CT 的敏感性为91%（95%CI 72%至99%），特异性为79%（95%CI 69%至87%），+LR为4.3（95%CI 2.8至6.7），-LR为0.11（95%CI 0.03至0.34）。
目标导向超声心动图在早期识别严重右心室功能障碍和肺栓塞风险分层方面具有高度准确性。脑钠肽敏感但特异性较低，而肌钙蛋白敏感性较低但特异性较高。CT具有良好的敏感性和中等特异性。
