Department of Radiology, University of Michigan Health System, B1 132G Taubman Center/5302, 1500 East Medical Center, Ann Arbor, MI 48109.
Department of Radiology, University of Michigan Health System, B1 132G Taubman Center/5302, 1500 East Medical Center, Ann Arbor, MI 48109; Nuclear Medicine Service, VA Ann Arbor Health Care System, Ann Arbor, Michigan.
Acad Radiol. 2018 May;25(5):561-572. doi: 10.1016/j.acra.2017.11.014. Epub 2018 Jan 11.
This study aimed to calculate the multiple-level likelihood ratios (LRs) and posttest probabilities for a positive, indeterminate, or negative test result for multidetector computed tomography pulmonary angiography (MDCTPA) ± computed tomography venography (CTV) and magnetic resonance pulmonary angiography (MRPA) ± magnetic resonance venography (MRV) for each clinical probability level (two-, three-, and four-level) for the nine most commonly used clinical prediction rules (CPRs) (Wells, Geneva, Miniati, and Charlotte). The study design is a review of observational studies with critical review of multiple cohort studies. The settings are acute care, emergency room care, and ambulatory care (inpatients and outpatients).
Data were used to estimate pulmonary embolism (PE) pretest probability for each of the most commonly used CPRs at each probability level. Multiple-level LRs (positive, indeterminate, negative test) were generated and used to calculate posttest probabilities for MDCTPA, MDCTPA + CTV, MRPA, and MRPA + MRV from sensitivity and specificity results from Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and PIOPED III for each clinical probability level for each CPR. Nomograms were also created.
The LRs for a positive test result were higher for MRPA compared to MDCTPA without venography (76 vs 20) and with venography (42 vs 18). LRs for a negative test result were lower for MDCTPA compared to MRPA without venography (0.18 vs 0.22) and with venography (0.12 vs 0.15). In the three-level Wells score, the pretest clinical probability of PE for a low, moderate, and high clinical probability score is 5.7, 23, and 49. The posttest probability for an initially low clinical probability PE for a positive, indeterminate, and negative test result, respectively, for MDCTPA is 54, 5 and 1; for MDCTPA + CTV is 52, 2, and 0.7; for MRPA is 82, 6, and 1; and for MRPA + MRV is 72, 3, and 1; for an initially moderate clinical probability PE for MDCTPA is 86, 22, and 5; for MDCTPA + CTV is 85, 10, and 4; for MRPA is 96, 25, and 6; and for MRPA + MRV is 93, 14, and 4; and for an initially high clinical probability of PE for MDCTPA is 95, 47, and 15; for MDCTPA + CTV is 95, 27, and 10; for MRPA is 99, 52, and 17; and for MRPA + MRV is 98, 34, and 13.
For a positive test result, LRs were considerably higher for MRPA compared to MDCTPA. However, both a positive MRPA and MDCTPA have LRs >10 and therefore can confirm the presence of PE. Performing venography reduced the LR for a positive and negative test for both MDCTPA and MRPA. The nomograms give posttest probabilities for a positive, indeterminate, or negative test result for MDCTPA and MRPA (with and without venography) for each clinical probability level for each of the CPR.
本研究旨在计算多排螺旋 CT 肺动脉造影（MDCTPA）±CT 静脉造影（CTV）和磁共振肺动脉造影（MRPA）±MRV 在每个临床概率水平（两级、三级和四级）下，九个最常用的临床预测规则（CPR）（Wells、Geneva、Miniati 和 Charlotte）中每个 CP 的阳性、不确定和阴性试验的多级似然比（LR）和后验概率。该研究设计为观察性研究的综述，并对多个队列研究进行了关键评估。研究场所为急性护理、急诊室护理和门诊护理（住院患者和门诊患者）。
使用数据来估计最常用的 CPR 中每个 CPR 在每个概率水平的肺栓塞（PE）的预先测试概率。从 Prospective Investigation of Pulmonary Embolism Diagnosis（PIOPED）II 和 PIOPED III 的灵敏度和特异性结果生成多级 LR（阳性、不确定、阴性试验），并用于计算 MDCTPA、MDCTPA+CTV、MRPA 和 MRPA+MRV 在每个 CPR 的每个临床概率水平下的后验概率。还创建了列线图。
与 MDCTPA 无静脉造影（76 比 20）和 MDCTPA 有静脉造影（42 比 18）相比，MRPA 的阳性试验结果的 LR 更高。与 MDCTPA 相比，MRPA 无静脉造影（0.18 比 0.22）和 MDCTPA 有静脉造影（0.12 比 0.15）的阴性试验结果的 LR 较低。在三级 Wells 评分中，PE 的低、中、高临床概率评分的 PE 初始临床概率分别为 5.7、23 和 49。MDCTPA 的初始低临床概率 PE 的阳性、不确定和阴性试验的后验概率分别为 54、5 和 1；MDCTPA+CTV 为 52、2 和 0.7；MRPA 为 82、6 和 1；MRPA+MRV 为 72、3 和 1；对于初始中等临床概率的 PE，MDCTPA 为 86、22 和 5；MDCTPA+CTV 为 85、10 和 4；MRPA 为 96、25 和 6；MRPA+MRV 为 93、14 和 4；对于初始高临床概率的 PE，MDCTPA 为 95、47 和 15；MDCTPA+CTV 为 95、27 和 10；MRPA 为 99、52 和 17；MRPA+MRV 为 98、34 和 13。
对于阳性试验结果，MRPA 的 LR 明显高于 MDCTPA。然而，MRPA 和 MDCTPA 的阳性结果都有 LR>10，因此可以确认 PE 的存在。进行静脉造影降低了 MDCTPA 和 MRPA 阳性和阴性试验的 LR。列线图为每个 CPR 的每个临床概率水平下 MDCTPA 和 MRPA（有和无静脉造影）的阳性、不确定或阴性试验的后验概率提供了参考。
