Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
Department of Emergency Medicine, CHU Angers, University Hospital of Angers, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CARME, Angers, France; F-CRIN INNOVTE research network, Saint-Etienne, France.
J Thromb Haemost. 2023 Mar;21(3):606-615. doi: 10.1016/j.jtha.2022.11.025. Epub 2022 Dec 22.
Few studies evaluated the performance of noninvasive diagnostic strategies for suspected acute pulmonary embolism (PE) in pregnant women.
The aim of this study was to establish the safety and efficiency of the Wells rule with fixed and adapted D-dimer threshold, and the YEARS algorithm, combined with compression ultrasonography (CUS), in pregnant women with suspected PE in an individual patient data meta-analysis.
We performed a systematic review to identify prospective diagnostic management studies in pregnant women with suspected PE. Primary outcomes were safety, defined as the failure rate, ie, the 3-month venous thromboembolism (VTE) incidence after excluding PE without chest imaging, and efficiency, defined as the proportion of patients in whom chest imaging could be avoided.
We identified 2 relevant studies, of which individual patient-level data were analyzed in a fixed-effect meta-analysis, totaling 893 pregnant women. The Wells rule with fixed and adapted D-dimer threshold as well as the YEARS algorithm could safely rule out acute PE (failure rate, 0·37%-1·4%), but efficiency improved considerably when applying pretest probability-adapted D-dimer thresholds. The efficiency of bilateral CUS was limited (2·3% overall; number needed to test 43), especially in patients without symptoms of deep-vein thrombosis (efficiency 0·79%; number needed to test 127).
This study supports the latest guideline recommendations (European Society of Cardiology 2019) to apply pretest probability assessment and D-dimer tests to rule out PE in pregnant women. From an efficiency perspective, the use of a strategy with pretest probability-adapted D-dimer threshold is preferred. The yield of CUS was very limited in patients without concomitant symptoms of deep-vein thrombosis.
很少有研究评估针对疑似急性肺栓塞（PE）的孕妇的非侵入性诊断策略的性能。
本研究旨在通过个体患者数据的荟萃分析，建立 Wells 规则结合固定和适应 D-二聚体阈值以及 YEARS 算法，联合压缩超声（CUS）在疑似 PE 的孕妇中的安全性和有效性。
我们进行了一项系统评价，以确定在疑似 PE 的孕妇中进行前瞻性诊断管理研究。主要结局是安全性，定义为失败率，即排除无胸部影像学检查的 PE 后 3 个月静脉血栓栓塞（VTE）的发生率，以及有效性，定义为可以避免进行胸部影像学检查的患者比例。
我们确定了 2 项相关研究，其中个体患者水平的数据进行了固定效应荟萃分析，总共纳入了 893 名孕妇。固定和适应 D-二聚体阈值的 Wells 规则以及 YEARS 算法可以安全地排除急性 PE（失败率为 0.37%-1.4%），但当应用预测试概率适应的 D-二聚体阈值时，效率显著提高。双侧 CUS 的效率有限（总体为 2.3%；需要测试的人数为 43），特别是在没有深静脉血栓形成症状的患者中（效率为 0.79%；需要测试的人数为 127）。
本研究支持最新的指南建议（欧洲心脏病学会 2019 年），即在孕妇中应用预测试概率评估和 D-二聚体检测来排除 PE。从效率的角度来看，使用预测试概率适应的 D-二聚体阈值的策略更为优选。在没有深静脉血栓形成伴随症状的患者中，CUS 的收益非常有限。
