通过D-二聚体检测、我们改良的新心电图评分及临床预测规则进行急性肺栓塞的预测试概率评估。
Acute pulmonary embolism pretest probability estimation by d-dimer test, our modified, new ECG score and clinical prediction rules.
作者信息
Simon András, Ámon Tamás, Baracsi-Botos Viktória, Pálfi Tímea, Szőke Vince Bertalan, Püspöki Zsuzsanna, Varga Zoltán, Kiss Loretta Zsuzsa, Szénási Gábor, Járai Zoltán, Vereckei András
机构信息
Department of Cardiology, South Buda Central Hospital, Saint Emeric University Teaching Hospital, Budapest, Hungary.
Hotel Service Department, South Buda Central Hospital, Saint Emeric University Teaching Hospital, Budapest, Hungary.
出版信息
Heliyon. 2024 Aug 14;10(17):e36326. doi: 10.1016/j.heliyon.2024.e36326. eCollection 2024 Sep 15.
OBJECTIVES
We investigated whether a sufficiently sensitive D-dimer test could exclude acute pulmonary embolism (acPE) as a stand-alone diagnostic test and compared our previously published, modified ECG score with the Wells and Geneva scores in the estimation of acPE pretest probability.
METHODS
We retrospectively evaluated 345 patients who underwent chest CT angiography (CTA) for the suspicion of acPE. The pretest probability of acPE was assessed in 120 D-dimer negative [DD (-)] and 225 D-dimer positive [DD (+)] patients.
RESULTS
Chest CTA verified acPE in 57/345 (16.5 %) patients and in 1/120 (0.8 %) DD (-) patient. In DD (-) patients the test accuracy (TA) and specificity (SP) of the ECG score (98 %, 99 %) were better than those of the Wells score (92.5 %, 92.4 %) (p = 0.063 and p < 0.05 respectively) and the Geneva score (76.7 %, 76.5 %) (p < 0.001 for both), the Wells score TA and SP were greater than those of the Geneva score (p < 0.001 for both). In DD (+) patients the SPs, TAs and positive predictive values (PPV) of the ECG score (94 %, 78.6 %, 69 %) and the Wells score (91.8 %, 75.1 %, 48 %) were greater than those of the Geneva score (71.3 %, 64.9 %, 38.2 %) (p < 0.001 for both SP and TA respectively, and p < 0.001 for PPV of the ECG score vs. the Geneva score and p < 0.05 for PPV of the Wells score vs. Geneva score), their sensitivities (SE) (36.4 %, 23.6 %) were less than that of the Geneva score (47.5 %) (p < 0.05 and p < 0.001 respectively). The ECG score's TA in a trend, its SE and PPV were significantly (p < 0.01 and p < 0.001) better than those of the Wells score.
CONCLUSION
In contrast to the current guidelines, a stand-alone high sensitivity DD (-) test, without prediction rules, could reliably exclude acPE. Our ECG score slightly outperformed the Wells score, the ECG score and Wells score far outperformed the Geneva score in the estimation of acPE pretest probability. An acPE diagnosis with the ECG score, in addition to the supportive diagnosis with the clinical prediction rules, may further increase the chance of true DD positivity.
目的
我们研究了一种灵敏度足够高的D - 二聚体检测能否作为单独的诊断试验排除急性肺栓塞（acPE），并在评估acPE的预检概率时，将我们之前发表的改良心电图评分与Wells评分和Geneva评分进行比较。
方法
我们回顾性评估了345例因怀疑acPE而接受胸部CT血管造影（CTA）的患者。在120例D - 二聚体阴性[DD（-）]和225例D - 二聚体阳性[DD（+）]患者中评估acPE的预检概率。
结果
胸部CTA证实57/345（16.5%）例患者存在acPE，其中1/120（0.8%）例为DD（-）患者。在DD（-）患者中，心电图评分的检测准确性（TA）和特异性（SP）（分别为98%，99%）优于Wells评分（分别为92.5%，92.4%）（p = 0.063和p < 0.05）和Geneva评分（分别为76.7%，76.5%）（两者p < 0.001），Wells评分的TA和SP大于Geneva评分（两者p < 0.001）。在DD（+）患者中，心电图评分（分别为94%，78.6%，69%）和Wells评分（分别为91.8%，75.1%，48%）的SP、TA和阳性预测值（PPV）大于Geneva评分（分别为71.3%，64.9%，38.2%）（SP和TA两者p < 0.001，心电图评分的PPV与Geneva评分相比p < 0.001，Wells评分的PPV与Geneva评分相比p < 0.05），其灵敏度（SE）（分别为36.4%，23.6%）低于Geneva评分（47.5%）（分别为p < 0.05和p < 0.001）。心电图评分的TA呈趋势性，其SE和PPV显著优于Wells评分（p < 0.01和p < 0.001）。
结论
与当前指南不同，一项单独的高灵敏度DD（-）检测，无需预测规则，可可靠地排除acPE。我们的心电图评分略优于Wells评分，在评估acPE预检概率方面，心电图评分和Wells评分远优于Geneva评分。除了通过临床预测规则进行支持性诊断外，采用心电图评分进行acPE诊断可能会进一步增加D - 二聚体真正阳性的几率。
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