Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism:: A multicenter clinical management study of 510 patients
Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism:: A multicenter clinical management study of 510 patients
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DOI：
10.7326/0003-4819-138-4-200302180-00009
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发表时间：
2003-02-18
影响因子：
39.2
通讯作者：
Pattynama, PMT
中科院分区：
文献类型：
--
作者：
van Strijen, MJL;de Monyé, W;Pattynama, PMT
背景：螺旋CT是诊断肺栓塞(PE)的有效工具，但其在临床疑似PE患者治疗中的作用尚未完全确立。目的：探讨螺旋CT作为临床疑似PE患者主要诊断检查的有效性和安全性。设计：多中心前瞻性临床结果研究。地点：荷兰2所学术医院和1所大型教学医院。患者：连续510例临床疑似PE的住院患者和门诊患者随访3个月。干预：患者出现PE症状和体征后24小时内行肺动脉CT检查。如果CT结果正常或不确定，则在CT当天进行加压超声检查，如果首次加压超声检查正常，则在第4天和第7天重复。当CT或压缩超声检查结果为血栓栓塞症阳性时，开始抗凝。当CT结果为PE阴性或提示可解释临床体征和症状的替代诊断时，或当连续加压超声检查结果正常时，不开始抗凝。测量：患者接受指示，在3个月的随访期内报告PE或深静脉血栓(DVT)的任何症状或体征。结果：510例患者中，CT诊断为PE 124例(24.3%)，确诊为PE 130例(25.5%)，CT正常248例(48.6%)。8例(1.6%)CT扫描不能解释，2例未发现。2例患者首次检查时发现DVT，第4天和第7天重复按压超声检查结果正常。246例螺旋CT扫描正常者的死亡率为4.1%(10/246)。本组无一例死于致死性PE，1例发展为非致命性PE，0.4%的患者发生静脉血栓栓塞症(95%CI，0%~2.2%)。在另一种诊断的患者中，1例患者在随访期间客观检测到DVT。这组患者的死亡率为21.5%(130名患者中的28名)；在其中1名患者中，不能肯定地排除PE是导致死亡的原因之一。静脉血栓栓塞率为1.5%(CI为0.2%~5.6%)。结论：对于疑似PE的患者，螺旋CT可安全地作为排除PE的主要诊断方法。连续加压超声检查的附加价值有限。
Background: Helical computed tomography (CT) is a readily available tool for diagnosing pulmonary embolism (PE); however, its role in the management of patients with clinically suspected PE has not been fully established.Objective: To determine the effectiveness and safety of using helical CT of the pulmonary arteries as the primary diagnostic test in patients with suspected PE.Design: Multicenter, prospective clinical outcome study.Setting: Two academic hospitals and one large teaching hospital in the Netherlands.Patients: 510 consecutive inpatients and outpatients with clinically suspected PE followed for 3 months.Interventions: Patients underwent helical CT of the pulmonary arteries within 24 hours after presenting with signs and symptoms of PE. If CT results were normal or inconclusive, compression ultrasonography was performed on the same day as CT and repeated on days 4 and 7 if findings on the first compression ultrasonography were normal. When CT or compression ultrasonography results were positive for thromboembolism, anticoagulation was started. Anticoagulation was not started when results of CT were negative for PE or indicated an alternative diagnosis that explained the clinical signs and symptoms, or when results on serial compression ultrasonography were normal.Measurements: Patients received instructions to report any symptoms or signs of PE or deep venous thrombosis (DVT) during the 3-month follow-up period. The authors performed compression ultrasonography or phlebography for suspected DVT and pulmonary angiography for suspected PE.Results: Computed tomography identified PE in 124 of 510 patients (24.3%) and an alternative diagnosis in 130 patients (25.5%); CT scans were normal in 248 patients (48.6%). The CT scan could not be interpreted in 8 patients (1.6%) and was not obtained in 2. Compression ultrasonography revealed DVT in 2 patients at the first examination; findings on repeated compression ultrasonography at days 4 and 7 were normal. Mortality in the patients with normal helical CT scans was 4.1% (10 of 246 patients). No patients in this group died of fatal PE, 1 patient developed nonfatal PE, and venous thromboembolism occurred in 0.4% of these patients (95% CI, 0% to 2.2%). In the patients with alternative diagnoses, 1 patient had DVT on objective testing during follow-up. Mortality in this group was 21.5% (28 of 130 patients); in 1 of these patients, PE could not be confidently ruled out as a contributing cause of death. Venous thromboembolism occurred in 1.5% of these patients (CI, 0.2% to 5.6%).Conclusions: In patients with suspected PE, helical CT can be used safely as the primary diagnostic test to rule out PE. Serial compression ultrasonography has limited additional value.