Excluding pulmonary embolism at the bedside without diagnostic imaging: Management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer
Excluding pulmonary embolism at the bedside without diagnostic imaging: Management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer
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DOI：
10.7326/0003-4819-135-2-200107170-00010
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发表时间：
2001-07-17
影响因子：
39.2
通讯作者：
Kovacs, MJ
中科院分区：
文献类型：
--
作者：
Wells, PS;Anderson, DR;Kovacs, MJ
背景资料：目前的诊断标准，通气灌注肺扫描的局限性，复杂的疑似肺栓塞患者的管理。我们以前证明，确定预测试的概率可以帮助管理和某些D-二聚体检测的高阴性预测值可以简化诊断过程。目的：为了确定使用简单的临床模型结合D-二聚体检测来管理急诊科疑似肺栓塞患者的安全性。设计：前瞻性队列研究。设置：加拿大四家三级医院的急诊科。患者：930名疑似肺栓塞的连续患者。干预措施：医生首先使用临床模型来确定患者的肺栓塞预测试概率，然后进行D-二聚体测试。预检测概率低且D-二聚体结果阴性的患者无需进一步检测，并被认为排除了肺栓塞诊断。其余患者均行肺通气-灌注扫描。如果扫描不能诊断，则进行双侧深静脉超声检查。是否做进一步的测试（通过系列超声或血管造影）取决于患者的pretest概率和肺扫描results.Measurements结果：患者接受了肺栓塞的诊断，如果他们有一个高概率的通气灌注扫描，一个异常的结果超声或肺血管造影，或静脉血栓栓塞事件在随访期间。对诊断被排除的患者随访3个月，以了解血栓栓塞事件的发生情况。结果如下：分别有527、339和64例患者（1.3%、16.2%和37.5%的患者发生肺栓塞）的预测概率为低、中和高。在849例最初排除肺栓塞诊断的患者中，5例（0.6% [95%CI，0.2%-1.4%]）在随访期间发生肺栓塞或深静脉血栓形成。然而，其中4名患者没有接受适当的诊断测试方案。在7名被诊断为肺栓塞的患者中，医生进行了比算法要求的更多的诊断测试。在849例初始评估未发现肺栓塞的患者中，有759例正确遵循了诊断方案。这759例患者中仅1例（0.1% [CI，0.0%至0.7%]）在随访期间发生血栓栓塞事件。在437例D-二聚体结果阴性且临床概率较低的患者中，仅1例在随访期间发生肺栓塞;因此，在这些患者中使用临床模型与D-二聚体检测的联合策略的阴性预测值为99.5%结论：根据预测概率和σ-二聚体结果管理疑似肺栓塞患者是安全的，并减少了对诊断性成像的需求。
Background: The limitations of the current diagnostic standard, ventilation-perfusion lung scanning, complicate the management of patients with suspected pulmonary embolism. We previously demonstrated that determining the pretest probability can assist with management and that the high negative predictive value of certain D-dimer assays may simplify the diagnostic process.Objective: To determine the safety of using a simple clinical model combined with D-dimer assay to manage patients presenting to the emergency department with suspected pulmonary embolism.Design: Prospective cohort study.Setting: Emergency departments at four tertiary care hospitals in Canada.Patients: 930 consecutive patients with suspected pulmonary embolism.Interventions: Physicians first used a clinical model to determine patients' pretest probability of pulmonary embolism and then performed a D-dimer test. Patients with low pretest probability and a negative D-dimer result had no further tests and were considered to have a diagnosis of pulmonary embolism excluded. All other patients underwent ventilation-perfusion lung scanning. If the scan was nondiagnostic, bilateral deep venous ultrasonography was done. Whether further testing (by serial ultrasonography or angiography) was done depended on the patients' pretest probability and the lung scanning results.Measurements: Patients received a diagnosis of pulmonary embolism if they had a high-probability ventilation-perfusion scan, an abnormal result on ultrasonography or pulmonary angiography, or a venous thromboembolic event during follow-up. Patients for whom the diagnosis was considered excluded were followed up for 3 months for the development of thromboembolic events. Results: The pretest probability of pulmonary embolism was low, moderate, and high in 527, 339, and 64 patients (1.3%, 16.2%, and 37.5% had pulmonary embolism), respectively. Of 849 patients in whom a diagnosis of pulmonary-embolism had initially been excluded, 5 (0.6% [95% CI, 0.2% to 1.4%]) developed pulmonary embolism or deep venous thrombosis during followup. However, 4 of these patients had not undergone the proper diagnostic testing protocol. In 7 of the patients who received a diagnosis of pulmonary embolism, the physician had performed more diagnostic tests than were called for by the algorithm. In 759 of the 849 patients in whom pulmonary embolism was not found on initial evaluation, the diagnostic protocol was followed correctly. Only 1 (0.1% [CI, 0.0% to 0.7%]) of these 759 patients developed thromboembolic events during follow-up. Of the 437 patients with a negative D-dimer result and low clinical probability, only 1 developed pulmonary embolism during follow-up; thus, the negative predictive value for the combined strategy of using the clinical model with D-dimer testing in these patients was 99.5% (CI, 99.1% to 100%).Conclusion: Managing patients for suspected pulmonary embolism on the basis of pretest probability and sigma -dimer result is safe and decreases the need for diagnostic imaging.