A clinical perspective of venous thromboembolism
A clinical perspective of venous thromboembolism
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DOI：
10.1161/atvbaha.108.162818
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发表时间：
2008-03-01
影响因子：
8.7
通讯作者：
Moll, Stephan
中科院分区：
文献类型：
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作者：
Moll, Stephan
已经建立了基于患者静脉血栓栓塞危险因素和临床症状和结果的评分系统，以确定出现腿部或肺部症状的患者患静脉血栓栓塞或肺动脉栓塞的可能性有多大。2,3将预测概率分为低、中或高，有助于指导进行哪些进一步的诊断测试。全血或血浆d -二聚体试验评价良好且有用，但临床可能未充分利用试验。对于DVT或PE预诊概率较低的患者，敏感的d -二聚体检测阴性可可靠地排除VTE，无需进一步影像学检查。2-4然而，DVT或PE预诊概率较低且d -二聚体检测阳性的患者以及DVT或PE预诊概率中等或较高的患者都需要进行影像学检查。2-4然而，不幸的是，d -二聚体检测的广泛应用受到大量不同检测方法的限制，一些检测方法高度敏感，另一些检测方法不太敏感，而且检测方法缺乏标准化。由于临床医生通常不知道他们实验室使用的d -二聚体检测的类型，因此不知道他们可用的特定检测的预测价值，因此依赖d -二聚体结果进行临床决策可能是不安全的，除非该检测已在当地得到验证。根据已建立的标准（Well’s标准5），基于以下因素，本例患者PE的预诊概率很高：(1)存在DVT的临床症状和体征，(2)心率100/min，(3)无其他基础疾病，因此PE最有可能被诊断。d -二聚体测试没有帮助。她应该接受肺部影像学检查以评估肺栓塞。根据以下Well’s标准2，患者深静脉血栓的预诊概率也很高：(1)全腿肿胀；(2)腿部凹陷性水肿。尽管从急性治疗的角度来看，该患者没有必要进行腿部影像学检查，因为她已经有了适应症
Scoring systems based on a patient’s VTE risk factors and clinical symptoms and findings have been established to determine how likely it is that a patient presenting with leg or lung symptoms has DVT or PE. 2, 3 The grouping into low and intermediate or high pretest probability helps guide what further diagnostic tests to perform. The whole blood or plasma D-dimer tests are well evaluated and useful but clinically probably underused tests. In patients with a low pretest probability for DVT or PE, a negative test with a sensitive D-dimer assay reliably rules out VTE and no further imaging study is needed. 2–4 However, patients with a low pretest probability for DVT or PE and a positive D-dimer test and any patient with moderate or high pretest probability for DVT or PE needs to undergo imaging studies. 2–4 The generalized application of D-dimer testing is, however, unfortunately limited by the large number of different assays available, some highly sensitive and others less sensitive, and a lack of standardization of assays. As clinicians are often not aware of the type of D-dimer assay their laboratory uses and, thus, do not know the predictive value of the particular assay available to them, reliance on the D-dimer results for clinical decision making can be unsafe, unless the test has been locally validated.The patient presented here has, by established criteria (Well’s criteria5), a high pretest probability for PE, based on:(1) presence of clinical symptoms and signs of DVT,(2) heart rate 100/min,(3) absence of other underlying diseases, making PE the most likely diagnosis. A D-dimer test would not be helpful. She should undergo a lung imaging study to evaluate for PE. The patient also has a high pretest probability for DVT, based on the following Well’s criteria2:(1) swelling of the entire leg,(2) pitting edema of the leg. Although a leg imaging study in this patient is not necessary from an acute management point of view, as she already has an indication