结合临床概率、D-二聚体检测和CT的决策体系在疑似肺栓塞患者临床处理中的价值

查看全文 作　　者：Huisman [1]M.V.;黄浙勇 机构地区：[1]Leiden University Medical Center, Section of Vascular Medicine, Department of General Internal Medicine, C4- 68, Albinusdreef 2, 2333 ZA, Leiden, Netherlands,Dr. 出　　处：《世界核心医学期刊文摘(心脏病学分册)》索引2006年第2卷第5期,共2页 摘　　要：Context: Previous studies have evaluated the safety of relatively complex combinations of clinical decision rules and diagnostic tests in patients with suspected pulmonary embolism. Objective: To assess the clinical effectiveness of a simplified algorithm using a dichotomized clinical decision rule, D-dimer testing, and computed tomography(CT) in patients with suspected pulmonary embolism. Design, Setting, and Patients: Prospective cohort study of consecutive patients with clinically suspected acute pulmonary embolism, conducted in 12 centers in the Netherlands from November 2002 through December 2004. The study population of 3306 patients included 82% outpatients and 57% women. Interventions: Patients were categorized as “ pulmonary embolism unlikely” or “ pulmonary embolism likely” using a dichotomized version of the Wells clinical decision rule. Patients classified as unlikely had D-dimer testing, and pulmonary embolism was considered excluded if the D-dimer test result was normal. All other patients underwent CT, and pulmonary embolism was considered present or excluded based on the results. Anticoagulants were withheld from patients classified as excluded, and all patients were followed up for 3 months. Main Outcome Measure: Symptomatic or fatal venous thromboembolism(VTE) during 3-month follow-up. Results: Pulmonary embolism was classified as unlikely in 2206 patients(66.7% ). The combination of pulmonary embolism unlikely and a normal D-dimer test result occurred in 1057 patients(32.0% ), of whom 1028 were not treated with anticoagulants; subsequent nonfatal VTE occurred in 5 patients(0.5% [95% confidence interval {CI}, 0.2% - 1.1% ]). Computed tomography showed pulmonary embolism in 674 patients(20.4% ). Computed tomography excluded pulmonary embolism in 1505 patients, of whom 1436 patients were not treated with anticoagulants; in these patients the 3- month incidence of VTE was 1.3% (95% CI, 0.7% - 2.0% ). Pulmonary embolism was considered a possible cause of death in 7 patients after a negative CT scan(0.5% [95% CI, 0.2% - 1.0% ]). The algorithm was completed and allowed a management decision in 97.9% of patients. Conclusions: A diagnostic management strategy using a simple clinical decision rule, D-dimer testing, and CT is effective in the evaluation and management of patients with clinically suspected pulmonary embolism. Its use is associated with low risk for subsequent fatal and nonfatal VTE. 关 键 词：D-二聚体检测 疑似肺栓塞 门诊患者 临床价值 CT检查 决策体系 前瞻性队列研究 概率 理中 判断标准