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应用根据临床概率校正的d-二聚体诊断肺栓塞
Diagnosis of Pulmonary Embolism with D-Dimer Adjusted to Clinical Probability


Clive Kearon ... 心脑血管疾病 呼吸系统疾病 • 2019.11.28
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摘要


背景

回顾性分析提示,临床验前概率(C-PTP)低的患者如果d-二聚体水平低于1,000 ng/mL,C-PTP中等的患者如果d-二聚体水平低于500 ng/mL,则可排除肺栓塞。

 

方法

我们开展了一项前瞻性研究,本研究认为C-PTP低且d-二聚体水平低于1,000 ng/mL或者C-PTP中等且d-二聚体水平低于500 ng/mL的门诊患者可排除肺栓塞,而不需要进一步检查。所有其他患者均接受了胸部影像学检查(通常为计算机断层肺动脉造影)。如果未诊断为肺栓塞,则患者不接受抗凝治疗。本试验对所有患者进行了3个月随访,旨在检测静脉血栓栓塞。

 

结果

共计2,017例患者被纳入研究并接受了评估,其中7.4%在最初诊断性检查中被诊断为肺栓塞。在C-PTP低(1,285例患者)或中等(40例患者)并且d-二聚体检测结果呈阴性(即分别<1,000 ng/mL或<500 ng/mL)的1,325例患者中,无任何患者在随访期间发生静脉血栓栓塞(95%置信区间[CI],0.00~0.29%)。其中包括C-PTP低且d-二聚体水平为500~999 ng/mL的315例患者(95% CI,0.00~1.20%)。在最初未被诊断为肺栓塞且未接受抗凝治疗的全部1,863例患者中,有1例患者(0.05%;95% CI,0.01%~0.30%)发生了静脉血栓栓塞。我们的诊断策略使34.3%的患者接受了胸部影像学检查,而如果肺栓塞排除策略是C-PTP低且d-二聚体水平低于500 ng/mL,则会使51.9%的患者接受胸部影像学检查(差异,-17.6个百分点;95% CI,-19.2~-15.9)。

 

结论

通过综合应用C-PTP低且d-二聚体水平低于1,000 ng/mL,我们发现了一个随访期间肺栓塞风险低的患者人群(由加拿大卫生研究院[Canadian Institutes of Health Research]等资助;PEGeD在ClinicalTrials.gov注册号为NCT02483442)。





作者信息

Clive Kearon, M.B., Ph.D., Kerstin de Wit, M.B., Sameer Parpia, Ph.D., Sam Schulman, M.D., Ph.D., Marc Afilalo, M.D., Andrew Hirsch, M.D., Frederick A. Spencer, M.D., Sangita Sharma, M.D., Frédérick D’Aragon, M.D., Jean-François Deshaies, M.D., Gregoire Le Gal, M.D., Ph.D., Alejandro Lazo-Langner, M.D., Cynthia Wu, M.D., Lisa Rudd-Scott, R.N., Shannon M. Bates, M.D., and Jim A. Julian, M.Math. for the PEGeD Study Investigators*
From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) — all in Canada. Address reprint requests to Dr. Kearon at the Thrombosis and Atherosclerosis Research Institute and Ontario Clinical Oncology Group, Juravinski Hospital, AE-73, 711 Concession St., Hamilton, ON L8V 1C3, Canada, or at kearonc@mcmaster.ca. *Lists of the PEGeD study investigators and committee members are provided in the Supplementary Appendix, available at NEJM.org.

 

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