D-二聚体阴性肺血栓栓塞症临床分析

目的对D-二聚体阴性肺血栓栓塞症(PTE)病例与D-二聚体升高者进行对比分析。方法螺旋CT肺动脉造影(CTPA)确诊的42例PTE患者进行回顾性分析,包括性别、年龄、危险因素、临床表现、心电图、血气分析、下肢静脉及心脏超声、D-二聚体值测定、发病至就诊时间等。结果 D-二聚体值:D-二聚体阴性组(313.91±132.96)ng/L,D-二聚体升高组为(1 711±2 182.76)ng/L。发病至就诊时间:D-二聚体阴性组(9.73±3.80)d,D-二聚体升高组(5.10±2.90)d,两组相比差异有统计学意义(P<0.05)。临床各种表现对比两组无明显差异,均以呼吸困难为最常见表现,达80%以上。危险因素对比:D-二聚体阴性组高龄增多。辅助检查结果对比:D-二聚体阴性组超声心动图阳性发现率高。结论 D-二聚体测定应该与临床表现等相结合,如高度怀疑肺栓塞,特别是超声心动图发现基础病难以解释的右心负荷加重,则应进一步做CTPA等相关检查,以减少漏诊和误诊。     

D-二聚体是筛除低临床概率肺栓塞的有效指标

目的 比较不同辅助检查在肺栓塞（Pulmonary Embolism,PE）患者的应用价值。方法 回顾诊断和非诊断肺栓塞的患者D二聚体、下肢静脉超声（lower extremity Doppler ultrasound DUS）,胸部螺旋CT（chest spiral Computer Tomography CT）的结果,找出合适敏感度和特异度的方法。结果 D-二聚体是筛除肺栓塞的良好指标,其医学决定性水平宜在500μg／L;临床概率低的患者总体D-二聚体偏高;确诊肺栓塞的患者检查敏感度分别为D-二聚体80％、螺旋CT90%、下肢静脉超声60%;对于低临床概率患者,D-二聚体阴性可以有效除外肺栓塞,漏诊率7．7％。结论 D-二聚体在医学决定性水平为500μg／L时,是一项高敏感度和阴性预计值的指标,尤其适合临床低概率患者的筛除,配合螺旋CT,可以很好地辅助肺栓塞的诊断。     

14例D-二聚体阴性急性肺栓塞临床分析

血浆D-二聚体(D-dimer)是交联纤维蛋白在纤溶系统作用下产生的可溶性降解产物,是一个特异性的纤溶过程标记物,其水平增高反映体内高凝状态和继发纤溶活性增强.D-二聚体对急性肺栓塞(acute pulmonary embolism,APE)诊断的敏感度高,目前普遍认为其阴性水平对急性肺血栓栓塞症有很大的排除诊断价值.我国2001年肺栓塞指南也指出,若血浆D-二聚体含量低于500 μg/L,可基本除外急性肺血栓栓塞症[1].然而,临床中仍常可见D-二聚体阴性的患者最后确诊为APE[2-3],近来更有大样本量研究发现D-二聚体阳性和阴性的疑似患者最后确诊为肺栓塞的比例差异无统计学意义[4-5].这表明D-二聚体阴性作为急性肺栓塞的排除诊断指标有待进一步研究.     

D-二聚体阴性肺栓塞四例误漏诊临床分析

目的总结D-二聚体阴性肺栓塞的临床特点,分析误漏诊原因。方法对我院收治的D-二聚体阴性肺栓塞4例临床资料进行回顾性分析。结果本组2例因呼吸困难、胸闷入院,1例因双下肢水肿、疼痛伴肌肉疲劳入院,1例因咳嗽、咳痰、活动后气促入院。诊断为慢性阻塞性肺疾病2例,冠心病、下肢深静脉血栓各1例,误漏诊3~10 d,后均经螺旋CT肺动脉造影(CTPA)检查、D-二聚体检测、动脉血气分析等确诊为D-二聚体阴性肺栓塞,予华法林或低分子肝素等治疗,后病情好转出院。随访3~6个月,均预后较好。结论临床应加强对D-二聚体阴性肺栓塞的认知及鉴别诊断,以减少或避免误漏诊的发生,提高诊治水平,改善预后。     

血浆D-二聚体对疑似肺栓塞患者诊断价值的研究

目的：探讨血浆 D-二聚体对对疑似肺栓塞患者的诊断价值。方法采用自动化免疫比浊法测定患者血浆D-二聚体水平。统计分析血浆D-二聚体诊断肺栓塞的敏感性、特异性、阴性及阳性预测值,并绘制ROC曲线以评价其诊断价值并对D-二聚体阴性排除肺栓塞价值进行分析。结果在317例疑似肺栓塞患者中D-二聚体＜500μg/L的患者73例,其中6例被诊断为肺栓塞。D-二聚体对肺栓塞的诊断的敏感性为95.86%（95%CI：91.27%～98.08%）,特异性为38.95%（95%CI：31.98%～41.41%）,阴性预测值为91.78%（95%CI：83.21%～96.18%）,阳性预测值为56.97%（95%CI：50.69%～63.02%）,诊断准确性为64.98%（95%CI：59.58%～70.03%）。ROC曲线下面积为0.674（95%CI：0.615～0.733）。结论 D-二聚体对肺栓塞的诊断具有较高的敏感性,阴性排除肺栓塞的准确性较高,但仍可受患者年龄、测试方法等的影响。     

D-二聚体与凝血因子Ⅷ联合检测对肺癌合并肺栓塞的诊断价值

目的探讨D-二聚体与凝血因子Ⅷ联合检测对肺癌合并肺栓塞的诊断价值。方法选择2013年6月至2018年6月新疆维吾尔自治区医院就诊的100例肺癌疑似肺栓塞患者作为研究对象,收集患者的一般临床资料和血液学指标,经多层螺旋CT肺动脉成像检测证实。比较肺癌合并肺栓塞组和非肺栓塞组的临床资料和血液学指标。应用Logistic回归分析D-二聚体、凝血因子Ⅷ是肺癌合并肺栓塞独立危险因素,并绘制受试者工作特征(ROC)曲线,分析D-二聚体、凝血因子Ⅷ诊断效能。结果 100例肺癌疑似肺栓塞患者中,最终确诊为肺栓塞30例,发生率30%。比较肺栓塞组和非肺栓塞组一般资料,肺栓塞组三酰甘油(TG)、D-二聚体、FⅧ明显高于非肺栓塞组,差异有统计学意义(P0.05);logistic多因素回归分析显示,D-二聚体、FⅧ是肺癌合并肺栓塞的独立危险因素(P0.05);ROC曲线分析D-二聚体诊断肺栓塞的AUC为0.833,FⅧ为0.752;D-二聚体联合FⅧ诊断肺癌合并肺栓塞的AUC为0.905,明显高于D-二聚体和FⅧ单独检测(Z=2.563、3.017,P0.05)。结论 D-二聚体与凝血因子Ⅷ联合检测可提高肺癌合并肺栓塞的诊断效能,具有诊断肺癌合并肺栓塞的重要价值。     

常规检查手段对肺栓塞辅助诊断价值的比较分析

目的探讨和比较心电图（ECG）、动脉血气分析、D-二聚体和超声心动图（UCG））4种常规检查手段对肺栓塞（PE）的辅助诊断价值。方法回顾性分析我院收治的90例经肺通气／灌注扫描和（或）肺动脉CT成像（CTPA）明确诊断的非大面积肺栓塞病例,以超声心动检查结果将其分为A组（次大面积肺栓塞组）和B组（非次大面积肺栓塞组）,通过对其ECG有无肺栓塞的典型表现、动脉血氧分压（PaO2）、D-二聚体和UCG测定的肺动脉收缩压（PASP）的大小等进行比较分析和评价。结果4种不同辅助检查手段对肺栓塞诊断的敏感度从高到低依次为：D-二聚体、血气分析、UCG和ECG。除ECG无定量分析外,本研究结果表明,D-二聚体在A、B组间差异无统计学意义;PaO2和PASP在A、B组间差异有统计学意义（P〈0．05或〈0．01）。结论4种检查手段从不同的方面反映出肺栓塞时的病生理变化,是对急性肺栓塞进行早期筛查扣辅助诊断的有力武器,尤其适用于门诊及急诊医生。     

修正Geneva评分联合D-二聚体在急性肺栓塞患者早期诊断中的价值评估

目的:评价修正Geneva评分联合D-二聚体在急性肺栓塞(APE)早期的诊断价值。方法:收集2018-01-01—2018-12-31期间南京大学医学院附属鼓楼医院疑似APE住院患者,通过CT肺动脉血管造影(CTPA)结果,将患者分成非肺栓塞组(144例)和肺栓塞组(97例),对两组患者一般资料、伴随疾病、临床症状、体征、修正Geneva评分和D-二聚体等进行统计和分析。结果:两组有恶性肿瘤活动病史、近期手术或骨折病史、单侧下肢肿胀或疼痛、首次就诊心率、修正Geneva评分和D-二聚体差异具有统计学意义(P0.05);根据多元Logistic回归分析,修正Geneva评分和D-二聚体为APE的高危因素(P0.05)。应用SPSS 16.0软件绘制修正Geneva评分、D-二聚体和二者联合的ROC曲线。修正Geneva评分、D-二聚体和二者联合的曲线下面积分别为0.830(95%CI:0.778～0.883)、0.883(95%CI:0.839～0.926)和0.922(95%CI:0.889～0.956)。其中修正Geneva评分联合D-二聚体诊断APE敏感度为95.9%,特异度为80.6%。结论:修正Geneva评分联合D-二聚体在APE患者早期诊断中具有重要的价值,值得临床推广和应用。     

D-二聚体阴性排除肺栓塞的临床价值

目的:了解D-二聚体阴性排除肺栓塞的临床价值。方法:回顾性分析CT肺动脉造影确诊肺栓塞患者60例血清D-二聚体水平。结果:以乳胶凝集法测定的D-二聚体诊断肺栓塞敏感率仅73.3%,阴性排除误诊率达26.7%。结论:D-二聚体阴性不一定能排除肺栓塞,需结合临床和所使用的检测方法。     

64例肺栓塞患者临床诊治分析

目的:分析不同严重程度肺栓塞患者的临床特征,以期早期发现肺栓塞并识别其危险分层,给予及时治疗。方法:收集我院64例住院肺栓塞患者的临床资料,将患者分为低危组、中危组、高危组,分析其临床表现、相关检查检验指标及治疗转归情况。结果:肺栓塞病因及诱因包括下肢静脉血栓、高血压、冠心病、骨折术后及肿瘤等;3组患者中晕厥症状、T波倒置、ST段改变及S_ⅠQ_ⅢT_Ⅲ征、三尖瓣返流、肺动脉高压、D-二聚体及BNP的数值、住院时间、住院费用等方面差异具有统计学意义;在肺栓塞危险程度的ROC曲线中,BNP的AUC值为0.917,D-二聚体的AUC值为0.912,二者联合的AUC值为0.926。结论:肺栓塞常见病因为下肢静脉血栓,不同危险分层的肺栓塞患者,其临床症状、心电图、心脏超声及治疗方式各不相同,通过联合检测肺栓塞患者BNP、D-二聚体水平,可以较好地评估肺栓塞的危险程度。     

The DAGMAR Score: D-dimer assay-guided moderation of adjusted risk. Improving specificity of the D-dimer for pulmonary embolism

We generated a novel scoring system to improve the test characteristics of D-dimer in patients with suspected PE (pulmonary emboli).Electronic Medical Record data were retrospectively reviewed on Emergency Department (ED) patients 18?years or older for whom a D-dimer and imaging were ordered between June 4, 2012 and March 30, 2016. Symptoms (dyspnea, unilateral leg swelling, hemoptysis), age, vital signs, medical history (cancer, recent surgery, medications, history of deep vein thrombosis or PE, COPD, smoking), laboratory values (quantitative D-dimer, platelets, and mean platelet volume (MPV)), and imaging results (CT, VQ) were collected.Points were designated to factors that were significant in two multiple regression analyses, for PE or positive D-dimer. Points predictive of PE were designated positive values and points predictive of positive D-dimer, irrespective of presence of PE, were designated negative values.The DAGMAR (D-dimer Assay-Guided Moderation of Adjusted Risk) score was developed using age and platelet adjustment and points for factors associated with PE and elevated D-dimer.Of 8486 visits reviewed, 3523 were unique visits with imaging, yielding 2253 (26.5%) positive D-dimers. 3501 CT scans and 156 VQ scans were completed, detecting 198 PE.In our cohort, a DAGMAR Score?<?2 equated to overall PE risk?<?1.2%. Specificity improved (38% to 59%) without compromising sensitivity (94% to 96%). Use of the DAGMAR Score would have reduced CT scans from 2253 to 1556 and lead to fewer false negative results.By considering factors that affect D-dimer and also PE, we improved specificity without compromising sensitivity.     

Risk of venous thromboembolism in patients with borderline quantitative D-dimer levels

Objective

The lower threshold for D-dimer in evaluating patients with low clinical risk of venous thromboembolism (VTE) ranges from 200 to 500 ng/mL. We compared the rates of VTE in patients based on D-dimer values. We hypothesized that the rate of VTE in low-risk patients with D-dimer levels less than 500 would be less than 1%.

Methods

Study Design: This was a retrospective chart review: Setting: The study was performed in a academic, suburban emergency department (ED). Subjects: Emergency department patients with suspected VTE and D-dimer obtained were included in the study. D-dimer assay: The D-dimer assay is a quantitative instrumentation latex suspension of plasma specimens. Outcomes: Presence of VTE within 30 days of ED visit. Data Analysis: Assuming a 0% event rate in patients with D-dimer levels between 200 and 500 ng/mL, a sample of 450 patients would result in a 95% confidence interval upper limit of 0.6%.

Results

There were 1270 ED patients with suspected VTE in which D-dimer levels were performed between October 2005 and October 2006. Patient mean age was 47.8 ± 19.3 years; 63.2% were female, 78.2% were white. Of all D-dimer levels, 497 (39.1%) were less than 200 ng/mL, 479 (37.7%) were between 200 and 500 μg/mL, and 294 (23.1%) were greater than 500 ng/mL. There were no VTE events diagnosed in any of the patients with D-dimer levels less than 200 ng/mL. Four patients with D-dimer levels between 200 and 500 μg/mL had a pulmonary embolism on computed tomography angiography. Of these 4 patients, 3 had moderate clinical risk based on Well's criteria and one had a false-positive computed tomography. There were no cases of VTE in the remaining 475 patients (0%; 95% confidence interval 0%-0.6%).

Conclusion

The rate of confirmed VTE in low-risk patients with D-dimer levels between 200 and 500 ng/mL is very low. Low-risk patients with suspected VTE with D-dimer levels less than 500 ng/mL might not require additional testing.     

Family history of venous thromboembolism predicts the diagnosis of acute pulmonary embolism in the emergency department

Background

Pulmonary embolism (PE) clinical decision rules do not consider a patient's family history of venous thromboembolism (VTE). We evaluated whether a family history of VTE predicts acute PE in the emergency department (ED).

580例主动脉夹层患者临床特征及预后分析

目的 探讨主动脉夹层(aortic dissection,AD)患者的临床特征及预后相关影响因素.方法 收集580例确诊AD患者的临床资料,对一般情况、既往病史、症状与体征、辅助检查、诊断、治疗及住院期间生存情况等进行回顾性分析,采用Logistic单因素及多因素回归分析比较Stanford A型和B型患者年龄、性别、高血压史、收缩压水平、舒张压水平、D-二聚体(D-dimer)、白细胞(white blood cell,WBC)、心肌钙蛋白T(cardiac troponin T,cTnT)、氨基端前脑钠肽(N-terminal pro-brain natriuretic peptide,NT-proBNP)、纤维蛋白原(fibrinogen,FIB)以及是否手术等因素是否与AD患者近期预后相关.结果 580例AD患者中男性发病明显高于女性,男女比例约3.57:1.58.62％的AD患者有高血压病史.主动脉夹层的临床表现多样,以单纯胸痛、背痛及同时胸背痛为主要症状,部分患者可伴有腹痛或转移痛.Stanford A型患者胸膜反应、中重度主动脉反流、心包积液、异常心电图发生率以及主动脉根部直径、血D-二.聚体、WBC、cTnT和NT-proBNP水平均明显高于B型患者(P＜0.05),主动脉异常、无主动脉反流和正常心电图发生率均明显低于B型患者(P＜0.05).本组病例以非手术组病死率高于手术组(70％ vs.8.61％,P＜0.05),Stanford A型病死率高于Stanford B型(29.43％ vs.13.75％,P＜0.05).Stanford A型患者Logistic多因素分析提示D-二聚体(OR=1.23)、NT-proBNP(OR=1.006)和是否手术(OR=0.124)为A型患者独立预后因素;Stanford B型患者Logistic多因素分析提示D-二聚体(OR=1.801)、WBC(OR=1.59)和是否手术(OR=0.142)为B型患者独立预后因素.结论 主动脉夹层的临床表现复杂,D-二聚体、NT-proBNP和是否手术是影响A型患者住院期间预后的独立因素,D-二聚体、WBC和是否手术是影响B型患者住院期间预后的独立因素.     

Management of suspected pulmonary embolism (PE) by D-dimer and multi-slice computed tomography in outpatients: an outcome study

OBJECTIVES: A prospective outcome study designed to evaluate a simple strategy for the management of outpatients with suspected pulmonary embolism (PE), based on clinical probability, D-dimer, and multi-slice computed tomography (MSCT). METHODS: A cohort of 432 consecutive patients admitted to the emergency department with suspected PE was managed by sequential non-invasive testing. Patients in whom PE was ruled out were not given anticoagulants, but were followed-up for 3 months. RESULTS: Normal D-dimer and low-intermediate clinical probability ruled out PE in 103 patients [24% (95% CI 20-28)]. Seventeen patients had normal D-dimer, but high clinical probability and proceeded to MSCT. All patients proved negative for PE. A total of 329 (76%) patients underwent MSCT examination. Pulmonary embolism was diagnosed in 93 patients [21.5% (95% CI 18-26)] and was ruled out by negative MSCT in 221 patients [51% (95% CI 46-56)]. MSCT scans were determined as inconclusive in 15 (4.5%) patients. No patient developed objectively verified venous thromboembolism (VTE) during the 3-month follow-up period. However, the cause of death was adjudicated as possibly related to PE in two patients, resulting in an overall 3-month VTE risk of 0.6% (95% CI 0-2.2%). The diagnostic algorithm yielded a definite diagnosis in 96.5% of the patients. CONCLUSIONS: This simple and non-invasive strategy combining clinical probability, D-dimer, and MSCT for the management of outpatients with suspected PE appears to be safe and effective.     

Management of venous thromboembolism: an update

Venous thromboembolism (VTE), which constitutes pulmonary embolism and deep vein thrombosis, is a common disorder associated with significant morbidity and mortality. Landmark trials have shown that direct oral anticoagulants (DOACs) are as effective as conventional anticoagulation with vitamin K antagonists (VKA) in prevention of VTE recurrence and associated with less bleeding. This has paved the way for the recently published guidelines to change their recommendations in favor of DOACs in acute and long-term treatment of VTE in patients without cancer. The recommended treatment of VTE in cancer patients remains low-molecular-weight heparin. The initial management of pulmonary embolism (PE) should be directed based on established risk stratification scores. Thrombolysis is an available option for patients with hemodynamically significant PE. Recent data suggests that low-risk patients with acute PE can safely be treated as outpatients if home circumstances are adequate. There is lack of support for use of inferior vena cava filters in patients on anticoagulation. This review describes the acute, long-term, and extended treatment of VTE and recent evidence on the management of sub-segmental PE.     

Differential value of risk factors and clinical signs for diagnosing pulmonary embolism according to age

INTRODUCTION: The diagnostic value of clinical presentation of pulmonary embolism (PE) is uncertain in the elderly, who often have concomitant cardiopulmonary diseases that may mimic PE. The aim of our study was to assess the differential value of risk factors, symptoms and clinical signs of venous thromboembolism, results of electrocardiogram and chest X-ray for the diagnosis of PE in suspected patients according to age. METHODS: We analyzed data from two outcome studies which enrolled 1721 consecutive patients presenting in the emergency department with clinically suspected PE defined as acute onset of new or worsening shortness of breath or chest pain without any other obvious etiology. All patients underwent a sequential diagnostic work-up and a 3-month follow-up. RESULTS: The proportion of confirmed PE was 24.2% (416 of 1721). Strength of the association with PE did not differ according to age group for history of venous thromboembolism (VTE), recent surgery, tachypnea at admission or right ventricular strain on electrocardiogram. Active malignancy, hemoptysis, tachycardia, hemidiaphragmatic elevation and pleural effusion at chest X-ray were no more associated with PE in the patients aged of 75 years or more. Finally, symptoms and signs of deep venous thrombosis, and an alternative diagnosis less probable than PE were associated with PE in all age groups, but the strength of this association decreased significantly with advancing age. CONCLUSION: Some risk factors, symptoms and signs of VTE are less strongly or even not at all associated with PE in the elderly. Physicians should take this into account when attending elderly patients suspected of PE and when assessing their clinical probability of PE.     

Combined computed tomography venography and pulmonary angiography for the diagnosis PE and DVT in the ED

The purpose of this study is to evaluate the usefulness of combined computed tomography venography and pulmonary angiography (CTVPA) in the diagnosis of venous thromboembolic (VTE) disease in the emergency department (ED). CTVPA images and clinical data of 73 nonselected patients with suspected pulmonary embolism (PE) and/or deep venous thrombosis (DVT) were retrospectively assessed. CTVPA correctly identified 33 of 34 patients with VTE disease, including 7 patients with PE alone, 11 patients with DVT alone, and 16 patients with both PE and DVT. Among the 27 patients with DVT, CTVPA disclosed thrombosis involving the abdominal and pelvic veins in 4 patients, and isolating to the inferior vena cava and iliac vein in one patient. CTVPA showed high accuracy in the diagnosis of both PE and DVT, in comparison with lower extremity venous sonography and ventilation-perfusion scintigraphy. In 26 (66%) of the 39 patients without of evidence VTE, CTVPA provided important ancillary information that suggests additional or alternative diagnoses. CTVPA is therefore an appropriate single diagnostic tool for evaluation VTE disease in the ED.     

D-dimer levels in VTE patients with distal and proximal clots

Objectives

There is growing evidence that venous thromboembolism (VTE) patients with distal clots (distal calf deep vein thrombosis [DVT] and sub-segmental pulmonary embolism [PE]) may not routinely benefit from anticoagulation. We compared the D-dimer levels in VTE patients with distal and proximal clots.

Tandem measurement of D-dimer and myeloperoxidase or C-reactive protein to effectively screen for pulmonary embolism in the emergency department

OBJECTIVES: The hypothesis was that the tandem measurement of D-dimer and myeloperoxidase (MPO) or C-reactive protein (CRP) could significantly decrease unnecessary pulmonary vascular imaging in emergency department (ED) patients evaluated for pulmonary embolism (PE) compared to D-dimer alone. METHODS: The authors measured the sequential combinations of D-dimer and MPO and D-dimer and CRP in a prospective sample of ED patients evaluated for PE at two centers. Patients were followed for 90 days for venous thromboembolism (VTE, either PE or deep venous thrombosis [DVT]), which required the consensus of two of three blinded physician reviewers. RESULTS: The authors enrolled 304 patients, 22 with VTE (7%; 95% confidence interval [CI] = 5% to 10%). The sensitivity and specificity of a D-dimer alone (cutoff > or = 500 ng/mL) were 100% (95% CI = 85% to 100%) and 59% (95% CI = 53% to 65%), respectively, and was followed by pulmonary vascular imaging negative for PE in 38% (115/304; 95% CI = 32% to 44%). The combination of either a negative D-dimer, or MPO < 22 mg/dL, had a sensitivity of 100% and specificity of 73% (95% CI = 67% to 78%). Thus, tandem measurement of D-dimer and MPO would have decreased the frequency of subsequent negative pulmonary vascular imaging from 38% to 25% (95% CI of the difference of -13% = -5% to -20%). The combination of CRP and D-dimer would not have significantly improved the rate of negative imaging. CONCLUSIONS: The tandem measurement of D-dimer and MPO would have significantly decreased negative pulmonary vascular imaging compared with D-dimer alone and should be validated prospectively.