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。     

急性肺栓塞血浆NT-ProBNP与D-二聚体水平的动态分析

目的：通过检测急性肺栓塞（APE）患者溶栓前后血浆氨基末端脑钠肽前体（NT-ProBNP）、D-二聚体水平,探讨其变化特点及意义。方法60例疑似APE患者,其中经CT确诊并符合溶栓条件的APE患者40例设为实验组,经CT排除APE患者20例为对照组。测定两组治疗前及实验组溶栓治疗2周后血浆 NT-ProBNP 与D-二聚体水平并进行比较。结果 NT-proBNP检测对早期APE患者的诊断灵敏度为92．3％,特异度为65％;D-二聚体检测对早期APE患者的诊断的灵敏度为100％,特异度为70％;实验组溶栓前血浆NT-ProBNP与D-二聚体水平显著高于对照组,差异有统计学意义（P＜0．01）。结论血浆NT-ProBNP与D-二聚体对APE具有重要的临床意义,可为APE患者早期诊断及疗效观察提供依据。     

纤维蛋白原联合D-二聚体对肺栓塞诊断价值的Meta分析

目的系统评价纤维蛋白原联合D-二聚体在肺栓塞诊断中的临床价值。方法计算机检索PubMed(1966~2014.7)、Embase(1980~2014.7)、Web of science(1980~2014.7)、中国生物医学文献数据库(CBM,1978~2014.7)、中国知网(CNKI,1979~2014.7)、维普数据库(VIP,1989~2014.7)、万方数据库(WF,1982~2014.7)。收集用纤维蛋白原联合D-二聚体诊断肺栓塞的试验研究,依据QUADAS质量评价标准评价纳入研究的质量后,采用Meta-Disc软件(version1.4)进行Meta分析。结果最终纳入8篇研究。合计1 015例受试者。Meta分析结果显示:纤维蛋白原联合D-二聚体诊断肺栓塞的合并特异度、灵敏度、阴性似然比、阳性似然比、诊断比值比和ROC曲线下面积分别0.63(0.58,0.67),0.90(0.87,0.92),0.14(0.07,0.27),2.35(1.91,2.88),18.99(12.08,29.85),0.859 7。结论纤维蛋白原联合D-二聚体在肺栓塞诊断中具有中等特异度和较高的灵敏度,可作为临床筛查肺栓塞患者的有效措施之一。     

Exclusion of pulmonary embolism using quantitative plasma D-dimer assays

Recent quantitative studies using pulmonary angiography as reference method have indicated that the overall accuracy of quantitative D-dimer assays for the exclusion of pulmonary embolism (PE) in patients suspected of PE is poorer than was reported in earlier studies in which the same D-dimer assays were used (90-94% vs 98-100%). An explanation can be found in the fact that the earlier studies are hampered by the fact that the reference method was a compilation of clinical data and non-invasive diagnostic tests rather than a true gold standard. Furthermore, in those studies no discrimination was made between the milder cases of subsegmental PE and the more severe cases of segmental and larger PE. The lack of a true gold standard and preselection leading to reduced proportions of cases of subsegmental PE in the earlier studies rather than differences in the storage conditions of plasma samples or treatment with heparin, appear to have caused the discrepancies in the reported accuracy of D-dimer assays. It is concluded that the sensitivity and negative predictive values obtained with different quantitative D-dimer assays are in close agreement with each other, that is poor for subsegmental PE and excellent for segmental and larger PE. In diagnostic algorithms D-dimer can reliably exclude acute segmental and/or massive PE. Further work-up within 48 hours is still necessary in negative D-dimer outcomes to exclude subsegmental PE.     

Turbidimetric D-dimer test in the diagnosis of pulmonary embolism: a metaanalysis

BACKGROUND: Clinicians in outpatient clinics and emergency departments desire an accurate quantitative D-dimer assay. The study objective was to evaluate the diagnostic performance characteristics of the latex turbidimetric D-dimer test in the diagnosis of pulmonary embolism (PE) in the emergency department population. METHODS: We conducted a search of MEDLINE, EMBASE, and bibliographies of previous systematic reviews with no language restriction. Experts in the field of PE research were contacted to identify unpublished studies. Prospective investigations involving predominately outpatient populations with suspected PE that used a turbidimetric D-dimer test were included. Two authors extracted data independently and assessed study quality based on the composition of the patient spectrum and the reference standard used. Consensus was reached by conference. The analysis was based on a summary ROC curve and combining sensitivity and specificity independently across studies using a random-effects model. RESULTS: The search yielded 264 publications and 2 unpublished studies. Nine studies met the inclusion criteria and provided a sample of 1901 individuals. Eight of the nine studies were homogeneous in terms of both sensitivity and specificity. One study had similar sensitivity but higher specificity. Combining the studies yielded an overall sensitivity of 0.93 (95% confidence interval, 0.89-0.96) and an overall specificity of 0.51 (95% confidence interval, 0.42-0.59). CONCLUSIONS: The turbidimetric D-dimer test is sensitive but nonspecific for the detection of PE in the emergency department setting. D-Dimer tests using latex turbidimetric methods appear to have test characteristics comparable to those for ELISA methods.     

Wells评分联合D-dimer在急性肺栓塞诊断的临床预测价值

目的 评价Wells评分联合D-dimer在急性肺栓塞诊断的临床预测价值.方法 收集2008年至2011年就诊北京朝阳医院急诊科疑似肺栓塞患者540例,以CTPA检查阳性为确诊肺栓塞的依据,分为肺栓塞(PE)组与非肺栓塞(Non-PE)组,对两组患者在人口学特征、基础疾病、主诉、体征、静脉血栓危险因素、相关实验室检查、Wells评分等进行比较和统计学分析.结果 最终入选患者502例,PE组246例,Non-PE组256例,近期术后或卧床、近期骨盆或下肢骨折、咯血、一过性意识障碍、单侧下肢肿胀、低氧低碳酸血症、D-dimer升高、高危Wells评分等在PE组出现的频率显著高于Non-PE组,P＜0.05,其他参数在两组中差异无统计学意义.Wells评分、D-dimer值及二者联合的ROC曲线下面积分别是0.775 (95％CI:0.719～0.831),0.802(95％CI:0.751～0.853),0.899 (95％ CI:0.834～0.964),二者联合ROC曲线下面积大于二者单独应用,P ＜0.05.截点值Wells评分5分,D-dimer 1 724.00 μg/L为敏感度与特异度加权最大值,超过截点值时,诊断PE的可靠性明显提高;低于截点值时,排除PE的可靠性也明显升高.结论 Wells评分联合D-Dimer检查比单独应用在急性肺栓塞预测中更具备临床价值.     

Wells评分和血浆D-二聚体对肺栓塞的诊断价值分析

目的 探讨采用Wells评分、血浆D-二聚体检测和二者相结合对肺栓塞(PE)的诊断和排除价值.方法 2008-03~2010-05在昆明医学院第二附属医院呼吸内科住院的疑似PE患者,均进行CT肺动脉造影(CTPA)、血浆D-二聚体检测,采用Wells评分进行临床可能性评估.以CTPA结果 为标准,分析各组患者的PE诊断率.结果 入选的126例疑似PE患者,进行CTPA检查后诊断PE 32例,D-二聚体阳性、Wells评分阳性、二者均为阳性的PE发生率分别为49.1%、41.7%、51.5%,三组比较差异无统计学意义(P>0.05).D-二聚体阴性、Wells评分阴性、二者均为阴性的PE发生率分别为8.2%、30.0%、2.2%,三组比较差异有统计学意义(P<0.01).D-二聚体检测和Wells评分诊断PE的敏感性和特异性相似,分别为81.3%、78.1%和71.3%、62.8%;二者阴性预测值也相似,分别为91.8%、89.4%;二者均为阳性诊断PE的敏感性为53.3%,特异性为83.0%,阴性预测值为83.9%;二者均为阴性排除PE的敏感性为93.8%,特异性为47.8%,阴性预测值为97.9%.结论 D-二聚体阳性、Wells评分阳性和二者均为阳性对PE的诊断率相近;D-二聚体和Wells评分均为阴性时并不能完全排除PE;D-二聚体检测结合Wells评分能更准确地预测PE的发病风险,当二者均为阴性时,排除疑似PE更加安全有效.     

脑钠肽和D-二聚体检测对急性肺栓塞早期诊断及预后评估的价值

目的应用脑钠肽和D-二聚体的检测方法,以期达到对急性肺栓塞的早期诊断及预后判断。方法26例急性肺栓塞患者分为两组：观察组12例,给予脑钠肽、D-二聚体检查,确诊为肺栓塞后给予溶栓、抗凝治疗。对照组14例,给予心电图、胸片、心超、血气分析检查及外院肺通气灌注扫描检查,确诊为肺栓塞后给予溶栓、抗凝治疗;比较两组患者的确诊时间、病死率。结果观察组的确诊时间（14．1±1．8h）和病死率（25．0％）显著低于对照组（23．3±1．5h、35．7％）,差异均具有显著性（P〈0．05）。结论联合应用脑钠肽和D-二聚体的检测方法对急性肺栓塞患者能够有效的缩短确诊时间、改善临床症状、降低死亡率。     

D-二聚体检测在胸外科患者术后肺栓塞中的诊断价值

目的探讨D-二聚体检测在胸外科患者术后肺栓塞中的诊断价值。方法回顾性分析2008年-2013年期间我院收治的18 128例胸外科手术治疗患者术后发生肺栓塞的临床资料,并选取其中的35例胸外科手术治疗患者进行D-二聚体检测。结果胸外科手术年龄≧50岁的患者与〈50岁的患者比较,肥胖患者与体重合格者比较,发生恶性肿瘤与良性肿瘤比较,肺栓塞发生率均有显著性差异（P〈0.05）;进行D-二聚体检测诊断肺栓塞的阴性预测值以及敏感性均为100%,假阳性率为94.7%（18/19）。结论行胸外科手术治疗的肥胖、高龄和恶性肿瘤患者术后发生肺栓塞的可能性较大,而采用D-二聚体检测,能够较精确地对肺栓塞进行诊断,阴性结果正确率高,值得临床上进一步推广与研究。     

肺栓塞的超声诊断价值探讨

目的探讨肺栓塞的超声诊断价值。方法将CT肺动脉血管造影(CTPA)诊断为肺栓塞的15例患者,行心脏、胸腔、四肢静脉的彩色多普勒超声检查。结果所有病例超声未发现肺栓塞的直接征象;但可发现一些间接征象如:6例发现右心增大,少~大量三尖瓣反流,肺动脉压升高;7例发现肺动脉血流流速曲线上的RPEP/RVET比值升高>0.30;2例发现肺部梗塞区;6例发现下肢静脉血栓形成;5例发现下肢静脉血流淤滞。结论超声发现肺栓塞直接征象的几率较低,不能作为确诊肺栓塞的主要检查方法。但超声能发现一些肺栓塞的间接征象,对临床的诊断、治疗和观察疗效有重要意义。     

Clinical probability score and D-dimer estimation lack utility in the diagnosis of childhood pulmonary embolism

Summary.  Background : Childhood pulmonary embolism (PE) causes significant mortality and evidence suggests that it is under-diagnosed. Clinical probability scores and D-dimer estimation to assess pre-test probability have not been studied in children with suspected PE. Patients/Methods : This retrospective cohort study evaluated Wells simplified probability score for PE in 50 children with PE and 25 PE negative control patients, and D-dimer values in 27 PE positive and 12 PE negative children. Results : PE positive and PE negative groups had similar rates of risk factors for venous thromboembolism (VTE). Wells simplified probability score showed a small difference between PE positive and PE negative children (median score: PE positive, 4.5; PE negative, 4; P  =   0.009), children with PE are more likely to obtain a 'PE likely' score (score > 4), P  =   0.012. The difference was of slightly greater significance when the Wells score was adjusted to account for pediatric normal ranges for heart rate, P  =   0.007, and signs/symptoms of upper limb DVT, P  =   0.006. Children with PE were as likely as PE negative patients to have a D-dimer value within the normal range (PE positive, 15%; PE negative, 25%; P  =   0.654). A combination of a 'PE unlikely' score and normal D-dimer value occurred in 1/12 (8%) of PE negative children. Conclusions : The Wells clinical probability score and D-dimer estimation may lack utility in the determination of pre-test probability of PE in children. Validation of a pediatric clinical probability score, incorporating D-dimer estimation, by prospective study, would be difficult as a result of the rarity of childhood PE.     

超声心动图诊断急性肺栓塞的临床意义

目的探讨经胸彩色多普勒超声心动图诊断急性肺栓塞的价值。方法对63例临床诊断为急性肺栓塞的患者行经胸超声心动图检查,与CT各参数比较;并将肺动脉高压患者分为3组,进行组间分析。结果超声心动图发现右房内血栓1例,主肺动脉干或左右肺动脉血栓3例,右心腔增大38例,肺动脉增宽33例,右室壁运动异常19例,肺动脉高压45例,肺动脉血流流速曲线异常19例。CT发现右房内血栓及肺动脉内血栓7例,右心系统形态改变及肺动脉高压例数均低于超声心动图。3组肺动脉高压患者随肺动脉收缩压(SPAP)升高,右室舒张末期内径(RVDD)与主肺动脉内径明显增大(P<0.05)。结论超声心动图简便易行,对急性肺动脉栓塞的诊断有非常重要的价值。     

Prognostic value of plasma D-dimer levels in patients with small-cell lung cancer

ObjectiveLittle data exists with respect to the relationship between the level of plasma D-dimer and prognosis of small cell lung cancer (SCLC).The aim of this study was to investigate whether the levels of plasma D-dimer could be served as a prognostic factor in patients with SCLC.MethodsA total of 393 patients with SCLC were addressed in the present retrospective study. Plasma D-dimer levels were measured by immunoturbidimetric assay. The correlation between plasma D-dimer levels and other clinical features, progression free survival (PFS) and overall survival (OS) was analyzed statistically.ResultsThe plasma D-dimer levels were significantly correlated with karnofsky performance status (KPS), tumor stage, number of metastatic sites, and treatment response. The PFS and OS of patients with elevated D-dimer levels before chemotherapy were significantly shorter than that of patients with normal D-dimer levels (PFS: 6.2 months versus 9.6 months, P < 0.001; OS: 15.7 months versus 24.4 months, P < 0.001). The patients with D-dimer levels converting from high to normal had better PFS and OS than those with D-dimer levels remaining high after two cycles of chemotherapy. According to multivariate analysis, elevated D-dimer level was confirmed to be an independent prognostic factor for worse survival.ConclusionsElevated plasma D-dimer level could be served as an independent determinant of poor prognosis in patients with SCLC.     

螺旋CT肺动脉造影诊断急性肺动脉栓塞的研究

目的：探讨螺旋CT诊断急性肺动脉栓塞（PE）的方法与价值。材料与方法：回顾性分析249例临床怀疑急性PE的病人资料,探讨螺旋CT肺动脉造影（SCTPA）方法及PE表现特征。结果：测得主肺动脉干强化峰值时间约10.8s;经SCTPA共检出68例PE,发生栓塞的肺动脉705支,其中偏心型506支,占71.8%,中心型147支,占20.8%,附壁型33支,占4.7%,全堵型最少,为19支,占2.7%;181例未发现确切PE征象,但其中105例检出其它疾病。结论：SCTPA是诊断急性PE的重要方法,能较准确地诊断肺内其它病变,对于临床怀疑急性PE的就诊者,SCTPA应作为首选检查。     

超声诊断高原地区肺动脉栓塞的临床价值

目的探讨超声在诊断高原地区肺动脉栓塞中的临床价值。方法分析29例超声检查并经临床证实的高原地区的肺动脉栓塞患者的声像图特征。结果超声心动图异常者24例,显示肺动脉收缩压不同程度增高,21例发生右心系统形态改变;超声发现下肢深静脉血栓13例,右颈部静脉血栓1例,右上肢深静脉血栓2例。结论声像图的直接和间接征象对快速早期诊断肺动脉栓塞具有重要的临床价值。     

D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry

OBJECT: Few studies have addressed the prognostic implications of D-dimer in patients with pulmonary embolism. The aim of this study was to investigate the correlation between D-dimer levels and mortality in patients with pulmonary embolism. DESIGN: Observational study. SETTING: Hospitals participating in the Registro Informatizado de la Enfermedad Tromboembólica (RIETE). PATIENTS: A total of 588 consecutive patients with symptomatic pulmonary embolism who were included in the RIETE between March 2001 and December 2004. INTERVENTIONS: Quantitative D-dimer measurement was performed on admission using an automated latex agglutination test (IL Test D-dimer). All patients underwent clinical follow-up for 3 months. MEASUREMENTS AND MAIN RESULTS: Overall mortality rate was 10.5%. The cause of death was pulmonary embolism in 18 patients (3.0%), fatal bleeding in one patient (0.2%), and other causes in 43 patients (7.3%). There were 28 (4.8%) nonfatal venous thromboembolism recurrences and 35 (6.0%) nonfatal bleeding episodes. The incidence of D-dimer 500-2499 ng/mL, D-dimer 2500-4999 ng/mL, and D-dimer >or=5000 ng/mL was 47.8%, 26.0%, and 20.4%, respectively. Compared with patients with D-dimer 500-2499 ng/mL, the relative risk (odds ratio) of overall mortality was 1.91 (95% confidence interval 0.91-4.09) and 2.94 (95% confidence interval 1.42-6.25) in patients with D-dimer 2500-4999 ng/mL and D-dimer >or= 5000 ng/mL, respectively (p = .032). Patients with D-dimer >or=5000 ng/mL showed higher risk of death from fatal pulmonary embolism (odds ratio 4.4, 95% confidence interval 0.5-33.0) than death from other causes (odds ratio 2.1, 95% confidence interval 0.7-6.0). Elevated D-dimer levels were associated with more severe disease, as assessed by clinical features. CONCLUSIONS: In patients who present with pulmonary embolism, D-dimer concentration is an independent predictive factor associated with all-cause and pulmonary embolism-related death. D-dimer >or=5000 ng/mL occurs in about one in five patients and is associated with a 2.9-fold increased risk of overall mortality. These results suggest that D-dimer quantification could be a useful biomarker and help determine initial therapies.