D-二聚体在急诊主动脉夹层早期诊断的临床应用

目的：探讨血浆D-二聚体水平在急性主动脉夹层中早期诊断的临床价值。方法：回顾性分析我院2011-05-2013-08因急诊胸痛24h内入院患者共285例,所有患者入院即抽血行全血D-二聚体快速测试,比较不同病因组D-二聚体水平。所有数据采用SPSS 16.0统计软件分析处理,计量资料采用珚x±s及中位数（M）、四分位数间距（QR）进行描述,各组间D-二聚体中位数的比较采用Kruskal-Wallis H检验,Nemenyi法进一步两两比较;绘制D-二聚体水平诊断急性主动脉夹层（AAD）的受试者工作曲线（ROC曲线）,分析D-二聚体鉴别急性主动脉夹层的敏感性、特异性、预测值和似然比（P〈0.05认为差异具有统计学意义）。结果：急性主动脉夹层组（AAD）和急性肺栓塞组（APE）血浆D-二聚体水平显著高于急性心肌梗死（AMI）、心绞痛、急性心包炎、急性胸膜炎及其他病因不明的急性胸痛病例组;AMI组D-二聚体水平大于心绞痛组（P〈0.01）;D-二聚体界值250μg/L鉴别诊断AAD的敏感度和阴性预测值均达到100%,随着D-二聚体水平的升高,诊断AAD的敏感性降低,特异性升高;低于500μg/L值能很好区分排除AAD,阴性预测值97.97%,对应阴性似然比0.02;在急性胸痛患者区分AAD诊断最佳临界点为982.5μg/L,受试者工作曲线下面积为0.972±0.010（95%CI,0.953 0.991）。结论：D-二聚体可作为急性胸痛患者中鉴别诊断主动脉夹层的方便指标。     

血浆D-二聚体检测在急性主动脉夹层患者抢救中的诊断价值

目的探讨血浆D-二聚体检测在急性主动脉夹层(acute aortic dissection,AAD)患者抢救中的诊断价值。方法选取我院2014年3月—2017年1月收治的AAD 24例(夹层组)与急性心肌梗死45例(心梗组)为研究对象。比较两组入院时血浆D-二聚体水平及不同类型AAD患者D-二聚体水平变化,绘制受试者工作特征曲线(receiver operating characteristic curve,ROC),计算D-二聚体诊断AAD的临界值,分析诊断效能。结果急诊入院时夹层组、心梗组血浆D-二聚体水平分别为(10366.91±945.93)μg/L、(3859.43±590.37)μg/L,差异有统计学意义(P=0.002)。Stanford A型AAD患者血浆D-二聚体水平显著高于Stanford B型,差异有统计学意义(P=0.029);De BakeyⅠ型、Ⅱ型、Ⅲ型AAD患者血浆D-二聚体水平比较差异有统计学意义(P=0.032)。ROC分析显示,当D-二聚体临界值设定为500μg/L时,其曲线下面积最大,诊断灵敏度为92.4%,特异度为90.3%,阴性预测值为100.0%,阳性预测率为93.5%。结论血浆D-二聚体检测对AAD早期诊断具有重要价值,能协助急诊医生进行AAD快速筛查,提高诊断准确性及救治成功率。     

风险评分结合D-二聚体在主动脉夹层急诊早期诊断中的意义

目的:评估主动脉夹层风险评分结合D-二聚体在急性主动脉夹层(AAD)急诊快速筛查中的意义。方法:收集31例经主动脉CT血管造影(CTA)确诊为主动脉夹层病人的临床资料,根据2014年欧洲心脏病学会(ESC)制定的《主动脉疾病诊疗指南》里的主动脉夹层风险评分对全部病人进行夹层风险评分并结合D-二聚体检测,评估早期筛检AAD的敏感性。结果:在高风险组急性主动脉夹层患者概率得分比非主动脉夹层患者明显增高(61.3%vs 3.0%,P0.05)。而高风险组敏感性为63.8%,特异性为96.7%误诊率9.5%;在低风险组D-二聚体检测的敏感性和特异性AAD分别92.8%和64.3%,阴性预测值为97.8%,误诊率为1.6%,两组特异性、误诊率有统计学意义(P0.05)。结论:动脉夹层风险评分、D-二聚体较高的病人诊断主动脉夹层有良好的特异性。相反,动脉夹层风险评分、D-二聚体较低的病人可安全有效地排AD,误诊率较低。     

D-二聚体在急诊筛查急性主动脉夹层及肺栓塞的临床价值

目的探讨应用D-二聚体在急诊筛查急性主动脉夹层（acute aortic dissection,AAD）及肺栓塞（pulmonary embolism,PE）的临床价值。方法对2008年1月到2010年12月在我院急诊科就诊的71例胸痛患者的临床资料进行回顾性分析,比较急性主动脉夹层组（AAD组）、急性肺栓塞组（APE组）与对照组的D-二聚体水平差异;绘制D-二聚体诊断AAD及APE的受试者工作曲线（ROC曲线）,计算曲线下面积及其标准误、95％可信区间;计算当D-二聚体水平为0．5ug／ml时,诊断AAD及APE的效度。结果AAD组及APE组D-二聚体水平数据呈偏态分布,两两比较差异无统计学意义（P〉0．05）,但均明显高于对照组（P〈0．05）;D-二聚体诊断AAD的ROC曲线下面积为0．826±0．048（95％CI,0．732—0．923）,诊断APE的ROC曲线下面积为0．855±0．044（95％CI,0．769～0．940）,鉴别AAD与APE的ROC曲线下面积为0．550±0．107（95％CI,0．341—0．759）。当D-二聚体水平为0．5ug／ml时诊断AAD的敏感性为0．938,阴性似然比为0．088;诊断APE的敏感性为0．933．阴性似然比为0．096。结论D-二聚体临床应用价值较高,可以作为急诊筛查AAD及APE的指标。     

主动脉夹层风险评分联合D-二聚体在主动脉夹层诊断中的应用价值

目的探讨主动脉夹层风险评分联合D-二聚体对于诊断主动脉夹层(AAD)的应用价值。方法收集近5年我科收治的怀疑急性主动脉夹层而行主动脉CT造影的病例共387例,根据最终诊断分为急性主动脉综合征(AAS)组和非AAS组。分析其临床资料,计算主动脉夹层风险评分(ADD-RS),并分析D-二聚体水平(243ng/mL为阳性)。结果AAS共161例,包括主动脉夹层AAD 151例(93.79%),壁间血肿5例(3.11%),主动脉溃疡3例(1.86%),腹主动脉瘤破裂2例(1.24%)。AAD中Stanford A型占71例(47.02%),Stanford B型占80例(52.98%)。D-二聚体阳性诊断AAS的敏感性为90.7%,特异性为26.1%;而D-二聚体>5000ng/mL诊断AAS的敏感性为22.4%,特异性为95.1%。15例AAS患者D-二聚体<243ng/mL。在AAS组内,ADD-RS=0、ADD-RS=1及ADD-RS>1分别占4.97%(8/161)、78.88%(127/161)及16.15%(26/161)。ADD-RS1诊断ASS的敏感性为95.0%,特异性为35.0%。ADD-RS=0并D-二聚体阴性者为22例,均为非AAS组,表明ADD-RS=0联合D-二聚体阴性排除AAS的敏感性为100%。ADD-RS>1联合D二聚体>5000ng/mL诊断AAS的敏感性为100%。结论ADD-RS联合D-二聚体可以极大提高临床排除或诊断AAD的准确性。     

血D-二聚体浓度对主动脉夹层的诊断价值

目的探讨血D-二聚体浓度对主动脉夹层的诊断价值.方法37例经心脏超声、食道超声、CT、MRI或血管造影确诊的主动脉夹层患者,同期住院的35例急性心肌梗死患者作为对照组.所有患者入院当时抽血检测D-二聚体、C反应蛋白(CRP)和肌钙蛋白Ⅰ水平.结果17例主动脉夹层患者为Stanford A型,20例B型.所有主动脉夹层患者D-二聚体水平升高(＞0.3 μr/mL),均值2.0±1.9(0.4～8.4)μg/mL,敏感性100%.自症状发作到D-二聚体测定的时间为1.5 h～14d,D-二聚体升高的程度与病程呈负相关(r=-0.42,P=0.04).病变范围越大,D-二聚体水平越高,死亡组D-二聚体均高于5 μg/mL,提示D-二聚体升高对判断预后有指导价值.与主动脉夹层患者相比,仅4例急性心肌梗死患者血D-二聚体水平轻度升高(＜0.7 μg/mL).结论D-二聚体阴性有助于排除急性主动脉夹层的诊断.D-二聚体升高对判断病变范围和预后有一定的指导价值.     

血浆D-二聚体检测对下肢深静脉血栓形成的诊断价值研究

目的探讨D-二聚体检测对于下肢深静脉血栓形成(DVT)诊断的临床价值。方法对80例疑诊为DVT的患者(患者组)及61例健康体检者(对照组)血浆中的D-二聚体进行定量检测,并对检测结果进行分析比较。结果患者组血浆D-二聚体浓度明显高于对照组,差异有统计学意义(t=7.125,P<0.01)。血浆D-二聚体对于DVT诊断的敏感性为100.0%、特异性为55.6%、阳性预测值为94.6%、阴性预测值为100.0%。结论 D-二聚体可作为DVT诊断的敏感、快速指标,值得在临床推广。     

D-二聚体联合B超早期诊断主动脉夹层的临床应用价值

目的:研究D-二聚体联合B超早期诊断主动脉夹层的临床应用价值。方法:选取我院2018-01—2019-12期间收治的70例主动脉夹层患者为观察组,另选同期70例健康体检者为对照组,对2组受试者D-二聚体、主动脉弹性指标(膨胀性、主动脉僵硬指数、最大主动脉直径方向运动速度)进行测定和比较,利用二分类Logistic回归分析法检验D-二聚体、主动脉弹性指标早期诊断主动脉夹层的可行性,研究D-二聚体联合B超早期诊断主动脉夹层的应用价值。结果:观察组D-二聚体、主动脉弹性指标与对照组相比较,差异有统计学意义(P0.05);二分类Logistic回归分析结果提示,D-二聚体、主动脉弹性指标与主动脉夹层有关(P0.05);以CT血管造影结果为参照,D-二聚体联合B超检出率为92.86%(65/70)、D-二聚体检出率为67.14%(47/70)、B超检出率为82.86%(58/70),三者检出率相比较,差异有统计学意义(P0.05)。结论:D-二聚体联合B超早期诊断主动脉夹层结果可靠,不失为一种实用、简捷且可靠的诊断方法,值得推广使用。     

D-二聚体测定在急诊主动脉夹层诊治中的价值分析

目的:探讨D-二聚体(D-D)可作为一种快速、简便筛查急诊主动脉夹层(AD)的方法,分析血D-二聚体检测在急诊主动脉夹层诊断中的价值。方法:回顾性研究32例经高分辨率影像学确诊的主动脉夹层病例作为实验组,选择同一时期初诊疑似主动脉夹层而最终排除的30例患者为对照组。两组患者均接受了血浆D-D检测和高分辨率动脉成像检查,比较2组间D-D值差异。结果:主夹层组血浆D-D值明显高于对照组,2组间血D-D值水平差异有统计学意义(P<0.05);AD亚组间统计学差异提示D-D值可作为AD患者夹层撕脱程度及病情预后的指标。结论:血浆D-二聚体检测对于主动脉夹层诊断,血管内膜撕脱程度及病情预后具有高度的敏感性和准确性,可作为一种简便、快速的急诊AD诊断筛查方法。     

急性主动脉夹层患者血浆miR-30a及D-二聚体水平检测对临床预后判断价值

目的　探讨血浆微小核糖核酸 (miR)-30a及 D-二聚体 (D-dimer, D-D)水平对急性主动脉夹层（ acute aortic dissection ,AAD）预后判断价值。方法　选取 2018年 1月～ 2020年 12月海口市第三人民医院收治的 AAD患者 152例和 65例健康对照组作为研究对象,根据 AAD患者住院期间的预后情况分为存活组（ n=107例）和死亡组（ n=45例）,检测各组血浆 miR-30a及 D-二聚体水平。应用受试者工作特征（ ROC）曲线分析血浆 miR-30a及 D-二聚体水平预测 AAD死亡的价值。结果　AAD组血浆 miR-30a（1.93±0.78）及 D-二聚体（6.28±1.72μg/ml）水平均明显高于对照组（0.72±0.25,0.36±0.08μg/ml）,差异有统计学意义（ t=13.758, 16.814,均 P<0.001）。死亡组血浆 miR-30a（2.42±1.13）及 D-二聚体（ 8.62±2.24μg/ml）水平均明显高于存活组（ 1.30±0.56,3.64±1.35μg/ml）,差异有统计学意义（ t=11.624, 14.735,均 P<0.001）。ROC曲线显示, miR-30a及 D-二聚体两项联合预测 AAD死亡的曲线下面积（ 0.936,95%CI: 0.875～ 0.992）最大,其敏感度和特异度分别为 94.0%,88.6%。结论　AAD患者血浆 miR-30a及 D-二聚体水平明显升高,两项联合检测对 AAD预后判断具有较好的价值。     

现场快速检测高敏肌钙蛋白在老年急性心肌梗死早期的临床诊断价值

目的:观察现场快速检测高敏肌钙蛋白I(hs-cTnI)在急诊老年胸痛患者人群中的表达情况,并评价其对急性心肌梗死(AMI)的诊断效能.方法:选择2018年6月-2021年5月期间我院急诊科收治的胸痛疑似急性冠脉综合征(ACS)而行现场快速检测hs-cTnI的315例老年患者作为研究对象,观察hs-cTnI在老年急性胸痛...     

Performance of HEART and TIMI scores in predicting major adverse cardiovascular events (MACEs) of chest pain patients in the emergency department: A prospective observational study

Objective: To compare the value of HEART and TIMI scores in predicting major adverse cardiovascular events (MACEs) of patients with chest pain in the emergency department at a tertiary care hospital in Ahmedabad, a city in western India. Methods: A prospective study was conducted on chest pain patients from January to December 2019. All adult patients with non-traumatic chest pain presenting to the emergency department were included, and their HEART and TIMI scores were evaluated. The patients were followed up within 4 weeks for monitoring any major adverse cardiac events or death. The receiver-operating characteristics (ROC) curve was used to determine the value of HEART and TIMI scores in predicting MACEs. Besides, the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the two scores were assessed and compared. Results: A total of 350 patients were evaluated [mean age (55.03±16.6) years, 56.6％ of males]. HEART score had the highest predictive value of MACEs with an area under the curve (AUC) of 0.98, followed by the TIMI score with an AUC of 0.92. HEART score had the highest specificity of 98.0％ (95％ CI: 96.4％-99.6％), the sensitivity of 75.0％ (95％ CI: 70.7％-79.3％), and PPV of 97.0％ (95％ CI: 94.1％-99.9％) and NPV of 82.5％ (95％ CI: 74.6％-90.4％) for low-risk patients. TIMI score had a specificity of 95.0％ (95％ CI: 92.4％-97.6％), sensitivity of 75.0％ (95％ CI: 69.4％-80.6％), PPV of 92.3％ (95％ CI: 88.1％-96.5％) and NPV of 82.3％ (95％ CI: 73.8％-90.8％) for low-risk patients. Conclusions: HEART score is an easier and more practical triage instrument to identify chest pain patients with low-risk for MACEs compared to TIMI score. Patients with high HEART scores have a higher risk of MACEs and require early therapeutic intervention and aggressive management.     

Ischemia-modified albumin measured with ultra-filtration assay in early diagnosis of acute coronary syndrome

BACKGROUND:

Patients with acute chest pain remain a great diagnostic challenge to emergency physicians. Ischemia-modified albumin (IMA) is a recently developed biomarker of transient myocardial ischemia. IMA has already been licensed by the US Food and Drug Administration for diagnosis of suspected myocardial ischemia. This study aimed to assess the diagnostic value of IMA in treatment of patients with acute coronary syndrome(ACS).

METHODS:

IMA level was detected by ultra-filtration assay combined with albumin-cobalt binding (ACB) test as well as tests of myoglobin (MYO), creatine kinase-MB (CK-MB) and cardiac troponin I (cTnI) in 169 consecutive patients with acute chest pain onset within 24 hours. Receiver operating characteristic (ROC) curve for IMA in diagnosing ACS was established to determine the cut-off point. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IMA and its combinations with other agents were analyzed.

RESULTS:

Area under the ROC curve (AUC) was 0.754. As the cut-off point for IMA in this study was 70.4 U/ml, the sensitivity, specificity, PPV and NPV of IMA were 79.8%, 65.2%±77.7%, and 69.7%, respectively. The sensitivity and NPV of IMA combined with the conventional cardiac marker panel for the diagnosis of ACS were 93.4% and 86.0%, respectively.

CONCLUSION:

IMA is a useful biochemical marker for the early diagnosis of ACS. IMA combined with the conventional cardiac marker panel can improve early diagnosis of ACS compared with the traditional combinations of myocardial biochemical markers.KEY WORDS: Ischemia-modified albumin, Acute coronary syndrome     

Computed tomography pulmonary angiography in the diagnosis of acute pulmonary embolism in the emergency department

This study was undertaken to evaluate the use of computed tomography pulmonary angiography (CTPA) in patients with pulmonary embolism (PE) who were followed in the emergency department (ED). The files and computer records of 850 patients older than 16 years of age who were seen in the Hacettepe University Hospital ED between April 10, 2001, and December 1, 2005, and who required CTPA for PE prediagnosis and/or another diagnosis, were studied retrospectively. PE was identified by CTPA in 9.4% of 416 women and in 5.8% of 434 men. A significant difference (P< .05) was noted in the women and men in whom PE was detected. The mean age of the patients was 58.13±17.88 y (range, 16–100 y). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for clinical susceptibility to PE among patients who underwent CTPA were assessed at 95.3%, 48.2%, 13%, and 99.2%, respectively. CTPA was done for different reasons: aortic aneurysm dissection (n=1), cough distinctive diagnosis (n=1), dyspnea distinctive diagnosis (n=6), chest pain distinctive diagnosis (n=3), PE prediagnosis (n=51), and other reasons (n=2). Also, sensitivity, specificity, PPV, and NPV were found to be 95.4%, 16.2%, 14.4%, and 96%, respectively, for D-dimer. CTPA, which is accessible on a 24-h basis in the ED, is a valuable tool for the diagnosis of PE.     

Rule out of acute aortic dissection with plasma matrix metalloproteinase 8 in the emergency department

Introduction

Matrix metalloproteinases (MMPs) are involved in aortic pathophysiology. Preliminary studies have detected increased plasma levels of MMP8 and MMP9 in patients with acute aortic dissection (AAD). However, the performance of plasma MMP8 and MMP9 for the diagnosis of AAD in the emergency department is at present unknown.

Methods

The levels of MMP8 and MMP9 were measured by ELISA on plasma samples obtained from 126 consecutive patients evaluated in the emergency department for suspected AAD. All patients were subjected to urgent computed tomography (CT) scan for final diagnosis.

Results

In the study cohort (N = 126), AAD was diagnosed in 52 patients and ruled out in 74 patients. Median plasma MMP8 levels were 36.4 (interquartile range 24.8 to 69.3) ng/ml in patients with AAD and 13.2 (8.1 to 31.8) ng/ml in patients receiving an alternative final diagnosis (P <0.0001). Median plasma MMP9 levels were 169.2 (93.0 to 261.8) ng/ml in patients with AAD and 80.5 (41.8 to 140.6) ng/ml in patients receiving an alternative final diagnosis (P = 0.001). The area under the curve (AUC) on receiver-operating characteristic (ROC) analysis of MMP8 and MMP9 for the diagnosis of AAD was respectively 0.75 and 0.70, as compared to 0.87 of D-dimer. At the cutoff of 3.6 ng/ml, plasma MMP8 had a sensitivity of 100.0% (95% CI, 93.2% to 100.0%) and a specificity of 9.5% (95% CI, 3.9% to 18.5%) and ruled out AAD in 5.6% of patients. Combination of plasma MMP8 with D-dimer increased the AUC on ROC analysis to 0.89. Presence of MMP8 <11.0 ng/ml and D-dimer <1.0 or <2.0 µg/ml provided a negative predictive value of 100% and ruled out AAD in 13.6% and 21.4% of patients respectively.

Conclusions

Low levels of plasma MMP8 can rule out AAD in a minority of patients. Combination of plasma MMP8 and D-dimer at individually suboptimal cutoffs could safely rule out AAD in a substantial proportion of patients evaluated in the emergency department.     

缺血修饰白蛋白在急性冠状动脉综合征早期诊断中的价值

目的 探讨缺血修饰白蛋白(IMA)对急性冠状动脉综合征(ACS)的早期诊断价值.方法 103例疑似ACS患者[非心肌缺血性胸痛(NICP)45例(NICP组),ACS 58例(ACS组)]在胸痛发作5 h内取血测定IMA、肌钙蛋白I(cTnI)、肌酸激酶同工酶MB(CK-MB)并在入院后即刻描记12导联心电图(ECG),同时选择30例健康对照(对照组)进行检测,经ROC曲线分析获得区分NICP与ACS最佳,临界值点(Cut-off值).IMA、cTnI、CK-MB及ECG结果分别与最终诊断结果(NICP,ACS)进行综合分析,评价其诊断ACS的敏感性.结果 ACS组与NICP组IMA值分别是(89.66±25.82)、(46.79±17.20)U/ml,2组间比较IMA值差异有统计学意义(P＜0.05);ROC曲线下面积0.935,最佳临界值为71.6 U/ml,此时IMA检测的敏感性、特异性、阳性预测值和阴性预测值分别为90.6%、71.4%、82.8%和83.3%.而同步测定cTnI、CK-MB、ECG诊断ACS的阳性率分别为29.3%、27.6%、48.3%.结论 IMA是诊断急性心肌缺血早期灵敏指标,可明显提高ACS早期诊断的敏感性.     

超声引导下粗针穿刺活检对甲状腺结节诊断价值的临床研究

目的回顾性分析大样本甲状腺结节超声引导下粗针穿刺活检（CNB）的结果,并评价其诊断价值。 方法2009年4月到2011年4月在解放军总医院超声诊断科行CNB的355个患者的369个结节纳入本研究。恶性结节以手术切除后组织病理学结果为诊断金标准。良性结节以手术切除后组织病理学结果或者粗针穿刺活检良性且随访至少3年无明显变化为标准。采用甲状腺针吸细胞学检查Bethesda分级标准,得出CNB诊断不明确的比率。计算CNB诊断的敏感度、特异度、阳性预测值、阴性预测值和准确性,计算受试者工作特性（ROC）曲线下面积。分析CNB诊断效果与结节声像图特征的相关性。 结果CNB结果中22（6.0%）个结节诊断不明确。CNB诊断的敏感度、特异度、阳性预测值、阴性预测值和准确性分别为97.7%,98.5%,99.1%,96.3%和98.0%。ROC曲线下面积为0.981±0.009（95%可信区间：0.964~0.998）。 结论超声引导下CNB对甲状腺结节诊断的准确性高,安全性好,可减少重复穿刺、诊断性手术和不必要的随访。CNB的诊断效果不受结节声像图表现的影响。因此,具有可疑恶性征象的甲状腺结节,超声引导下CNB可作为穿刺活检的方法。