急性肺栓塞非特异性临床表现特征分析与误诊原因探讨

目的:分析、评估急性肺栓塞患者的临床症状、心电图及心肌损伤标志物对急性肺栓塞(APE)临床可能性考虑的影响,探讨诊断技术显著提高下APE误诊率依然高居不下的原因。方法:回顾性分析我院自2002年1月至2012年1月心脏内科连续收治的最后出院诊断为APE的病例132例(男性54例,女性78例,年龄26～86岁,平均(62.5±14)岁。结果:与急性冠状动脉综合征(ACS)相似,APE好发于中老年患者,但女性多于男性。132例患者中大块肺栓塞108例(81.8%),按欧洲心脏病学会(ESC)危险分层,高、中危患者87例(65.9%)。22例患者(包括5例住院期间因肺栓塞死亡病例)在确诊肺栓塞前曾被诊为冠心病,误诊率16.7%。11例患者在确诊前曾被诊为肺部疾病,误诊率8.3%。胸闷或胸痛、心电图示心肌缺血改变(V1-4T波倒置,V1-6ST段压低、V1-4ST段抬高)和心肌损伤标志物升高,3项中至少2项同时存在,提示ACS的患者达70例(53%);呼吸困难、发热、咳嗽3项中至少2项同时存在,提示肺部疾病的患者达42例(31.8%)。曾误诊为ACS组的患者与非误诊组患者比较,其栓塞的解剖分类大小和危险分层高低差异无统计学意义,但曾误诊为肺病组的大块肺栓塞患者比例显著高于非误诊组(P<0.05)。曾误诊为ACS和肺病的两组患者中,临床表现分别提示ACS和肺病的患者比例均显著高于非误诊组(P<0.01),曾误诊为ACS组的患者缺血性心电图改变发生率显著高于非误诊组患者(P<0.01)。结论:急性肺栓塞的临床表现经常酷似ACS和肺病,容易误导医生,而没有考虑APE,并进行确诊检查,是误诊的主要原因。

Non-specific clinical features and analysis of the cause of misdiagnosis of acute pulmonary embolism

Objective: To assess the impact of clinical manifestations and investigations(ECG findings and elevated markers of myocardial injury) on consideration of clinical possibilities of acute pulmonary embolism(APE) in patients with APE and to analysis the reasons for high rate of misdiagnosis of APE regardless of great advances in diagnostic technology.Methods: We included in our retrospective study 132 consecutive patients(54 men and 78 women) from 26 to 86 years of age [mean age(62.5±14) years]hospitalized at our cardiology wards between January 2001and January 2012,discharged with the final diagnosis of APE.Results: Similar to ACS,APE was common in middle-aged and elderly people,but more women than men.Among the 132 patients,108 cases(81.8%) was massive and 87 cases(65.9%) were classified as high and intermediate risk according to the ECS risk stratification.22 patients including 5 patients died during hospitalization had been misdiagnosed as ACS before the diagnosis of APE and 11 patients had been misdiagnosed lung disease(misdiagnostic rate 16.7% and 8.3% respectively).70 cases(53%) were classified to the group suggestive of ACS(min.2 of: chest pain/chest tightness,ischemic changes on electrocardiogram and elevated cardiac troponin I level(cTnI>0.01 ng/mL) and 42 cases(31.8%) to the group suggestive of lung disease(min.2 of: dyspnea,cough,fever).There was no significant difference in the size of embolism and the severity of risk stratification of APE between patients misdiagnosed for ACS and patients non-misdiagnosed,but the proportion of massive pulmonary embolism in the group misdiagnosed for Ld was significantly higher than that in the group non-misdiagnosed(P<0.05).Compared with non-misdiagnosed patients,the proportions of the patients whose clinical manifestations suggestive of ACS and Ld respectively were significantly higher in both patients misdiagnosed for ACS and Ld(P<0.01),The incidence of ischemic ECG changes of patients misdiagnosed for ACS was significantly higher than that of non-misdiagnosed patients(P<0.01).Conclusion: In most patients with final diagnosis of APE,symptoms and initial investigation results can mislead to the diagnosis of ACS or lung disease.therefore,advances in diagnostic technology are useless when the presence of PE is not considered.