核素肺显像RM—PIOPED与PISA-PED评价标准用于急性肺栓塞诊断的比较研究

目的比较放射性核素肺显像的2种评价标准和临床肺栓塞危险度分层对诊断急性肺动脉血栓栓塞症（PTE）的一致性和效能。方法分析2005年10月至2007年7月共104例连续性临床疑诊急性PTE患者的放射性核素肺显像和临床情况，分别采用麦克马斯特（McMaster）临床危险度分层：核素肺显像修订版肺栓塞诊断前瞻陛研究（RM—PIOPED）评价标准、急性肺栓塞诊断前瞻性调查研究（PISA-PED）评价标准进行诊断。以汇总肺动脉增强CT扫描（CTPA）、肺动脉造影（PAA）、各实验室检查、临床病史及临床治疗反应讨论得出的最终诊断作为“标准诊断”，然后比较2种显像评价标准及McMaster临床危险度分层相互之间的一致性和诊断效能。采用Kappa分析比较2种评价方法之间的一致性；配对，检验比较2种评价方法之间的差异有无统计学意义。结果2种显像评价标准及McMaster临床危险度分层之间：PISA—PED评价标准与RM—PIOPED评价标准的一致性好（Kappa值为0．92，P〈0．05）；McMaster临床危险度分层与RM—PIOPED评价标准及PISA—PED评价标准的一致性差（Kappa值均为0．35，P均〉0．05）。104例患者中55例被诊断为急性PTE，占52．9％。McMaster临床危险度分层、RM—PIOPED评价标准及PISA—PED评价标准的灵敏度分别为69．1％（38／55）、90．9％（50／55）、92．7％（51／55）；特异性分别为73．5％（36／49）、73．5％（36／49）、75．5％（37／49）；准确性分别为71．2％（74／104）、82．7％（86／104）、84．6％（88／104）。对于该2种评价标准及McMaster临床危险度分层，特异性两两之间差异均无统计学意义（χ^2值分别为0．00，0．05，0．05，P均〉0．05）；RM-PIOPED评价标准的灵敏度与PISA—PED评价标准之间差异亦无统计学意义（χ^2=0．12，P〉0．05）；但McMaster临床危险度分层的灵敏度与2种评价标准之间?

Comparison of scintigraphic RM-PIOPED criteria and PISA-PED criteria in the diagnosis of acute pulmonary embolism

Objective Pulmonary thromboembolism (PTE) is a relatively common and potentially fatal disorder. Clinical presentation and scintigraphy are highly useful for the diagnosis of acute PTE. This study was to evaluate the diagnostic efficacy and concordance of different scintigraphic and clinical algo-rithms in the diagnosis of acute PTE. Methods One hundred and four consecutive patients with suspected acute PTE were enrolled and they underwent perfusion/ventilation (Q/V) scintigraphy, contrast enhanced multi slice spiral CT pulmonary angiography ( CTPA), chest radiography and other tests from October 2005 to July 2007. The analysis and subsequent grading of probability of pulmonary embolism were undertaken using three methods: the McMaster clinical criteria, the refined modified prospective investigation of pulmonary embolism diagnosis (RM-PIOPED) criteria, and the prospective investigative study of acute pulmonary em-bolism diagnosis (PISA-PED) criteria. Kappa test was used to analyze the degree of agreement among the diagnostic criteria. The differences between the diagnostic criteria were tested for significance using paramet-ric chi-square test. P<0.05 was considered statistically significant. The final clinical diagnosis was based on all imaging modalities, all available laboratory records, medical history and clinical therapeutic re-sponse. This "final clinical diagnosis" was regarded as the "gold standard" of this study. Results The concordance of PISA-PED criteria and RM-PIOPED criteria was good (Kappa = 0.92, P<0.05). Howev-er, the concordance of RM-PIOPED criteria and McMaster clinical criteria and the concordance of PISA-PED criteria and McMaster clinical criteria were low ( both Kappa =0.35, both P>0.05). Acute PTE was diagnosed in 55 (52.9%, 55/104) of the 104 patients. The sensitivities of McMaster clinical criteria, RM-PIOPED criteria and PISA-PED criteria were 69.1% (38/55), 90.9% (50/55) and 92.7% (51/55),respectively; the specificities were 73.5% (36/49), 73.5% (36/49) and 75.5% (37/49), respective-ly; the total consistent rates were 71.2% (74/104), 82.7% (86/104) and 84.6% (88/104), respec-tively. There was no statistical difference between the specificity of the three algorithms (X2=0.00,0.05, 0.05, all P>0.05). There was also no statistical difference between the sensitivities of RM-PIOPED criteria and PISA-PED criteria (X2=0.12, P>0.05). However, there was statistical difference between the sensitiv-ities of RM-PIOPED criteria and McMaster clinical criteria X2=8.18,P<0.05) and between PISA-PED criteria and McMaster clinical criteria (X2=9.95,P<0.05). Conclusions RM-PIOPED criteria and PISA-PED criteria both had good diagnostic accuracy in acute pulmonary embolism, and their correlative concord-ance was good. McMaster clinical criteria had relatively lower sensitivity and it should not be used alone.