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[NEJM发表论文]:根据临床概率校正的D-二聚体诊断肺动脉栓塞
2019年12月04日 时讯速递, 进展交流 暂无评论

ORIGINAL ARTICLE FREE PREVIEW

Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability

Clive Kearon, Kerstin de Wit, Sameer Parpia, et al

N Engl J Med 2019; 381:2125-2134
DOI: 10.1056/NEJMoa1909159

BACKGROUND 背景

Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP.

回顾性分析提示,对于临床验前概率(C-PTP)较低的患者,d-二聚体< 1000 ng/ml可除外肺栓塞,而对C-PTP中等概率的患者,d-二聚体< 500 ng/ml可排除肺栓塞。

METHODS 方法

We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism.

我们进行了一项前瞻性研究,对于低C-PTP且d-二聚体< 1000 ng/ml或中等C-PTP且d-二聚体< 500 ng/ml的门诊患者,不经过进一步检查即考虑除外肺动脉栓塞。所有其他患者均进行胸部影像学检查(通常为CTPA)。如果不能诊断肺动脉栓塞,则患者不接受抗凝治疗。所有患者均随访3个月,以检测静脉血栓栓塞。

RESULTS 结果

A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, −17.6 percentage points; 95% CI, −19.2 to −15.9).

共有2017名患者入选并接受评估,通过初始诊断检查诊断7.4%的患者为肺动脉栓塞。1325名患者为低C-PTP (1285名患者) 或中度C-PTP (40名患者)且d-二聚体检查结果阴性(即分别<1000 or <500 ng/ml),在随访期间没有发生静脉血栓栓塞 (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%)。对于1863名最初没有诊断肺动脉栓塞且未接受抗凝治疗的患者,1名患者(0.05%; 95% CI, 0.01 to 0.30)发生静脉血栓栓塞。根据我们的诊断策略,34.3% 的患者接受了胸部影像学检查,而依据低C-PTP且d-二聚体< 500 ng/ml排除肺动脉栓塞的策略,将由51.9%的患者 (差异, −17.6 个百分点; 95% CI, −19.2 to −15.9) 接受胸部影像学检查。

CONCLUSIONS 结论

A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up.

综合低C-PTP与d-二聚体< 1000 ng/ml,可以鉴别随访期间发生肺动脉栓塞风险较低的一组患者。

(Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442. opens in new tab.)

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