{"title":"肺栓塞的诊断策略。","authors":"Margaret Mary Glazier, James J Glazier","doi":"10.1055/s-0044-1779661","DOIUrl":null,"url":null,"abstract":"<p><p>Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.</p>","PeriodicalId":13798,"journal":{"name":"International Journal of Angiology","volume":null,"pages":null},"PeriodicalIF":0.5000,"publicationDate":"2024-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11152624/pdf/","citationCount":"0","resultStr":"{\"title\":\"Diagnostic Strategies in Pulmonary Embolism.\",\"authors\":\"Margaret Mary Glazier, James J Glazier\",\"doi\":\"10.1055/s-0044-1779661\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><p>Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. 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引用次数: 0
摘要
诊断肺栓塞(PE)的关键是进行仔细的床边评估。在此之后,还有三个诊断步骤。对所有患者进行肺栓塞临床可能性评估。另外两个步骤是在有指征时测量 D-二聚体,在有指征时进行胸部造影。PE 的临床概率估计为低、中或高。临床概率低的患者 PE 患病率低于 15%,临床概率中等的患者 PE 患病率为 15%至 40%,临床概率高的患者 PE 患病率高于 40%。临床态势对估计 PE 的概率非常有用。然而,临床预测规则,如韦尔斯标准、改良日内瓦评分和 PE 排除标准,已被提倡作为辅助手段。在临床概率较高的患者中,PE 的高患病率会降低 D-二聚体的阴性预测值,从而增加诊断失败的风险。因此,PE 可能性高的患者需要直接进行胸部成像检查,而无需事先测量 D-二聚体水平。确定哪些中低概率患者需要进行胸部成像的主要研究有:排除肺栓塞的年龄调整 D-二聚体临界值(ADJUST-PE)、疑似肺栓塞的简化诊断管理(YEARS)和肺栓塞分级 D-二聚体试验。对于临床可能性较低的患者,如果 D-二聚体低于 1,000 纳克/毫升,则无需进行造影检查即可排除 PE。对于 PE 可能性不低的患者,如果 D-二聚体低于年龄调整阈值,则无需影像学检查即可排除 PE。
Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.