D-二聚体阴性肺栓塞患者的危险因素分析

The analysis of risk factors of pulmonary embolism in patients with negative D-dimer

目的 分析总结D-二聚体阴性肺栓塞患者的危险因素,以指导是否应行肺血管增强（CTA）检查以防漏诊.方法 回顾分析广东省人民医院急危重症医学部收治的106例可疑肺栓塞但血浆D-二聚体阴性的患者,且所有患者均接受了肺CTA检查.按肺CTA检查结果分为两组：有肺栓塞组（41例）和无肺栓塞组（65例）.比较两组的临床表现、发病至就诊的时间间隔、脑钠肽前体（NT-proBNP）、高危因素（如各种原因制动3周以上、单侧肢体浮肿或疼痛、深静脉血栓史、恶性肿瘤）以及Wells量化临床评分（≥4分者为高危患者）;用Logistic回归方法分析各因素对D-二聚体阴性患者发生肺栓塞的风险.结果 本研究发现临床上怀疑肺栓塞但D-二聚体阴性患者,肺CTA提示肺栓塞达38.6％.D-二聚体阴性肺栓塞患者的一个重要临床特点是发病至就诊的时间间隔均较长[（9.51 ±2.01）dvs.（4.01±1.92）d,P＜0.05],即就诊延迟;这些D-二聚体阴性的肺栓塞患者均存在肺栓塞高危因素（P＜0.01）,其中Wells临床评分≥4分的机率较无肺栓塞患者增加（P＜0.01）,血浆NT-proBNP水平也显著升高（P＜0.01）;Logistic回归分析显示,气促、NT-proBNP升高以及Wells临床评分≥4分是本组D-二聚体阴性患者发生肺栓塞的危险因素.结论 就诊延迟是漏诊D-二.聚体阴性肺栓塞的主要原因.D-二聚体阴性的可疑肺栓塞患者,如具有气促、血清NT-proBNP升高、Wells临床评分≥4分提示很可能存在肺栓塞,应积极行肺CTA检查;但当不存在这些临床特征时,则可不予考虑存在肺栓塞.

Objective To analyze the risk factors of pulmonary embolism in patients with negative Ddimer in serum in order to determine the need of pulmonary computed tomography angiograph （CTA） to confirm the final diagnosis in those patients for avoidance of misdiagnosis.Methods A retrospective analysis of 106 patients suspected to suffer from pulmonary embolism （PE） with serum negative D-dimer checked with pulmonary CTA was carried out.According to the results of CTA, the patients were divided into two groups, namely PE group （n =41） and non-PE group （n =65）.The difference in clinic presentation, the time elapsed from onset to visit, N-terminal pro-brain natriuretic peptide （NT-proBNP）, high risk factors （such as immobilization for 3 weeks, leg swelling and pain to palpation, history of deep vein thrombosis, malignancy） and Wells score （≥ 4 points indicates probability of PE）.And logistic regression analysis was made to investigate the risk factors in PE with negative D-dimer.Results The analysis study showed that 38.6% of total patients suspected to suffer from PE with serum negative D-dimer were checked by CTA to confirm the presence of PE.One important characteristics of the D-dimer negative PE patients was the longer time consumed from onset to visit [（9.51 ±2.01） d vs.（4.01 ±1.92） d, P〈 0.05], and majority of the CTA positive patients suspected to suffer from PE with negative D-dimer had high risks of PE （P 〈0.01）.Compared with the non-PE group, the Wells score ≥4 points and the level of serum NT-proBNP significantly increased in the PE group （P 〈 0.01）.Logistic regression analysis revealed that dyspnea, high NT-proBNP level and Wells sore ≥ 4 points were risk factors for D-dimer negative PE.Conclusion Delayed treatment was the main cause of misdiagnosis of D-dimer negative PE.Dyspnea, high NT-proBNP level and Wells sore ≥4 points were risk factors for suspected PE patients with negative D-dimer, and these patients should be confirmed by pulmonary CTA.On the contrary, PE could be excluded if patients with D-dimer negative had no these risk factors.