2014欧洲肺栓塞指南在首诊中存在的疑虑

Doubt of 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism in the first diagnosis

目的 探讨2014欧洲版肺栓塞指南在提高肺栓塞（acute pulmonary embolism,APE）首诊检出率的价值。方法 用2014肺栓塞指南回顾楚雄彝族自治州医院2013年9月~2016年7月经CTA明确诊断为肺栓塞的115例住院患者的首诊情况,比较肺栓塞检出率。结果 （1）简化版（SPESI）与原始版（SPES）肺栓塞严重程度评分比较：低危组分别检出44例（38.26%）、66（Ⅰ级＋Ⅱ级）例（57.39%）。中低危组（Ⅲ级）分别检出61例（53.04%）、20例（17.39%）。中高危组（Ⅳ级）分别检出5例（4.34%）及16例（13.91%）。高危组（Ⅴ级）分别检出5例（4.34%）、13例（11.30%）。（2）简化版与原始版Wells评分比较：采用二级分类法,“可能肺栓塞”检出率分别为39.13%、20.00%;“不太可能肺栓塞”检出率分别为60.86%、80.00%。（3）简化版与原始版Geneva评分比较：采用二级分类法,“不太可能肺栓塞”检出率分别为63.47%、56.52%;“可能肺栓塞”检出率分别为36.52%、43.47%。采用三级分类法,“低可能性”检出率分别为29.56%、26.95%;“中度可能性”检出率分别为64.34%、66.08%;“高度可能性”检出率分别为6.08%、6.95%。结论 （1）SPESI可显著提高中低危（Ⅲ级）肺栓塞的检出率。（2）简化版Wells二级分类法可提高“可能肺栓塞”检出率。（3）与原始版Geneva比较：采用二级分类法,简化版Geneva对“可能肺栓塞”的检出率明显降低;采用三级分类法,二者无差异。（4）以牺牲敏感性及特异性为代价,为降低计算难度而删减评分项目不可取。

Objective To investigate the value of 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism in the detection rate of the first diagnosis of acute pulmonary embolism（APE）. Methods 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism was applied to review the first diagnosis of a total of 115 inpatients with pulmonary embolism who were clearly diagnosed by CTA from September 2013 to July 2016 in Chuxiong Hospital, and the detection rate of pulmonary embolism was compared. Results（1）SPESI was compared with the original version（SPES）： 44 cases（38.26%） and 66 cases（57.39%, grade Ⅰ＋Ⅱ） were detected in low risk group respectively. 61 cases（53.04%） and 20 cases（17.39%） were detected in middle and low risk group（grade Ⅲ）. 5 cases（4.34%） and 16 cases（13.91%） were detected in middle and high risk group（grade Ⅳ）. 5 cases（4.34%） and 13 cases（11.30%） were detected in high risk group（grade Ⅴ）.（2）The simplified version of Wells score was compared with the original version of Wells score： bifurcate classification was applied, and the detection rate of ＂possible pulmonary embolism＂ was 39.13% and 20.00% respectively. The detection rate of ＂unlikely pulmonary embolism＂ was 60.86% and80.00% respectively.（3）The simplified version of Geneva score was compared with the original version of Geneva score：bifurcate classification was applied, and the detection rate of ＂less likely pulmonary embolism＂ was 63.47% and 56.52%respectively; the detection rate of ＂possible pulmonary embolism＂ was 36.52% and 43.47% respectively. Trifurcate classification was applied, and the detection rate of ＂low probability＂ was 29.56% and 26.95% respectively; the detection rate of ＂moderate probability＂ was 64.34% and 66.08% respectively; the detection rate of ＂high probability＂ was6.08% and 6.95% respectively. Conclusion（1）SPESI can significantly improve the detection rate of pulmonary em bolism in middle and low risk（grade Ⅲ）.（2）Simplified Wells bifurcate classification can improve the detection rate of ＂possible pulmonary embolism＂.（3）Compared with the original Geneva： bifurcate classification is applied, and the detection rate of ＂possible pulmonary embolism＂ is significantly reduced by simplified Geneva; trifurcate classification is applied, and there is no difference between the two.（4）It is undesirable to delete the scoring items in order to reduce the calculation difficulty at the cost of sacrifice of sensitivity and specificity.