主动脉夹层风险评分在急性主动脉综合征诊断中的应用价值：附342例急性胸痛患者的病例分析

Application value of aortic dissection detection risk score in diagnosis of acute aortic syndromes： analysis of 342 patients with acute chest pain enclosed

目的 探讨主动脉夹层风险评分在急性主动脉综合征（AAS）诊断中的价值.方法 选择2013年1月至2016年4月厦门大学附属第一医院急诊科接诊的急性胸背痛患者342例,最后确诊为AAS患者71例（AAS组）和非AAS患者271例（非AAS组）.根据主动脉夹层风险评分将患者分为低危（主动脉夹层风险评分≤1分）和高危（主动脉夹层风险评分＆gt;1分）两个亚组.观察两组主动脉夹层风险指标及不同风险评分的患者比例;绘制受试者工作特征曲线（ROC曲线）,评估主动脉夹层风险评分诊断AAS的价值.结果 与非AAS组比较,AAS组高危疼痛特征风险指标如突发性疼痛和撕裂样痛比例明显增高〔83.1%（59/71）比31.0%（84/271）,29.6%（21/71）比0（0/271）〕,而AAS组高危体检特征风险指标如四肢收缩压差异和局限性神经功能缺损的患者比例也均明显增加〔23.9%（17/71）比0（0/271）,11.3%（8/71）比0（0/271）,均P＆lt;0.05〕;AAS组高危评分患者比例也明显多于非AAS组〔66.2%（47/71）比1.5%（4/271）,P＆lt;0.01〕.ROC曲线分析显示：主动脉夹层风险评分≥1分对诊断AAS的敏感度以及ROC曲线下面积（AUC）均高于主动脉夹层风险评分≥2分者（敏感度为98.6%比66.2%,AUC为0.819比0.564）,而主动脉夹层风险评分≥2分对诊断AAS的特异度和阳性预测值均高于主动脉夹层风险评分≥1分（分别为98.5%比59.8%,92.2%比39.1%）.主动脉夹层风险评分≥1分的优势比（OR）=104.0,95%可信区间（95%CI）为0.761-0.877,P=0.000;主动脉夹层风险评分≥2分的OR=130.7,95%CI为0.516-0.612,P=0.003.结论 主动脉夹层风险评分对诊断AAS有较高的敏感度,当主动脉夹层风险评分为高危时（〉1分）,对诊断AAS的特异度高,对协助早期诊断AAS有重要价值.

Objective To investigate the value of aortic dissection detection （ADD） risk score in the diagnosis of acute aortic syndromes （AAS）. Methods Three hundred and forty-two patients with acute chest pain or back pain admitted to the Department of Emergency of the First Affiliated Hospital of Xiamen University from January 2013 to April 2016 were enrolled. At last, 71 patients were definitely diagnosed as AAS （AAS group）, and 271 cases were diagnosed as non-AAS （non-AAS group）. Furthermore, according to the ADD risk score, they were subdivided into two groups： low-risk （ADD score ≤ 1） and high risk （ADD score ＆gt;1） subgroups. In the two groups, the ADD risk indexes and the proportions of patients with different risk scores were observed; the receiver operating characteristic curve （ROC curve） was drawn to evaluate the value of ADD risk score for diagnosing AAS. Results Compared with the non-AAS group, the proportions of patients in AAS group with indicators of high-risk pain characteristics, such as sudden pain and laceration-like pain were increased significantly [83.1% （59/71） vs. 31.0% （84/271）, 29.6% （21/71） vs. 0 （0/271）];meanwhile, the proportions of patients with high-risk physical examination indicators, such as systolic blood pressure differences among the 4 extremities and the defect of local nerve function in AAS group were also significantly increased [23.9% （17/71） vs. 0 （0/271）, 11.3% （8/71） vs. 0 （0/271）, both P ＆lt; 0.05]; the proportion of patients with high risk AAS score in AAS group was higher than that in the non-AAS group [66.2% （47/71） vs. 1.5% （4/271）, P 〈 0.01]. The sensitivity of ADD score ≥ 1 for diagnosis of AAS and area under ROC curve （AUC） were all higher than those of ADD score ≥2 （sensitivity： 98.6% vs. 66.2%, AUC： 0.819 vs. 0.564）, moreover, the specificity and the positive predictive value of ADD score ≥ 2 for diagnosis of AAS were higher than those of ADD score ≥ 1 （98.5% vs. 59.8%, 92.2% vs. 39.1%respectively）. When the ADD risk score ≥ 1, its odds ratio （OR） = 104.0, 95% confidence interval （CI） was 0.761-0.877, P = 0.000; while ADD risk score ≥ 2, OR = 130.7, 95%CI was 0.516-0.612, P = 0.003. Conclusion It is shown that when ADD risk score （〉 1） is used to diagnose AAS, it has relatively high sensitivity, when ADD score being high risk （〉 1 score） is applied to diagnose AAS, its specificity is high, thus ADD risk score has important value in helping the early diagnosis of AAS.