基于D-二聚体分层策略的急诊患者肺栓塞临床可能性评估新模型

A new assessment model for the clinical possibility of pulmonary embolism in emergency patients based on D-dimer stratification strategy

目的评价基于D-二聚体分层策略的肺栓塞临床可能性评估方法用于预测评估急诊患者肺栓塞的效果,探寻适合急诊科的肺栓塞临床可能性评估新模型。方法对徐州医科大学附属淮安医院急诊科诊治的262例疑似肺栓塞患者检测血浆D-二聚体水平,确定其最佳截断值并联合简化Wells评分、修订版Geneva评分进行分层评估并改良YEARS法,评价它们与YEARS评估法对肺栓塞的预测效能。采用CT肺动脉造影(CTPA)用于确诊肺栓塞。最后将预测效能最高的临床可能性评估方法与D-二聚体最佳截断值纳入logistic回归分析,建立Nomogram模型预测急诊患者疑似肺栓塞的临床可能性,并使用AUC、校准曲线验证模型效能。结果:在联合D-二聚体进行分层评估策略下,简化Wells评分、修订版Geneva评分及YEARS法、改良YEARS法的ROC曲线下面积依次为0.757、0.660、0.638及0.716;敏感度依次为94.25%、86.21%、97.7%及95.40%,特异度依次为49.14%、42.29%、22.29%及41.71%,准确率依次为64.12%、56.87%、47.33%及59.54%,差异有统计学意义(P<0.05)。Nomogram预测模型显示,模型有较好的预测能力。结论D-二聚体分层联合简化Wells评分对急诊患者肺栓塞的评估价值最高,适当提高YEARS法的D-二聚体分层界值进行评估,可提高YEARS法预测效能。新构建的Nomogram模型是预测评估急诊患者疑似肺栓塞实用且有价值的临床工具。

Objective To evaluate the clinical possibility assessment method of pulmonary embolism based on D dimer stratification strategy to predict and evaluate the efficacy of pulmonary embolism in emergency patients,and to explore a new model for clinical possibility assessment of pulmonary embolism suitable for emergency departments.Methods Plasma D-dimer level was detected in 262 patients with suspected pulmonary embolism diagnosed and treated in the emergency department of our hospital.The optimal cut-off value was determined and stratified with simplified Wells score and revised Geneva score,and the improved YEARS method was used to evaluate their efficacy in predicting pulmonary embolism.CT pulmonary artery angiography(CTPA)was used to confirm pulmonary embolism.Finally,logistic regression analysis was performed to establish a Nomogram model to predict the clinical possibility of suspected pulmonary embolism in emergency patients using the most efficient clinical possibility assessment method and the best D-dimer cut-off value,and AUC and calibration curves were used to verify the model.Results The areas under ROC curve of simplified Wells score,revised Geneva score,YEARS method and improved YEARS method were 0.757%,0.660%,0.63%8 and 0.716%,respectively,under the layered evaluation strategy with D-dimer.The sensitivity were 94.25%,86.21%,97.7%and 95.40%,the specificity was 49.14%,56.57%,22.29%and 41.71%,and the accuracy was 64.12,56.87,47.33%and 59.54%,respectively.The difference was statistically significant(P<0.05).Conclusion D-dimer stratification combined with simplified Wells score has the highest evaluation value for emergency patients with pulmonary embolism.Appropriately increasing the d-dimer stratification boundary value of YEARS method can improve the prediction efficiency of YEARS method.The newly constructed Nomogram model is a practical and valuable clinical tool to predict and evaluate suspected pulmonary embolism in emergency patients.