本文選題：肺栓塞　切入點：Wells評分　出處：《濱州醫(yī)學院》2013年碩士論文

【摘要】：目的： 評價Wells評分和修正的Geneva評分對急性肺栓塞的預測價值,期望得到適合我國肺栓塞患者的量表,減少肺栓塞誤診、漏診率。 方法： 采用回顧性分析方法,連續(xù)收集我院疑似肺栓塞住院患者共168例,排除不符合標準的15例,有效病例共153例,最終經(jīng)肺動脈造影(CTPA)確診肺栓塞患者78例。排除標準：(1)患者意識不清,家屬不熟知病情,不能提供準確的臨床資料者；(2)近半年內(nèi)確診肺栓塞且王接受抗凝治療復查CTPA者；(3)有肝腎功能不全、造影劑過敏等CTPA檢查禁忌癥者。以CTPA作為診斷急性肺栓塞的“金標準”,應用受試者工作特征曲線(ROC curve)評價Wells評分、修正的Geneva評分對肺栓塞的診斷價值。 結(jié)果： 1. Wells評分對急性肺栓塞診斷的預測價值：153例疑診肺栓塞患者中,采用Wells評分臨床評估為低度、中度、高度可能肺栓塞者分別為14例、111例、28例,其中經(jīng)CTPA確診為肺栓塞者分別為0例、55例、23例,確診率分別為0.0%(0/14)、49.5%(55/111)、82.1%(23/28)；Wells評分中低度可能對急性肺栓塞診斷的陰性預測值為100.0%,Wells評分中高度可能對急性肺栓塞診斷的陽性預測值為82.1%。 2.修正的Geneva評分對急性肺栓塞診斷的預測價值：153例疑診肺栓塞患者中,采用修正的Geneva評分評估為低度、中度、高度可能肺栓塞者分別為48例、94例、11例,其中經(jīng)CTPA確診為肺栓塞者分別為16例、52例、10例,確診率分別為33.3%(16/48)、55.3%(52/94)、90.9%(10/11),修正的Geneva評分中低度可能對急性肺栓塞診斷的陰性預測值為66.7%,修正的Geneva評分中高度可能對急性肺栓塞診斷的陽性預測值為90.9%。 3. Wells評分ROC曲線下的面積為0.770(95%CI0.696-0.844),修正的Geneva評分ROC曲線下的面積為0.733(95%CI0.653-0.813)。根據(jù)二者95%可信區(qū)間存在交叉,可以判斷兩條ROC曲線下的面積尚無統(tǒng)計學差異。 4.Wells評分預測診斷急性肺栓塞最佳截止值(cut off直)為3.5分,靈敏度為76.9%,特異度為66.7%；修改的Geneva評分預測診斷急性肺栓塞最佳截止值為5.5分,靈敏度為60.33%,特異度為82.7%。 結(jié)論： Wells評分、修正的Geneva評分可以對急性肺栓塞做出較為準確的預測,兩者之間的預測價值相似,兩種評分結(jié)合可進一步提高臨床應用價值。對于疑診肺栓塞的診斷策略,首先進行臨床可能性評估,對于兩種評分低度可能者可以結(jié)合D-二聚體檢查,如D-二聚體正常,可較安全排除肺栓塞,CTPA是D-二聚體升高患者的二線檢查方法。兩種評分中、高度可能者CTPA為其一線的檢查方法。
[Abstract]:Objective:. To evaluate the predictive value of Wells score and modified Geneva score in patients with acute pulmonary embolism, we hope to obtain a suitable scale for patients with pulmonary embolism in China, and to reduce misdiagnosis and missed diagnosis rate of pulmonary embolism. Methods:. A total of 168 suspected patients with pulmonary embolism in our hospital were collected by retrospective analysis, 15 cases were excluded and 153 cases were effective. Finally, 78 patients with pulmonary embolism were diagnosed by pulmonary angiography (CTPA). The exclusion standard was 1: 1) the patients' consciousness was not clear, and the family members were not familiar with the condition. Those who could not provide accurate clinical data were diagnosed with pulmonary embolism within half a year and those who received anticoagulant therapy to check up CTPA (n = 3) had liver and kidney dysfunction. CTPA was used as the "gold standard" for the diagnosis of acute pulmonary embolism. The Wells score was evaluated by using the operating characteristic curve of the subjects. The modified Geneva score was used to evaluate the diagnostic value of pulmonary embolism. Results:. 1. The predictive value of Wells score in the diagnosis of acute pulmonary embolism; among 153 suspected pulmonary embolism patients, the clinical evaluation with Wells score was low, moderate, and highly probable pulmonary embolism was 14 cases or 28 cases, respectively. Among them, there were 0 cases of pulmonary embolism diagnosed by CTPA in 55 cases and 23 cases of pulmonary embolism, respectively. The diagnostic rate was 0 / 14 / 49.5% and 82.1% respectively. The negative predictive value of the lowest possible negative predictive value for the diagnosis of acute pulmonary embolism was 100.00.The positive predictive value of the highly probable positive predictive value for the diagnosis of acute pulmonary embolism was 82.1%. 2. The predictive value of modified Geneva score in the diagnosis of acute pulmonary embolism. Among 153 suspected pulmonary embolism patients, the revised Geneva score was used to evaluate the degree of pulmonary embolism as low, moderate and highly probable. Among them, there were 16 cases of pulmonary embolism diagnosed by CTPA and 10 cases of pulmonary embolism. The diagnostic rates were 33. 3 / 48 / 55.3and 52 / 94 / 90.910 / 11, respectively. The negative predictive value of the low degree of the revised Geneva score for the diagnosis of acute pulmonary embolism was 66. 7, and the positive predictive value of the highly probable positive predictive value of the modified Geneva score for the diagnosis of acute pulmonary embolism was 90.9. 3. The area under the ROC curve of Wells score is 0.770 ~ 95CI0.696-0.844, and the area under the modified ROC curve of Geneva score is 0.733 ~ 95CI0.653-0.8130.According to the fact that there is a cross between the two 95% confidence intervals, it can be concluded that there is no statistical difference in the area under the two ROC curves. The 4.Wells score predicted the best cut-off value for diagnosis of acute pulmonary embolism (cut off straight) was 3.5, the sensitivity was 76.9 and the specificity was 66.7.The modified Geneva score predicted the best cut-off value for the diagnosis of acute pulmonary embolism was 5.5 points, the sensitivity was 60.33 and the specificity was 82.7. Conclusion:. Wells score, modified Geneva score can make accurate prediction for acute pulmonary embolism, and the predictive value between them is similar. The combination of the two scores can further improve the clinical application value. First of all, the clinical possibility assessment was carried out. For those with low probability of scoring, they could be combined with D- dimer examination. If D- dimer is normal, it is safer to exclude that CTPA is a second line examination method in patients with elevated D- dimer. The highly probable CTPA is the first line inspection method.
【學位授予單位】：濱州醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2013
【分類號】：R563.5

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本文編號：1665647