4级肺栓塞临床概率评分对老年急性肺栓塞的预测价值研究

doi:10.12114/j.issn.1007-9572.2023.0511

摘要/Abstract

摘要： 背景老年人是发生急性肺栓塞（APE）的高危人群，而老年APE早期患者识别及诊断困难，积极寻找一种对老年疑似APE患者的最优预测方法，已成为必须面对的医学问题。目的探讨4级肺栓塞临床概率评分（4PEPS）在老年疑似APE患者中的预测价值。方法收集2017—2021年于遵义医科大学第三附属医院完成螺旋CT肺动脉造影（CTPA）检查的老年（年龄≥60岁）住院患者的基本信息及相关临床数据。参照2018年《肺血栓栓塞症诊治与预防指南》CTPA诊断肺栓塞标准，将研究对象分为APE组和非APE组。分别采用4PEPS、Standard算法、年龄校正的D-二聚体（AADD）算法、YEARS算法及PEGeD算法对研究对象进行APE预测，根据预测结果分为阳性组和阴性组，统计各预测方法的真阳性人数、真阴性人数、假阳性人数、假阴性人数。计算5种预测方法的效能评价指标并对其预测价值进行比较。结果 1 193例完成CTPA检查的老年住院患者中，男608例（50.96%），女585例（49.04%），中位年龄为74（68，81）岁，APE患者323例（27.07%），非APE患者870例（72.93%）；老年APE与非APE患者性别、年龄比较，差异无统计学意义（P>0.05）。4PEPS、AADD算法、Standard算法、YEARS算法及PEGeD算法预测老年疑似APE患者的灵敏度分别为95.05%、97.83%、98.76%、97.21%、97.83%，特异度分别为31.84%、18.16%、12.87%、22.41%、22.41%，正确率分别为48.95%、39.73%、36.13%、42.67%、42.83%，Youden指数分别为0.27、0.16、0.12、0.20、0.20。4PEPS、Standard算法、YEARS算法及PEGeD算法对比AADD算法的净重新分类指数（NRI）分别为0.218、-0.087、0.073、0.085，其中4PEPS对比AADD算法的NRI差异有统计学意义（P<0.05）。结论 4PEPS预测老年疑似APE患者的特异度、正确率、Youden指数较高，总体预测价值明显优于其余4种方法，可能是老年APE患者的最优预测方法。

关键词: 肺栓塞, 急性肺栓塞, 4级肺栓塞临床概率评分, 螺旋CT肺动脉造影, 老年人, 预测价值

Abstract:

Background

The elderly are at high risk for acute pulmonary embolism (APE) , and the difficulty of early identification and diagnosis of APE in the elderly has made the active search for an optimal prediction method for elderly patients with suspected APE a medical problem that must be faced.

Objective

To investigate the predictive value of the 4-level Clinical Pretest Probability Score (4PEPS) for pulmonary embolism (PE) in elderly patients with suspected APE.

Methods

Basic information and related clinical data were collected from elderly (age≥60 years) hospitalized patients who completed spiral CT pulmonary arteriography (CTPA) examinations in the Third Affiliated Hospital of Zunyi Medical University from 2017 to 2021. The study subjects were divided into the APE group and non-APE group according to the CTPA criteria for the diagnosis of PE in 2018 Guidelines for the Diagnosis, Treatment and Prevention of Pulmonary Thromboembolism. The 4PEPS, Standard algorithm, age-adjusted D-dimer (AADD) algorithm, YEARS algorithm and pulmonary embolism graduated D-dimer (PEGeD) algorithm were used to predict the APE of the study subjects, respectively, who were divided into the positive and negative groups, and the number of true positives, true negatives, false positives and false negatives of each prediction method was counted. The efficacy evaluation indexes of the five prediction method were calculated and their prediction values were compared.

Results

Among 1 193 elderly hospitalized patients who completed CTPA examination, 608 (50.96%) were male and 585 (49.04%) were female, with a median age of 74 (68, 81) years; 323 (27.07%) were APE patients and 870 (72.93%) were non-APE patients; there was no statistically significant difference between elderly APE patients and elderly non-APE patients in terms of gender and age (P>0.05) . 4PEPS, AADD algorithm, Standard algorithm, YEARS algorithm and PEGeD algorithm for elderly patients with suspected APE had a sensitivity of 95.05%, 97.83%, 98.76%, 97.21%, 97.83%, the specificity of 31.84%, 18.16%, 12.87%, 22.41%, 22.41%, the correctness of 48.95%, 39.73%, 36.13%, 42.67%, 42.83%, Youden index of 0.27, 0.16, 0.12, 0.20, 0.20. The net reclassification improvement (NRI) of 4PEPS, Standard algorithm, YEARS algorithm and PEGeD algorithm compared to AADD algorithm were 0.218, -0.087, 0.073, and 0.085, the difference of the NRI of 4PEPS compared to AADD algorithm was statistically significant (P<0.05) .

Conclusion

4PEPS predicts elderly patients with suspected APE with high specificity, correctness, and Youden index, and the overall predictive value is significantly better than the remaining four methods, which may be the optimal prediction method for elderly patients with APE.

Key words: Pulmonary embolism, Acute pulmonary embolism, 4-Level Clinical Pretest Probability Score, Computed tomography pulmonary angiogram, Aged, Predictive value

曾令聪,张龙举,周玲,等. 4级肺栓塞临床概率评分对老年急性肺栓塞的预测价值研究[J]. 中国全科医学, 2024, 27(09): 1062-1067. DOI: 10.12114/j.issn.1007-9572.2023.0511.
ZENG Lingcong,ZHANG Longju,ZHOU Ling, et al. Analysis of the Predictive Value of 4-level Clinical Pretest Probability Score in Elderly Patients with Acute Pulmonary Embolism[J]. Chinese General Practice, 2024, 27(09): 1062-1067. DOI: 10.12114/j.issn.1007-9572.2023.0511.

图/表 10

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项目	诊断标准	积分（分）
4PEPS	年龄
	<50岁	-2
	50~64岁	-1
	≥65岁	0
	慢性呼吸道疾病	-1
	心率<80次/min	-1
	胸痛和急性呼吸困难	1
	男性	2
	激素治疗	2
	静脉血栓栓塞史	2
	晕厥	2
	4周内制动史	2
	血氧饱和度<95%	3
	小腿疼痛和/或单侧下肢水肿	3
	PE为最可能的诊断	5
临床概率	非常低的临床预测概率：可直接排除PE	<0
	低临床预测概率：如果D-二聚体<1 000 ng/mL，则可以排除PE	0~5
	中度临床预测概率：如果患者<50岁且D-二聚体<500 ng/mL或患者年龄≥50岁且D-二聚体<年龄×10 ng/mL，则可以排除PE	6~12
	高临床预测概率：没有影像学检查不能排除PE	≥13

项目	诊断标准	积分（分）
4PEPS	年龄
	<50岁	-2
	50~64岁	-1
	≥65岁	0
	慢性呼吸道疾病	-1
	心率<80次/min	-1
	胸痛和急性呼吸困难	1
	男性	2
	激素治疗	2
	静脉血栓栓塞史	2
	晕厥	2
	4周内制动史	2
	血氧饱和度<95%	3
	小腿疼痛和/或单侧下肢水肿	3
	PE为最可能的诊断	5
临床概率	非常低的临床预测概率：可直接排除PE	<0
	低临床预测概率：如果D-二聚体<1 000 ng/mL，则可以排除PE	0~5
	中度临床预测概率：如果患者<50岁且D-二聚体<500 ng/mL或患者年龄≥50岁且D-二聚体<年龄×10 ng/mL，则可以排除PE	6~12
	高临床预测概率：没有影像学检查不能排除PE	≥13

项目	评分标准	得分（分）
Wells评分法	既往DVT或PE病史	1.5
	4周内手术或制动史	1.5
	肿瘤	1
	咯血	1
	心率>100次/min	1.5
	深静脉血栓的临床征象	3
	其他临床诊断的倾向性<PE	3
临床可能性	三分法
	低度风险	<2
	中度风险	2~6
	高度风险	>6
	二分法
	PE不可能	≤4
	PE可能	>4

项目	评分标准	得分（分）
Wells评分法	既往DVT或PE病史	1.5
	4周内手术或制动史	1.5
	肿瘤	1
	咯血	1
	心率>100次/min	1.5
	深静脉血栓的临床征象	3
	其他临床诊断的倾向性<PE	3
临床可能性	三分法
	低度风险	<2
	中度风险	2~6
	高度风险	>6
	二分法
	PE不可能	≤4
	PE可能	>4

组别	例数	性别[例（%）]		年龄[M（P₂₅，P₇₅），岁]
组别	例数	男	女	年龄[M（P₂₅，P₇₅），岁]
APE组	323	158（48.9）	165（51.1）	73（68，80）
非APE组	870	450（51.7）	420（48.3）	75（68，81）
χ²（Z）值		0.743		-1.172^a
P值		0.389		0.241