Wells评分和修正的Geneva评分对肺栓塞的预测价值

发布时间：2018-03-26 01:04

本文选题：肺栓塞　切入点：Wells评分　出处：《滨州医学院》2013年硕士论文

【摘要】：目的：评价Wells评分和修正的Geneva评分对急性肺栓塞的预测价值,期望得到适合我国肺栓塞患者的量表,减少肺栓塞误诊、漏诊率。方法：采用回顾性分析方法,连续收集我院疑似肺栓塞住院患者共168例,排除不符合标准的15例,有效病例共153例,最终经肺动脉造影(CTPA)确诊肺栓塞患者78例。排除标准：(1)患者意识不清,家属不熟知病情,不能提供准确的临床资料者；(2)近半年内确诊肺栓塞且王接受抗凝治疗复查CTPA者；(3)有肝肾功能不全、造影剂过敏等CTPA检查禁忌症者。以CTPA作为诊断急性肺栓塞的“金标准”,应用受试者工作特征曲线(ROC curve)评价Wells评分、修正的Geneva评分对肺栓塞的诊断价值。结果： 1. Wells评分对急性肺栓塞诊断的预测价值：153例疑诊肺栓塞患者中,采用Wells评分临床评估为低度、中度、高度可能肺栓塞者分别为14例、111例、28例,其中经CTPA确诊为肺栓塞者分别为0例、55例、23例,确诊率分别为0.0%(0/14)、49.5%(55/111)、82.1%(23/28)；Wells评分中低度可能对急性肺栓塞诊断的阴性预测值为100.0%,Wells评分中高度可能对急性肺栓塞诊断的阳性预测值为82.1%。 2.修正的Geneva评分对急性肺栓塞诊断的预测价值：153例疑诊肺栓塞患者中,采用修正的Geneva评分评估为低度、中度、高度可能肺栓塞者分别为48例、94例、11例,其中经CTPA确诊为肺栓塞者分别为16例、52例、10例,确诊率分别为33.3%(16/48)、55.3%(52/94)、90.9%(10/11),修正的Geneva评分中低度可能对急性肺栓塞诊断的阴性预测值为66.7%,修正的Geneva评分中高度可能对急性肺栓塞诊断的阳性预测值为90.9%。 3. Wells评分ROC曲线下的面积为0.770(95%CI0.696-0.844),修正的Geneva评分ROC曲线下的面积为0.733(95%CI0.653-0.813)。根据二者95%可信区间存在交叉,可以判断两条ROC曲线下的面积尚无统计学差异。 4.Wells评分预测诊断急性肺栓塞最佳截止值(cut off直)为3.5分,灵敏度为76.9%,特异度为66.7%；修改的Geneva评分预测诊断急性肺栓塞最佳截止值为5.5分,灵敏度为60.33%,特异度为82.7%。结论： Wells评分、修正的Geneva评分可以对急性肺栓塞做出较为准确的预测,两者之间的预测价值相似,两种评分结合可进一步提高临床应用价值。对于疑诊肺栓塞的诊断策略,首先进行临床可能性评估,对于两种评分低度可能者可以结合D-二聚体检查,如D-二聚体正常,可较安全排除肺栓塞,CTPA是D-二聚体升高患者的二线检查方法。两种评分中、高度可能者CTPA为其一线的检查方法。
[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.
【学位授予单位】：滨州医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R563.5

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