摘要
目的 探讨血浆D-二聚体在急诊科区分急性心肌梗死（AMI）、急性肺栓塞（APE）、急性主动脉夹层（AAD）引起的致命性胸痛的效能.方法 回顾性分析2011年1月至2012年1月主因胸（背）痛和/或呼吸困难就诊于北京大学第三医院急诊科,最终确诊为AMI、APE或AAD的445例患者的临床资料,评估各组患者入急诊科后的D-二聚体水平.绘制受试者工作特征曲线（ROC曲线）,评价不同D-二聚体值判别AMI及非ST段抬高型心肌梗死（NSTEMI）的效果.结果 最终共纳入438例患者,其中AMI 327例[包括ST段抬高型心肌梗死（STEMI）253例,NSTEMI 74例],APE 76例,AAD 35例.AMI组D-二聚体水平[0.21（0.15,0.33） mg/L]明显低于APE组[1.06（0.86,3.01） mg/L,Z=-11.416,P＜0.001]、AAD组[1.79（0.83,3.37） mg/L,Z＝-8.715,P＜0.001]、APE/AAD组[1.15 （0.85,3.13） mg/L,Z＝-13.509,P＜0.001].STEMI组D-二聚体水平明显低于NSTEMI组[mg/L：0.20（0.15,0.30）比0.24（0.17,0.54）,Z＝-3.248,P=0.001].D-二聚体区分APE/AAD、判别AMI效果的ROC曲线下面积为0.929±0.015,最佳截断值为0.535 mg/L;当D-二聚体＜0.535 mg/L时,敏感度86.2％,特异度93.7％,阳性预测值97.6％,阴性预测值69.8％,阳性似然比13.68,阴性似然比0.15;当D-二聚体＜ 0.5 mg/L时,敏感度84.4％,特异度93.7％,阳性预测值97.5％,阴性预测值67.1％,阳性似然比13.40,阴性似然比0.17.D-二聚体区分APE/AAD、判别NSTEMI效果的ROC曲线下面积为0.881±0.028；当D-二聚体＜0.535 mg/L时,敏感度75.7％,特异度93.7％,阳性预测值88.9％,阴性预测值85.2％；当D-二聚体＜0.5 mg/L时,敏感度70.3％,特异度93.7％,阳性预测值88.1％,阴性预测值82.5％.结论 D-二聚体可作为急诊科区分AMI和APE/AAD的较好指标,从而指导临床医师选择进一步的检查和治疗,以提高诊断治疗效率.
Objective To investigate the role of plasma D-dimer in differentiating fatal chest pain due either to acute myocardial infarction （AMI）,acute pulmonary embolism （APE） or acute aortic dissection （AAD） in emergency department.Methods The data of a total of 445 consecutive patients complaining chest （back） pain and/or dyspnea who visited emergency department of Peking University Third Hospital from January 2011 to January 2012 were retrospectively analyzed.All cases were either diagnosed as AMI,APE or AAD finally.D-dimer concentrations were assessed and compared among different groups.The receiver operating characteristic curve （ROC curve） was established.The potency of D-dimer in distinguishing AMI,non-ST-segment elevation myocardial infarction （NSTEMI） by difference in values was assessed.Results Finally,438 cases were enrolled,including 327 AMI [253 ST-segment elevation myocardial infarction （STEMI） and 74 NSTEMI],76 APE and 35 AAD cases.The D-dimer concentrations in AMI group [0.21（0.15,0.33） mg/L] were significantly lower than those in APE group [1.06 （0.86,3.01） mg/L,Z=-11.416,P＜0.001],AAD group [1.79 （0.83,3.37） mg/L,Z＝-8.715,P＜0.001],APE/AAD group [1.15 （0.85,3.13） mg/L,Z＝-13.509,P＜0.001].The D-dimer concentrations in STEMI group were significantly lower than those in NSTEMI group [mg/L：0.20 （0.15,0.30） vs.0.24 （0.17,0.54）,Z=-3.248,P=0.001].The area under ROC curve（AUC） to discriminate AMI from APE/AAD was 0.929 ± 0.015,and optimal value was 0.535 mg/L.Sensitivity,specificity,positive predictive value （PPV）,negative predictive value （NPV）,positive likelihood ratio （PLR）,negative likelihood ratio （NLR） with cut-off value of 0.535 mg/L were 86.2％,93.7％,97.6％,69.8％,13.68,0.15,while sensitivity,specificity,PPV,NPV,PLR,NLR with cut-off value of 0.5 mg/L were 84.4％,93.7％,97.5％,67.1％,13.40,0.17.The AUC to discriminate NSTEMI from APE/AAD was 0.881 ± 0.028.Sensitivity,specificity,PPV,NPV with cut-off value of 0.535 mg/L were 75.7％,93.7％,88.9％,85.2％,while sensitivity,specificity,PPV,NPV with cut-off value of 0.5 mg/L were 70.3％,93.7％,88.1％,82.5％,respectively.Conclusion D-dimer is a better index in differentiating AMI from APE/AAD in emergency setting,guiding further examination and therapy,and increasing diagnosis efficiency.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2013年第11期655-659,共5页
Chinese Critical Care Medicine
基金
北京市科委科技计划项目（Z131107002213114）
关键词
急性心肌梗死
急性主动脉夹层
急性肺栓塞
D-二聚体
Acute myocardial infarction
Acute aortic dissection
Acute pulmonary embolism
D-dimer
