摘要
目的新型冠状病毒(COVID-19)感染与肺血栓栓塞症(PTE)风险增加密切相关。尽管在普通人群中D-二聚体阴性已常规用于验前概率评分低度可能性人群PTE的排除诊断,但其在COVID-19患者中的诊断阈值及排除作用仍存在争议。本研究旨在初探COVID-19患者合并PTE比例以及D-二聚体阴性PTE比例、影响因素和临床特征。方法回顾性分析2022年11月至2023年2月于上海交通大学医学院附属瑞金医院呼吸与危重症医学科因COVID-19住院并行静脉血栓栓塞症(VTE)排查的103例患者资料。根据影像学结果分为非肺栓塞组和肺栓塞组,肺栓塞组进一步依据年龄校正的D-二聚体分为阴性组和阳性组,比较各组间临床资料及实验室指标,并对D-二聚体阴性组患者临床特征进行描述性分析。结果PTE发生比例为29.13%(30/103)。与非肺栓塞组相比,肺栓塞组新发下肢深静脉血栓形成比例、淋巴细胞计数、D-二聚体、前白蛋白、高敏肌钙蛋白I、CD4+T淋巴细胞计数更高(均P<0.05),而Padua评分、简化Wells评分、修订版Geneva评分及其余方面无统计学差异(均P>0.05)。ROC曲线分析显示:D-二聚体和前白蛋白对COVID-19患者合并PTE的诊断价值AUC分别为0.721(95%CI 0.554~0.888,P=0.007)和0.708(95%CI 0.579~0.836,P=0.012)。PTE患者中D-二聚体阴性比例为46.67%(14/30)。与阳性组相比,阴性组SpO_(2)/FiO_(2)更高,新型冠状病毒感染临床分型更重,新型冠状病毒核酸连续2次转阴时间更短,新发下肢深静脉血栓形成比例、白细胞计数、中性粒细胞计数、D-二聚体、IgM更低(均P<0.05),而其余方面无统计学差异(均P>0.05)。D-二聚体阴性PTE临床特征分析显示,单侧段及以下发生栓塞比例为50%,无双侧段以上或主干栓塞;无中高及高危PTE。结论临床医师需重视COVID-19感染并伴有呼吸困难主诉患者PTE的排查,D-二聚体阴性不能排除PTE,对于CTPA阴性或存在检查禁忌者可行V/Q SPECT/CT。
Objective Infection with the novel coronavirus(COVID-19)is closely associated with an increased risk of pulmonary thromboembolism(PTE).Although a negative D-dimer result is routinely used to exclude PTE diagnosis in low pretest probability populations in the general public,its diagnostic threshold and exclusionary role in COVID-19 patients remain controversial.This study aims to initially explore the proportion of COVID-19 patients with PTE,the proportion of D-dimer-negative PTE,the influencing factors,and clinical characteristics.Methods A retrospective analysis was conducted on the data of 103 patients who were hospitalized due to COVID-19 and underwent screening for venous thromboembolism(VTE)in the Department of Respiratory and Critical Care Medicine of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from November 2022 to February 2023.According to the imaging results,the patients were divided into the non-PTE group and the PTE group.The pulmonary embolism group was further divided into the negative group and the positive group based on age-adjusted D-dimer.The clinical data and laboratory indicators among the groups were compared,and a descriptive analysis of the clinical characteristics of patients in the D-dimer negative group was conducted.Results The incidence of PTE was 29.13%(30/103).Compared with the non-PTE group,the PTE group had higher rates of new-onset lower extremity deep vein thrombosis,lymphocyte count,D-dimer,prealbumin,high-sensitivity troponin I,and CD4+T lymphocyte count(all P<0.05),while no significant differences were observed in Padua score,simplified Wells score,revised Geneva score,or other parameters(all P>0.05).ROC curve analysis showed that the area under the curve(AUC)values for D-dimer and prealbumin in diagnosing COVID-19-associated PTE were 0.721(95%CI 0.554-0.888,P=0.007)and 0.708(95%CI 0.579-0.836,P=0.012).Among patients with PTE,the proportion of D-dimer-negative cases was 46.67%(14/30).Compared with the D-dimer-positive group,the D-dimer-negative group had higher SpO_(2)/FiO_(2)ratios,more severe clinical COVID-19 classifications,a shorter time to two consecutive negative COVID-19 nucleic acid tests,and lower rates of new-onset lower extremity deep vein thrombosis,white blood cell count,neutrophil count,D-dimer,and IgM levels(all P<0.05).No significant differences were found for other parameters(all P>0.05).Clinical characterization of D-dimer-negative PTE revealed that 50%of cases involved unilateral segmental or more distal embolism,with no bilateral,main pulmonary artery embolism,or intermediate-high/high risk PTE observed.Conclusion Clinicians should be vigilant in screening for PTE in COVID-19-infected patients presenting with dyspnea,as a negative D-dimer cannot rule out PTE.For patients with negative or contraindicated CTPA results,V/Q SPECT/CT may be considered as an alternative diagnostic approach.
作者
苏桐
刘晶
陈昶
程齐俭
张海琴
SU Tong;LIU Jing;CHEN Chang;CHENG Qijian;ZHANG Haiqin(Department of Respiratory and Critical Care Medicine,Ruijin Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200025,China;Department of Respiratory and Critical Care Medicine,Loujiang New City Hospital of Taicang city(Ruijin Hospital Taicang Branch),Taicang,Jiangsu 215400,China;Department of Thoracic Surgery,Shanghai Pulmonary Hospital,Shanghai 200433,China)
出处
《临床肺科杂志》
2025年第11期1644-1651,共8页
Journal of Clinical Pulmonary Medicine
基金
国家重点研发计划(2024YFC3044600)。
