目的: 回顾性分析肺动脉栓塞（pulmonary embolism,PE）患者确诊前的临床资料,探讨临床评估量表在PE诊断中的应用价值。方法: 纳入上海交通大学医学院附属瑞金医院呼吸科2011年6月至2016年6月及瑞金北院呼吸科2012年12月至2016年6月确诊的PE患者共78例,回顾性分析其临床资料,用Wells量表和修正Geneva量表及各自简化量表分别对患者进行临床评估,并分析、比较其诊断PE的价值。结果: ①用Wells量表对患者进行评分,其中低度PE可能性者为12例（15.38%）,中度PE可能性者55例（70.51%）,高度PE可能性者11例（14.10%）;②用修正Geneva量表进行评估,低度PE可能性者为16例（20.52%）,中度PE可能性者55例（70.51%）,高度PE可能性者7例（8.98%）;③用简化Wells量表进行评估,PE不可能组为26例（33.33%）,PE可能组为52例（66.67%）;④用简化Geneva量表二分类评分,PE不可能组为43例（55.13%）,PE可能组为35例（44.87%）;用简化Geneva量表三分类评分,低度PE可能性者为15例（19.23%）,中度PE可能性者58例（74.36%）,高度PE可能性者5例（1.28%）;⑤Wells量表与修正Geneva量表两者分值大部分都集中于中度和高度PE可能性分值区域,其比例分别为84.61%和79.49%,两者间差异无统计学意义（ P=0.482）;⑥Wells量表和简化Wells量表诊断78例PE患者的灵敏度分别为84.61%和66.67%,差异有统计学意义（P<0.01）。78例确诊PE的患者中,经简化Wells量表和简化Geneva量表（二分类、三分类）评估为PE的比例分别为66.67%、44.87%和75.64%,其中,简化Geneva量表二分类与简化Wells量表、简化Geneva三分类评估法间差异均有统计学意义（P<0.01）。结论: 在对PE临床可能性的评估中,Wells量表、修正Geneva量表及其简化量表预测风险评分越高,则诊断PE的灵敏度越高。Wells量表和修正Geneva量表评估PE的价值相似,而简化Geneva量表三分类法较二分类、简化Wells量表更能提高临床医师对PE的警惕性,降低漏诊率。
Objective: To analyze the clinical data of pulmonary embolism(PE) patients retrospectively for evaluating the performance of clinical scores(Wellsscore, revised Geneva scoreand their simplified versions) in assessing the probabi-lity of PE. Methods: A total of 78 patients diagnosed as PE and received treatment were recruited at Ruijin Hospital from June 2011 to June 2016 and at Ruijin Hospital North Branch from December 2012 to June 2016. All the patients were assessed by Wells score, revised Geneva score and simplified Wells score and simplified revised Geneva score, respectively. The performance of these scores were analyzed and compared. Results: For Wells score,15.38% patients had low clinical probability, 70.51% patients had moderate clinical probability and 14.10% patients had high clinical probability. By revised Geneva score, the percentages of low, moderate and high clinical probability were 20.52%, 70.51% and 8.98%, respectively. Bysimplified Wells score, the percentages of PE unlikely and PE likely were 33.33% and 66.67%, respectively. By simplifiedrevised Geneva score, the percentages of PE unlikely and PE likely were 55.13% and 44.87%, respectively; and the percentages of low, moderate and high probability were 19.23%, 74.36% and 1.28%, respectively, when the three levels scoring was used. Most patients had moderate or high clinical probability of PE when assessed by Wells score and revised Geneva score, with a percentage of moderate or high clinical probability of 84.61% and 79.49%, respectively; there was no significant difference in performance between Wells score and revised Geneva score (P=0.482). Among these 78 patients, the sensitivity of Wells score and simplified Wells score for PE were 84.61% and 66.67%, respectively(P<; 0.01). The percentages of PE patients diagnosed by simplified Wells score, simplified revised Geneva score-two levels scoring and simplified revised Geneva score-three levels scoring were 66.67%, 44.87% and 75.64%, respectively. The difference between the simplified revised Geneva score-two levels scoring and simplified revised Geneva score-three levels scoring was statistically significant(P<; 0.01). Significant difference was also found between simplified Wells score and simplified revised Geneva score-two levels scoring. Conclusions: For assessing the clinical probability of PE, the higher the clinical score, the higher the sensitivity of Wells score, revised Geneva score and simplified Wells score for diagnosing PE is. The Wells score has similar performance with revised Geneva score in diagnosing PE. Compared with simplified Geneva score-two level and simplied Wells score, Simplified revised Geneva score-three levels scoring could improve the vigilance of PE and decrease the rate of missed diagnosis.
[1] Won-Ho Choi, Sung Uk Kwon, Yoon Jung Jwa, et al.The pulmonary embolism severity index in predicting the prognosis of patients with pulmonary embolism[J]. Ko-rean J Intern Med,2009,24(2):123-127.
[2] Gibson NS, Sohne M, Kruip MJ, et al.Further validation and simplification of the Wells clinical decision rule in pulmonary embolism[J]. Thromb Haemost,2008,99(1):229-234.
[3] 熊国均, 齐向前. 临床评分、D-二聚体检测对急性肺栓塞的诊断价值[J]. 山东医药,2011,51(21):47-48.
[4] 叶艳平, 李艳彦, 陈谨, 等. Wells评分和修改的Geneva评分对急性肺栓塞的预测价值[J]. 中华内科杂志,2012,51(8):626-629.
[5] 吴本权, 张文先, 刘慧, 等. Wells量表和修正的Geneva 评分对肺栓塞的预测价值[J]. 中山大学学报,2009,30(4):477-480.
[6] Konstantinides SV, Torbicki A, Agnelli G, et al.2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism[J]. Eur Heart J,2014,35(43):3033-3069,3069a-3069k.
[7] Douma RA, Mos IC, Erkens PM, et al.Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study[J]. Ann Intern Med,2011,154(11):709-718.
[8] Klok FA, Mos IC, Nijkeuter M, et al.Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism[J]. Arch Intern Med,2008,168(19):2131-2136.
[9] 王辰. 肺栓塞[M]. 北京:人民卫生出版社,2003:267.
[10] Wärntges S, Konstantinides SV.Progress in the management of acute pulmonary embolism[J]. Curr Opin Pulm Med,2015,21(5):417-424.
[11] 中华医学会心血管病学分会肺血管病学组. 急性肺栓塞诊断与治疗中国专家共识[J]. 中华心血管病杂志,2016,44(3):197-209.
[12] Wong DD, Ramaseshan G, Mendelson RM.Comparison of the Wells and Revised Geneva Scores for the diagnosis of pulmonary embolism: an Australian experience[J]. Intern Med J,2011,41(3):258-263.
[13] Klok FA, Kruisman E, Spaan J, et al.Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism[J]. J Thromb Haemost,2008,6(1):40-44.
[14] Wells PS, Anderson DR, Rodger M, et al.Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer[J]. Thromb Haemost,2000,83(3):416-420.
[15] Wolf SJ, McCubbin TR, Feldhaus KM, et al. Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism[J]. Ann Emerg Med,2004,44(5):503-510.
[16] Tamariz LJ, Eng J, Segal JB, et al.Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review[J]. Am J Med,2004,117(9):676-684.
[17] Righini M, LE Gal G, Perrier A, et al.Clinical probability assessment of pulmonary embolism by the Wells' score: is the easiest the best?[J]. J Thromb Haemost,2006,4(3):702-704.
[18] Wicki J, Perneger TV, Junod AF, et al.Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score[J]. Arch Intern Med,2001,161(1):92-97.
[19] Le Gal G, Righini M, Roy PM, et al.Prediction of pulmonary embolism in the emergency department: the revised Geneva score[J]. Ann Intern Med,2006,144(3):165-171.
[20] Klok FA, Mos IC, Nijkeuter M, et al.Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism[J]. Arch Intern Med,2008,168(19):2131-2136.
[21] 陈艳丽, 牛聪颖, 刘兴利, 等. 急性肺栓塞265例心电图分析[J]. 中国老年学杂志,2012,32(11):104-105.
[22] 赵玉珂, 冯广华. Wells 评分与修正的 Geneva 评分对肺栓塞的预测价值研究[J]. 实用心脑肺血管病杂志,2014,22(10):19-22.
[23] 王建国, 朱力, 刘敏, 等. 三种急性肺栓塞评分预测价值比较分析[J]. 中国实用内科杂志,2009,29(4):322-324.
[24] 潘丽萍, 慈光胜, 宋宏, 等. 58例急性肺栓塞误诊分析[J]. 内科理论与实践,2016,11(4):250-251.
