Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism

被引:225
作者
van der Pol, Liselotte M. [1 ,2 ]
Tromeur, Cecile [11 ]
Bistervels, Ingrid M. [4 ,5 ]
Ni Ainle, Fionnuala [19 ,20 ]
van Bemmel, Thomas [6 ]
Bertoletti, Laurent [12 ]
Couturaud, Francis [11 ]
van Dooren, Yordi P. A. [7 ]
Elias, Antoine [13 ]
Faber, Laura M. [8 ]
Hofstee, Herman M. A. [3 ]
van der Hulle, Tom [1 ]
Kruip, Marieke J. H. A. [9 ]
Maignan, Maxime [14 ]
Mairuhu, Albert T. A. [2 ]
Middeldorp, Saskia [4 ]
Nijkeuter, Mathilde [10 ]
Roy, Pierre-Marie [15 ]
Sanchez, Olivier [16 ,17 ]
Schmidt, Jeannot [18 ]
ten Wolde, Marije [5 ]
Klok, Frederikus A. [1 ]
Huisman, Menno V. [1 ]
机构
[1] Leiden Univ, Med Ctr, Dept Thrombosis & Hemostasis, Rm C7-68g,Albinusdreef 2, NL-2300 RC Leiden, Netherlands
[2] Haga Teaching Hosp, Dept Internal Med, Houten, Netherlands
[3] Haaglanden Med Ctr, Dept Internal Med, The Hague, Netherlands
[4] Univ Amsterdam, Amsterdam Cardiovasc Sci, Amsterdam Univ Med Ctr, Dept Vasc Med, Amsterdam, Netherlands
[5] Flevo Hosp, Dept Internal Med, Almere, Netherlands
[6] Gelre Hosp, Dept Internal Med, Apeldoorn, Netherlands
[7] Groene Hart Hosp, Dept Pulmonol, Gouda, Netherlands
[8] Red Cross Hosp, Dept Internal Med, Beverwijk, Netherlands
[9] Erasmus MC, Dept Hematol, Rotterdam, Netherlands
[10] Univ Med Ctr Utrecht, Dept Internal Med, Utrecht, Netherlands
[11] Univ Brest, Grp Etud Thrombose Bretagne Occidentale, Dept Internal Med & Chest Dis, Brest Hosp Ctr,EA 3878,CIC 1412,INSERM, Brest, France
[12] Univ Jean Monnet, Ctr Hosp Univ CHU St Etienne, Equipe Dysfonct Vasc & Hemostase,Unite 1059, Serv Med Vasc & Therapeut,INSERM,CIC 1408, St Etienne, France
[13] St Musse Hosp, Dept Vasc Med, Toulon, France
[14] CHU Grenoble Alpes, Emergency Dept, Hypoxy Physiopathol Lab HP2, INSERM 1042, Grenoble, France
[15] Univ Angers, CHU Angers, Emergency Dept, Inst Mitovasc,UMR 6015,CNRS,UMR 1083,INSERM, Angers, France
[16] Univ Paris 05, Univ Sorbonne Paris Cite, Hop Europeen Georges Pompidou, Fac Med,AP HP,INSERM,UMR S 1140,Dept Pulm Dis, Paris, France
[17] Univ Paris 05, Univ Sorbonne Paris Cite, Hop Europeen Georges Pompidou, Fac Med,AP HP,INSERM,UMR S 1140,Intens Care Unit, Paris, France
[18] CHU Clermont Ferrand, Emergency Dept, Clermont Ferrand, France
[19] Univ Coll Dublin, Sch Med, Dublin, Ireland
[20] Rotunda Hosp Dublin, INViTE Network, Dept Haematol, Dublin, Ireland
关键词
D-DIMER; VENOUS THROMBOEMBOLISM; CLINICAL PROBABILITY; DECISION RULE; WELLS RULE; MANAGEMENT; POSTPARTUM; GUIDELINES;
D O I
10.1056/NEJMoa1813865
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background Pulmonary embolism is one of the leading causes of maternal death in the Western world. Because of the low specificity and sensitivity of the d-dimer test, all pregnant women with suspected pulmonary embolism undergo computed tomographic (CT) pulmonary angiography or ventilation-perfusion scanning, both of which involve radiation exposure to the mother and fetus. Whether a pregnancy-adapted algorithm could be used to safely avoid diagnostic imaging in pregnant women with suspected pulmonary embolism is unknown. Methods In a prospective study involving pregnant women with suspected pulmonary embolism, we assessed three criteria from the YEARS algorithm (clinical signs of deep-vein thrombosis, hemoptysis, and pulmonary embolism as the most likely diagnosis) and measured the d-dimer level. Pulmonary embolism was ruled out if none of the three criteria were met and the d-dimer level was less than 1000 ng per milliliter or if one or more of the three criteria were met and the d-dimer level was less than 500 ng per milliliter. Adaptation of the YEARS algorithm for pregnant women involved compression ultrasonography for women with symptoms of deep-vein thrombosis; if the results were positive (i.e., a clot was present), CT pulmonary angiography was not performed. All patients in whom pulmonary embolism had not been ruled out underwent CT pulmonary angiography. The primary outcome was the incidence of venous thromboembolism at 3 months. The secondary outcome was the proportion of patients in whom CT pulmonary angiography was not indicated to safely rule out pulmonary embolism. Results A total of 510 women were screened, of whom 12 (2.4%) were excluded. Pulmonary embolism was diagnosed in 20 patients (4.0%) at baseline. During follow-up, popliteal deep-vein thrombosis was diagnosed in 1 patient (0.21%; 95% confidence interval [CI], 0.04 to 1.2); no patient had pulmonary embolism. CT pulmonary angiography was not indicated, and thus was avoided, in 195 patients (39%; 95% CI, 35 to 44). The efficiency of the algorithm was highest during the first trimester of pregnancy and lowest during the third trimester; CT pulmonary angiography was avoided in 65% of patients who began the study in the first trimester and in 32% who began the study in the third trimester. Conclusions Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy. CT pulmonary angiography was avoided in 32 to 65% of patients.
引用
收藏
页码:1139 / 1149
页数:11
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