Cilj istraživanja: utvrditi korelaciju kliničke vjerojatnosti (Wellsov bodovni sustav) i vrijednosti D-dimera s MSCT plućnom angiografijom i njezinu opravdanost u hitnoj službi
Nacrt studije: ova case control studija provedena je u OHBP-u Kliničke bolnice „Sveti Duh“ u razdoblju od siječnja do kraja prosinca 2019. godine.
Ispitanici i metode: u ispitivanom vremenskom razdoblju od godinu dana u OHBP-u (internističke ambulante) KB „Sveti Duh“ pregledano je 22 252 bolesnika. Na temelju kliničke slike, Wellsovog skora i povišenih vrijednosti D-dimera postavljena je sumnja na PE u 305 bolesnika. Kod 149 dijagnoza PE je potvrđena MSCT plućnom angiografijom, dok je kod preostalih 156 bolesnika ona isključena. Nakon uzimanja anamnestičkih podataka i fizikalnog pregleda bilježili smo vitalne pokazatelje (frekvenciju disanja, srčanu frekvenciju i zasićenost krvi kisikom na periferiji) i Wellsov bodovni skor (procijena kliničke vjerojatnosti) te su uzeti uzorci krvi za laboratorijsku analizu (D-dimeri, troponin, BNP). Na temelju prikupljenih informacija bolesnici su upućeni na MSCT plućnu angiografiju, čime je dijagnoza plućne embolije potvrđena ili isključena.
Rezultati: u 149 bolesnika u hitnoj službi KB „Sveti Duh“ postavljena je dijagnoza PE što je učestalost od 0,7%. Većina bolesnika (>80%) bila je starija od 60 godina te je oko 60% bolesnika bilo ženskog spola. Za Wellsov skor, D-dimere, troponin, frekvenciju disanja i SpO2 nađene su statistički značajne razlike između skupina bolesnika kojima je potvrđena, odnosno isključena dijagnoza PE (p70% bolesnika s masivnom plućnom embolijom nađena je i DVT donjih ekstremiteta. Kod 75% bolesnika s jašućim embolusom nije potvrđena DVT donjih ekstremiteta, čime pretpostavljamo porijeklo embolusa iz zdjeličnih vena (izostanak potvrde DVT zdjeličnih vena čini ograničenje našeg istraživanja). S obzirom da je u 48,85% bolesnika (149/305) MSCT plućnom angiografijom potvrđena dijagnoza PE mišljenja smo da je njezina primjena opravdana u hitnoj službi.
Zaključak: niski stupanj kliničke vjerojatnosti (Wellsov bodovni sustav) zajedno s normalnom koncentracijom D-dimera sigurna je strategija u isključenju dijagnoze PE. Kako PE zbog raznolike i nespecifične kliničke slike može proći neprepoznato, Wellsov skor i D-dimeri čine važan dijagnostički algoritam u ranom prepoznavanju i dijagnosticiranju PE. Bolesnici niskog rizika (Wellsov skor) i s normalnom koncentracijom D-dimera ne trebaju antikoagulantnu terapiju, dok se bolesnici niskog rizika, ali s potvrđenom dijagnozom PE mogu i ambulantno liječiti, što je u skladu s trenutno važećim smjernicama. MSCT plućna angiografija predstavlja dijagnostički zlatni standard, a prema rezultatima našeg istraživanja njezina je primjena u hitnoj službi opravdana kod kliničke sumnje na plućnu emboliju.Research goal: to determine the correlation of clinical probability (Wells scoring system) and D-dimer values with MSCT pulmonary angiography and its justification in the emergency department
Draft study: this case control study was conducted at the ED of the Clinical Hospital "Sveti Duh" in the period from January to the end of December 2019.
Subjects and methods: In the study period of one year, 22 252 patients were examined in the ED (internal medicine clinic) of the Clinical Hospital "Sveti Duh". Based on the clinical presentation, Wells score, and elevated D-dimer values, PE was suspected in 305 patients. In 149 of them, the diagnosis of PE was confirmed by MSCT pulmonary angiography, while in the remaining 156 patients it was excluded. After taking anamnestic data and physical examination, we recorded vital signs (respiratory rate, heart rate and peripheral oxygen saturation) and Wells score (clinical probability assessment) and blood samples were taken for laboratory analysis (D-dimers, troponin, BNP). Based on the information collected, patients were referred for MSCT pulmonary angiography, thus confirming or excluding the diagnosis of pulmonary embolism.
Results: 149 patients in the emergency department of KB "Sveti Duh" were diagnosed with PE, which has an incidence of 0.7%. The majority of patients (> 80%) were older than 60 years and about 60% of patients were female. For the Wells score, D-dimers, troponin, respiratory rate and SpO2, statistically significant differences were found between the groups of patients whose diagnosis of PE was confirmed or excluded (p 70% of patients with massive pulmonary embolism. In 75% of patients with riding embolism, DVT of the lower extremities was not confirmed, suggesting the origin of embolism from the pelvic veins (the absence of confirmation of DVT of the pelvic veins is a limitation of our study). Given that in 48.85% of patients (149/305) MSCT pulmonary angiography confirmed the diagnosis of PE, we are of the opinion that its use is justified in the emergency department.
Conclusion: a low degree of clinical probability (Wells scoring system) along with a normal D-dimer concentration is a safe strategy in excluding the diagnosis of PE. As PE may go unrecognized due to its diverse and nonspecific clinical picture, Wells score and D-dimers constitute an important diagnostic algorithm in the early detection and diagnosis of PE. Low-risk patients (Wells score) and with normal D-dimer concentrations do not need anticoagulant therapy, while low-risk patients with a confirmed diagnosis of PE can be treated on an outpatient basis, which is in line with current guidelines. MSCT pulmonary angiography is the diagnostic gold standard, and according to the results of our research, its use in the emergency department is justified in case of clinical suspicion of pulmonary embolism
