DOI QR코드

DOI QR Code

정상혈압 폐색전증에서 위험도 평가도구로서의 D-dimer의 역할

D-dimer as a Prognostic Tool in Patients with Normotensive Pulmonary Embolism

  • 윤재철 (전북대학교병원 응급의학과) ;
  • 김원영 (울산대학교 의과대학 서울아산병원 응급의학교실) ;
  • 최상식 (울산대학교 의과대학 서울아산병원 응급의학교실) ;
  • 정상구 (울산대학교 의과대학 서울아산병원 응급의학교실) ;
  • 손창환 (울산대학교 의과대학 서울아산병원 응급의학교실) ;
  • 김원 (울산대학교 의과대학 서울아산병원 응급의학교실) ;
  • 임경수 (울산대학교 의과대학 서울아산병원 응급의학교실) ;
  • 정태오 (전북대학교병원 응급의학과) ;
  • 진영호 (전북대학교병원 응급의학과) ;
  • 이재백 (전북대학교병원 응급의학과)
  • Yoon, Jae-Chol (Department of Emergency Medicine, Chonbuk National University Hospital) ;
  • Kim, Won-Young (Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Choi, Sang-Sik (Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Jung, Sang-Ku (Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Sohn, Chang-Hwan (Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Kim, Won (Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Lim, Kyoung-Soo (Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Jeong, Tae-O (Department of Emergency Medicine, Chonbuk National University Hospital) ;
  • Jin, Young-Ho (Department of Emergency Medicine, Chonbuk National University Hospital) ;
  • Lee, Jae-Baek (Department of Emergency Medicine, Chonbuk National University Hospital)
  • 투고 : 2009.12.07
  • 심사 : 2010.01.27
  • 발행 : 2010.02.28

초록

Background: D-dimer testing is widely applied as a first step in the diagnostic work-up of pulmonary embolism (PE). Although this is the most sensitive assay for ruling out PE, the prognostic implications of D-dimer testing in patients with normotensive PE are not well known. The aim of this study was to determine if D-dimer testing on admission predicts major adverse cardiac events (MACE) in patients with normotensive PE. Methods: A total of 180 consecutive patients with normotensive PE admitted between January 2003 and June 2009 were included. The group was divided into quartiles on the basis of their D-dimer levels. We compared the frequency of MACE by quartile of D-dimer level and estimated sensitivity, specificity, and predictive values for MACE in the first and fourth quartile. Results: In the 37 (20.6%) patients with MACEs, the median D-dimer level (7.94[IQR:4.03~18.17]${\mu}g/mL$) was higher than in patients with a benign course (5.29[IQR:2.60~11.52]${\mu}g/mL$, p<0.01). The occurrence of MACEs was increased with increasing D-dimer level (p=0.017). In the first quartile (D-Dimer <$2.76{\mu}g/mL$) sensitivity, specificity, and positive and negative predictive values for predicting MACEs were, respectively, 91.9%, 29.4%, 25.2%, and 93.3%. Conclusion: Patients with D-dimer levels below $2.76{\mu}g/mL$ have a low risk of MACEs. Our study suggest that D-dimer level may be used to identify low risk patients with normotensive PE.

키워드

참고문헌

  1. Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part II: risk stratification, treatment, and prevention. Circulation 2003;108:2834-8. https://doi.org/10.1161/01.CIR.0000098427.74047.42
  2. Kreit JW. The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism. Chest 2004;125:1539-45. https://doi.org/10.1378/chest.125.4.1539
  3. Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 2005;172:1041-6. https://doi.org/10.1164/rccm.200506-862OC
  4. Punukollu G, Gowda RM, Vasavada BC, Khan IA. Role of electrocardiography in identifying right ventricular dysfunction in acute pulmonary embolism. Am J Cardiol 2005;96:450-2. https://doi.org/10.1016/j.amjcard.2005.03.099
  5. Logeart D, Lecuyer L, Thabut G, Tabet JY, Tartiere JM, Chavelas C, et al. Biomarker-based strategy for screening right ventricular dysfunction in patients with nonmassive pulmonary embolism. Intensive Care Med 2007;33:286-92. https://doi.org/10.1007/s00134-006-0482-1
  6. Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation 2004;110:3276-80. https://doi.org/10.1161/01.CIR.0000147612.59751.4C
  7. Ghanima W, Abdelnoor M, Holmen LO, Nielssen BE, Ross S, Sandset PM. D-dimer level is associated with the extent of pulmonary embolism. Thromb Res 2006;120:281-8.
  8. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143-50. https://doi.org/10.1056/NEJMoa021274
  9. Galle C, Papazyan JP, Miron MJ, Slosman D, Bounameaux H, Perrier A. Prediction of pulmonary embolism extent by clinical findings, D-dimer level and deep vein thrombosis shown by ultrasound. Thromb Haemost 2001;86:1156-60.
  10. Klok FA, Djurabi RK, Nijkeuter M, Eikenboom HC, Leebeek FW, Kramer MH, et al. High D-dimer level is associated with increased 15-d and 3 months mortality through a more central localization of pulmonary emboli and serious comorbidity. Br J Haematol 2008;140: 218-22.
  11. Blamoun J, Alfakir M, Sedfawy AI, Moammar MQ, Maroules M, Khan MA, et al. The association of D-dimer levels with clinical outcomes in patients presenting with acute pulmonary embolism. Lab Hematol 2009;15: 4-9. https://doi.org/10.1532/LH96.08014
  12. Lobo JL, Zorrilla V, Aizpuru F, Grau E, Jimenez D, Palareti G, et al. D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE registry. J Thromb Haemost 2009;7:1795-801. https://doi.org/10.1111/j.1538-7836.2009.03576.x
  13. Grau E, Tenias JM, Soto MJ, Gutierrez MR, Lecumberri R, Perez JL, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: findings from the RIETE registry. Crit Care Med 2007;35:1937-41. https://doi.org/10.1097/01.CCM.0000277044.25556.93
  14. Kabbara R, Labarere J, Pernod G, Bosson JL. D-dimer level is not a prognostic biomarker specific of pulmonary embolism. Crit Care Med 2008;36:652-3; author reply 653.
  15. Bova C, Pesavento R, Marchiori A, Palla A, Enea I, Pengo V, et al. Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up. J Thromb Haemost 2009; 7:938-44. https://doi.org/10.1111/j.1538-7836.2009.03345.x
  16. Sohne M, Ten Wolde M, Buller HR. Biomarkers in pulmonary embolism. Curr Opin Cardiol 2004;19:558-62. https://doi.org/10.1097/01.hco.0000138991.82347.0e
  17. Aujesky D, Roy PM, Guy M, Cornuz J, Sanchez O, Perrier A. Prognostic value of D-dimer in patients with pulmonary embolism. Thromb Haemost 2006;96:478-82.
  18. Agterof MJ, van Bladel ER, Schutgens RE, Snijder RJ, Tromp EA, Prins MH, et al. Risk stratification of patients with pulmonary embolism based on pulse rate and D-dimer concentration. Thromb Haemost 2009;102:683-7.
  19. Vuilleumier N, Le Gal G, Verschuren F, Perrier A, Bounameaux H, Turck N, et al. Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study. J Thromb Haemost 2009;7:391-8. https://doi.org/10.1111/j.1538-7836.2008.03260.x
  20. Kucher N, Printzen G, Goldhaber SZ. Prognostic role of brain natriuretic peptide in acute pulmonary embolism. Circulation 2003;107:2545-7. https://doi.org/10.1161/01.CIR.0000074039.45523.BE
  21. Kline JA, Zeitouni R, Marchick MR, Hernandez-Nino J, Rose GA. Comparison of 8 biomarkers for prediction of right ventricular hypokinesis 6 months after submassive pulmonary embolism. Am Heart J 2008;156: 308-14. https://doi.org/10.1016/j.ahj.2008.03.026
  22. Vuilleumier N, Righini M, Perrier A, Rosset A, Turck N, Sanchez JC, et al. Correlation between cardiac biomarkers and right ventricular enlargement on chest CT in non massive pulmonary embolism. Thromb Res 2007;121:617-24.