Journal of the Korean Society of Radiology (대한영상의학회지)

The Korean Society of Radiology (대한영상의학회)
권호 표지

Use of CT Angiography in a Country with Low Pulmonary Embolism Prevalence: Correlation with Clinical Pretest Probability and D-dimer Values

폐색전증 빈도가 낮은 나라에서의 CT 혈관조영술: 임상예측확률과 D-dimer 값과의 상관 관계

  • Lee, Gee-Won (Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute) ;
  • Jeong, Yeon-Joo (Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute) ;
  • Kim, Kun-Il (Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Medical Research Institute) ;
  • Kim, Chang-Won (Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute) ;
  • Chung, Sung-Woon (Department of Cardiovascular and Thoracic Surgery, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute) ;
  • Kim, Yeong-Dae (Department of Cardiovascular and Thoracic Surgery, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute) ;
  • Song, Jong-Woon (Department of Radiology, Haeundae Paik Hospital, Inje University School of Medicine)
  • 이지원 (부산대학교병원 영상의학과) ;
  • 정연주 (부산대학교병원 영상의학과) ;
  • 김건일 (양산부산대학교병원 영상의학과) ;
  • 김창원 (부산대학교병원 영상의학과) ;
  • 정성운 (부산대학교병원 흉부외과) ;
  • 김영대 (부산대학교병원 흉부외과) ;
  • 송종운 (해운대백병원 영상의학과)
  • Published : 2011.05.01
⟨ Previous Next ⟩

Abstract

Purpose: To assess the use of CT angiography (CTA) in the diagnostic evaluation of pulmonary thromboembolism (PE) in a country with low PE prevalence and correlate the diagnostic performance of CTA with the clinical pretest probability and D-dimer values. Materials and Methods: The institutional review board approved this retrospective study. The observers reviewed all 660 CTAs and calculated the PE clot burden scores. The pretest probability of PE according to the Wells criteria and D-dimer values were calculated (clinical data were available for 371 of the 660 patients). We correlated the PE positivity rates of CTA and a PE clot burden score with the D-dimer values and pretest probability using Pearson's correlation coefficient. Results: Of the 371 patients whose clinical data were available, 122 (32.8%) had PEs. None of the patients with both a normal D-dimer value and a low clinical probability had a PE. PE positivity rates of CTA were correlated with clinical pretest probability (r = 0.164, p = 0.002) and D-dimer values (r = 0.361, p < 0.001). PE clot burden scores were correlated with D-dimer values (r = 0.296, p < 0.001). Conclusion: Although PE positivity rates of CTA in a country with low prevalence were higher than those in a country with a higher prevalence, approximately 30% of the yield still represents an overuse of CTA. CTA should be performed after the pretest probability has been assigned and if the result of a D-dimer assay is abnormal.

목적: 폐색전증의 빈도가 낮은 나라에서 급성 폐색전증을 진단하는 데 있어 CT 혈관조영술을 평가하고 임상예측확률과 D-dimer값과의 상관관계를 알아보기 위해 연구를 시행하였다. 대상과 방법: 2004년 10월에서 2008년 9월 사이에 3차 병원에서 시행된 총 660개의 CT 혈관조영술에서의 폐색전증을 검토하였다. 또한, 임상적 양상을 바탕으로 각 환자에서 Wells 기준에 따라 임상예측확률을 계산하였고 Ddimer값을 조사하였다. CT 혈관조영술에서의 폐색전증 양성확률과 폐색전증 clot burden score를 D-dimer 값과 임상예측확률과의 상관관계를 조사하였다. 결과: 임상 정보가 있었던 371명의 환자 중에서 122명(32.8%)이 폐색전증으로 진단되었다. D-dimer 값이 정상이고 낮은 임상예측확률을 가진 환자 중 아무도 폐색전증을 가지고 있지 않았다. CT 혈관조영술의 폐색전증 양성확률은 임상예측확률(r=0.164, p=0.002)과 D-dimer 값(r=0.361, p < 0.001)과 상관관계가 있었다. 폐색전증 clot burden score는 D-dimer 값과 상관관계가 있었다(r=0.296, p < 0.001). 결론: 폐색전증의 빈도가 낮은 나라에서 시행한 본 연구에서 비록 폐색전증 양성확률이 약 30%로 폐색전증의 빈도가 높은 나라에서보다 높았지만, 여전히 CT 혈관조영술이 과용되고 있는 것을 의미한다. 임상예측확률이 계산되고 D-dimer 값이 비정상적으로 나온 이후에 CT 혈관조영술을 시행해야 한다.

Keywords

References

  1. Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard JA, McLoud TC. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. Radiographics 2004;24:1219-1238 https://doi.org/10.1148/rg.245045008
  2. Quinn DA, Fogel RB, Smith CD, Laposata M, Taylor Thompson B, Johnson SM, et al. D-Dimers in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med 1999;159:1445-1449 https://doi.org/10.1164/ajrccm.159.5.9808094
  3. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990;263:2753-2759 https://doi.org/10.1001/jama.1990.03440200057023
  4. Turkstra F, Kuijer PM, van Beek EJ, Brandjes DP, ten Cate JW, Buller HR. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med 1997;126:775-781 https://doi.org/10.7326/0003-4819-126-10-199705150-00005
  5. Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med 2000;132:227-232 https://doi.org/10.7326/0003-4819-132-3-200002010-00009
  6. Shah AA, Davis SD, Gamsu G, Intriere L. Parenchymal and pleural findings in patients with and patients without acute pulmonary embolism detected at spiral CT. Radiology 1999;211:147-153 https://doi.org/10.1148/radiology.211.1.r99ap03147
  7. British thoracic society standards of care committee pulmonary embolism guideline development group. British thoracic society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470-483 https://doi.org/10.1136/thorax.58.6.470
  8. Schoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology 2004;230:329-337 https://doi.org/10.1148/radiol.2302021489
  9. Perrier A, Nendaz MR, Sarasin FP, Howarth N, Bounameaux H. Cost-effectiveness analysis of diagnostic strategies for suspected pulmonary embolism including helical computed tomography. Am J Respir Crit Care Med 2003;167:39-44 https://doi.org/10.1164/rccm.2106128
  10. van Erkel AR, van Rossum AB, Bloem JL, Kievit J, Pattynama PM. Spiral CT angiography for suspected pulmonary embolism: a cost-effectiveness analysis. Radiology 1996;201:29-36 https://doi.org/10.1148/radiology.201.1.8816516
  11. Paterson DI, Schwartzman K. Strategies incorporating spiral CT for the diagnosis of acute pulmonary embolism: a cost-effectiveness analysis. Chest 2001;119:1791-1800 https://doi.org/10.1378/chest.119.6.1791
  12. Giuntini C, Di Ricco G, Marini C, Melillo E, Palla A. Pulmonary embolism: epidemiology. Chest 1995;107:S3-S9 https://doi.org/10.1378/chest.107.1_Supplement.3S
  13. Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d'Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 2000;3:657-660
  14. Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997-1005 https://doi.org/10.7326/0003-4819-129-12-199812150-00002
  15. Riedel M. Diagnosing pulmonary embolism. Postgrad Med J 2004;80:309-319 https://doi.org/10.1136/pgmj.2003.007955
  16. Qanadli SD, El Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 2001;176:1415-1420 https://doi.org/10.2214/ajr.176.6.1761415
  17. Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991;151:933-938 https://doi.org/10.1001/archinte.1991.00400050081016
  18. Konstantinides S. Clinical practice. Acute pulmonary embolism. N Engl J Med 2008;359:2804-2813 https://doi.org/10.1056/NEJMcp0804570
  19. Lee S, Jeong H, In K, Yoo S, Kim S, Kim J, et al. Clinical characteristics of acute pulmonary thromboembolism in Korea. Int J Cardiol 2006; 108:84-88 https://doi.org/10.1016/j.ijcard.2005.05.032
  20. Kumasaka N, Sakuma M, Shirato K. Incidence of pulmonary thromboembolism in Japan. Jpn Circ J 1999;63:439-441 https://doi.org/10.1253/jcj.63.439
  21. Kitamukai O, Sakuma M, Takahashi T, Kagaya Y, Watanabe J, Shirato K. Incidence and characteristics of pulmonary thromboembolism in Japan 2000. Intern Med 2003;42:1090-1094 https://doi.org/10.2169/internalmedicine.42.1090
  22. Costantino MM, Randall G, Gosselin M, Brandt M, Spinning K, Vegas CD. CT angiography in the evaluation of acute pulmonary embolus. AJR Am J Roentgenol 2008;191:471-474 https://doi.org/10.2214/AJR.07.2552
  23. Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001;35:98-107
  24. Hochuli M, Duewell S, Frauchiger B. Quantitative D-dimer levels and the extent of venous thromboembolism in CT angiography and lower limb ultrasonography. Vasa 2007;36:267-274 https://doi.org/10.1024/0301-1526.36.4.267
  25. Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001;161:92-97 https://doi.org/10.1001/archinte.161.1.92
  26. Calisir C, Yavas US, Ozkan IR, Alatas F, Cevik A, Ergun N, et al. Performance of the Wells and Revised Geneva scores for predicting pulmonary embolism. Eur J Emerg Med 2009;16:49-52 https://doi.org/10.1097/MEJ.0b013e328304ae6d
  27. Chagnon I, Bounameaux H, Aujesky D, Roy PM, Gourdier AL, Cornuz J, et al. Comparision of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med 2002;113:269-275 https://doi.org/10.1016/S0002-9343(02)01212-3
  28. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent 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. Thromb Haemost 2000;83:416-420
  29. Douma RA, Gibson NS, Gerdes VE, Bu ¨ller HR, Wells PS, Perrier A, et al. Validity and clinical utility of the simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost 2009;101:197-200