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Prävalenz und Schwere der Lungenarterienembolie in Abhängigkeit von klinischen und paraklinischen Parametern

Analyse von 1943 konsekutiven Patienten mit CT-Pulmonalisangiographie

Prevalence and severity of pulmonary embolism are dependent on clinical and paraclinical parameters

Analysis of 1,943 consecutive patients with CT pulmonary angiography

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Zusammenfassung

Hintergrund

Die Lungenarterienembolie (LAE) hat eine heterogene Symptomatik. Altersadjustierte D‑Dimere und klinische Scores sollen helfen, die Diagnose zu stellen.

Methoden

Retrospektive Auswertung einer über fünf Kalenderjahre rekrutierten Kohorte von 1943 konsekutiven Patienten, welche bei positiven D‑Dimeren eine CT-Pulmonalisangiographie (CTPA) zum Nachweis einer LAE erhielten.

Ergebnisse

In der CTPA hatten n = 362 (19 %) eine Lungenarterienembolie. Die Prävalenz der LAE stieg stetig mit steigenden D‑Dimeren (Prävalenz LAE bei D‑Dimer Zehnerperzentilen: 3 %, 4 %, 7 %, 8 %, 8 %, 21 %, 20 %, 27 %, 37 %, 52 %; p < 0,001). D‑Dimere > 2,0 waren hochsignifikant assoziiert mit dem Vorliegen einer LAE (OR 7,17 95 % CI 5,27–9,76, p < 0,001). Thoraxbeschwerden und Tachypnoe zeigten keine Assoziation. Dyspnoe, Pleuritische Beschwerden und allgemeine Abgeschlagenheit zeigten signifikante Assoziationen mit einem Altersunterschied: Pleuritische Beschwerden waren bei jüngeren (< 76 Jahre) Patienten mit LAE häufiger als bei älteren (15 % vs. 3 %; p < 0,001) und hochsignifikant mit der LAE assoziiert (OR 4,99 95 % KI 2,83–8,81; p < 0,001). Allgemeine Abgeschlagenheit zeigte sich mehr bei älteren (> 76 Jahre) als bei jüngeren Patienten (44 % vs. 24 %; p < 0,001). LAE-Patienten mit D‑Dimeren > 6,0 mg/l waren hämodynamisch stärker kompromittiert als Patienten mit D‑Dimeren < 6,0 mg/l: Tachykardie 32 % vs. 20 %, p = 0,015; Rechtsherzbelastungszeichen im Echo: 38 % vs. 23 %, p = 0,003; Rechtsherzbelastungszeichen im EKG: 27 % vs. 13 %; p = 0,001; Reanimation 4 % vs. 0 %, p = 0,003; Lysenotwendigkeit 6 % vs. 1 %, p = 0,014.

Schlussfolgerung

Die Symptomatik von Patienten mit Lungenarterienembolie ist häufig vage, insbesondere bei älteren Patienten findet sich häufig allgemeine Abgeschlagenheit. Die absolute Höhe der D‑Dimere, insbesondere D‑Dimere > 2,0 mg/l, ist ein starker Prädiktor für das Vorliegen einer Lungenarterienembolie. D‑Dimere > 6,0 mg/l sind assoziiert mit stärkerer hämodynamischer Kompromittierung bei Patienten mit LAE.

Abstract

Background

Patients with pulmonary embolism (PE) have heterogeneous symptoms. Clinical scores and age-adjusted D‑dimer should help clinicians to establish the correct diagnosis.

Methods

A cohort of 1,943 consecutive patients with positive D‑dimer levels who were referred for CT pulmonary angiography (CTPA) over a period of 5 years to rule PE in or out were retrospectively analyzed.

Results

On CTPA n = 362 (19 %) had PE. The prevalence of PE increased stepwise with increasing D‑dimer levels (prevalence of PE with 10 percentiles of D‑dimers was: 3 %, 4 %, 7 %, 8 %, 8 %, 21 %, 20 %, 27 %, 37 %, 52 %; p < 0.001). D‑dimers > 2.0 were significantly associated with PE (OR 7.17 95 % CI 5.27–9.76, p < 0.001). Chest discomfort and tachypnea showed no association with PE. Dyspnoea, pleuritic pain, and general fatigue showed significant associations with age: pleuritic chest pain was more frequent in patients aged < 76 years than in patients aged > 76 years (15 % vs 3 %; p < 0.001) and was highly significantly associated with PE (OR 4.99 95 % CI 2.83–8.81; p < 0.001). General fatigue was more prevalent in patients aged > 76 years (44 % vs 24 %; p < 0.001). PE patients with D‑dimers > 6.0 mg/l were hemodynamically more compromised than patients with D‑dimers < 6.0 mg/l: tachycardia 32 % vs 20 %, p = 0.015; right ventricular strain on echocardiography: 38 % vs 23 %, p = 0.003; right ventricular strain on ECG: 27 % vs 13 %; p  = 0.001; resuscitation 4 % vs 0 %, p = 0.003; lytic therapy 6 % vs 1 %, p = 0.014.

Conclusion

The symptoms of PE patients are often vague. Particularly in older patients, fatigue may be the only symptom. The absolute level of D‑dimers, particularly > 2.0 mg/l, is a strong predictor of PE. A D‑dimer level > 6.0 mg/l is associated with more severe hemodynamic impairment in patients with PE.

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Authors and Affiliations

  1. Klinik für Innere Medizin und Intensivmedizin, Asklepios Kliniken Schildautal, Karl-Herold-Straße 1, 38723, Seesen, Deutschland

    P. Kocea,  H.-P. Volk, U. Eberle &  J. R. Ortlepp

  2. Medizinische Klinik I, Universitätsklinikum Aachen, RWTH Aachen, Aachen, Deutschland

    P. Kocea,  K. Mischke &  J. R. Ortlepp

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  1. P. Kocea
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  2. K. Mischke
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Correspondence to J. R. Ortlepp.

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P. Kocea, K. Mischke, H.-P. Volk, U. Eberle und J.R. Ortlepp geben an, dass kein Interessenkonflikt besteht.

Die Studie wurde durch die lokale Ethikkommission genehmigt. Es handelt sich um eine retrospektiv anonymisiert ausgewertete Studie nach Krankenakten. Ein Versuch an Menschen fand nicht statt. Die Deklaration von Helsinki wurde eingehalten.

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Der Beitrag entstand in folgender Einrichtung: Asklepios Kliniken Schildautal, Karl-Herold-Straße 1, 38723 Seesen.

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Tabelle 2 (ausführliche Version mit allen Parametern)

Univariate Assoziation einzelner Angaben, Symptome oder Befunde mit dem Nachweis eine LAE in der CT-Pulmonalisangiographie aller Patienten

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Kocea, P., Mischke, K., Volk, HP. et al. Prävalenz und Schwere der Lungenarterienembolie in Abhängigkeit von klinischen und paraklinischen Parametern. Med Klin Intensivmed Notfmed 112, 227–238 (2017). https://doi.org/10.1007/s00063-016-0144-1

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