폐동맥색전증의 임상 진단은 부정확합니다. 진단을 확진하거나 배제하기에 충분한 증상 또는 징후가 없습니다. 그러므로 진단은 폐동맥색전증에 대한 validated risk assessment models을 사용하여 pretest probability를 결정함으로서 시작합니다.
TABLE 74-3
PREDICTION RULE FOR LIKELIHOOD OF PULMONARY EMBOLISM
Adapted from Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.
그러나 이것 단독적인 방법으로 진단해서는 안되며 D-dimer와 같은 검사와 결합하여 진단해야 합니다. 이 값이 정상이면 low to moderate pretest probability 폐동맥색전증 환자에서는 폐동맥색전증을 배제합니다. 만일 이 값이 양성이거나 pretest probability가 높다면 computed tomography pulmonary angiography (CTPA)로 확진합니다.
FIGURE 74-2
Clinical approach in patients with suspected deep vein thrombosis (DVT) or pulmonary embolism (PE).
CTPA = computed tomographic pulmonary angiogram; CUS = compression ultrasound; VTE = venous thromboembolism.
폐동맥색전증이 low-to-moderate likelihood인 경우는 영상 검사 없이 초기 D-dimer 검사를 시행하며, high clinical likelihood인 경우는 D-dimer 검사를 생략하고 영상검사를 시행합니다.
PTE 진단에서 ventilation perfustion scan의 역할
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Goldman-Cecil 26th edition Although CTPA has largely replaced lung scanning for the diagnosis of pulmonary embolism, the lung scan is the diagnostic test of choice for patients with renal impairment or a history of allergy to angiographic contrast media and for women younger than 40 years to reduce radiation exposure to the breasts. For the diagnosis of pulmonary embolism in pregnancy, lung scanning produces less maternal and fetal radiation exposure and is sometimes preferred over CTPA. However, the incremental value of a ventilation-perfusion scan is very low in patients with a nondiagnostic CTPA. |
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Harrison's Internal Medicine, 20th edition Lung scanning has become a second-line diagnostic test for PE, used mostly for patients who cannot tolerate intravenous contrast. |
PTE 진단에서 Interventional Contrast Pulmonary Angiography의 역할
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Goldman-Cecil 26th edition Because of its associated risks and because CTPA offers similar or better information, direct pulmonary angiography is rarely performed. |
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Harrison's Internal Medicine, 20th edition Chest CT with contrast (see above) has virtually replaced invasive pulmonary angiography as a diagnostic test. Invasive catheter-based diagnostic testing is reserved for patients with technically unsatisfactory chest CTs and for those in whom an interventional procedure such as catheter-directed thrombolysis is planned. |
UpToDate 2020.11.27
Low probability of PE인 경우 D-dimer 검사를 시행하여 D-dimer < 500 ng/mL인 경우 폐동맥색전증을 배제하고 D-dimer ≥ 500 ng/mL이면 CT pulmonary angiography를 시행하고 양성이면 PE 진단, 음성이면 PE 배제, 결론을 내지 못하면 ventilation-perfusion scanning을 시행합니다.
Evaluation of the nonpregnant adult with low probability of pulmonary embolism
High probability of PE인 경우 CT pulmonary angiography를 시행하고 양성이면 진단, 음성이면 배제하고 결론을 내지 못하면 ventilation perfusion을 시행합니다.
Evaluation of the nonpregnant adult with high probability of pulmonary embolism
REF. UpToDate 2020.11.27
Goldman-Cecil Internal Medicine, 26th edition
Harrison's Internal Medicine, 20th edition
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