老年肺栓塞早期诊断延误的影响因素研究

摘要

目的 探讨老年肺栓塞早期诊断延误的影响因素.方法 选取2012年1月—2016年7月阜阳市人民医院收治的老年肺栓塞患者130例.根据患者入院后首次诊断是否考虑肺栓塞及是否进行相应检查,将纳入的所有患者分为早期诊断组(n=68)和早期延误组(n=62).比较两组患者临床资料,采用多因素Logistic回归分析探讨老年肺栓塞早期诊断延误的影响因素.结果 老年患者肺栓塞早期诊断延误率为47.7%(62/130).早期延误组患者年龄,首发症状为胸痛的患者比例,合并冠心病、慢性支气管炎、心功能不全的患者比例明显高于早期诊断组;早期延误组首发症状为晕厥、下肢水肿的患者比例,危险因素为近期手术/骨折史、深静脉血栓(DVT)、长期卧床的患者比例明显低于早期诊断组,差异有统计学意义(P<0.05).两组患者性别,首发症状为胸闷气喘、咳嗽、发热的患者比例,体征(体温、脉搏、呼吸频率、收缩压、舒张压),合并症为高血压、脑梗死、糖尿病的患者比例,危险因素为肿瘤/占位的患者比例比较,差异无统计学意义(P>0.05).早期延误组心电图异常表现为ST-T改变的患者比例明显高于早期诊断组,首诊至CT血管造影(CTPA)诊断时间、首诊至D-二聚体结果出现的时间明显长于早期诊断组;早期延误组心电图异常表现为S1Q3T3的患者比例,心脏彩超异常表现的患者比例明显低于早期诊断组,差异有统计学意义(P<0.05);两组患者CTPA栓塞部位(右肺动脉、左肺动脉、双侧肺动脉)、D-二聚体、C反应蛋白(CRP)、脑钠肽(BNP)、血气分析结果[pH值、氧分压(PaO2)、二氧化碳分压(PaCO2)]、肌钙蛋白I(CTnI)、同型半胱氨酸(Hcy)、总胆固醇、低密度脂蛋白胆固醇(LDL-C)比较,差异无统计学意义(P>0.05).多因素Logistic回归分析显示,年龄、心功能不全、冠心病、慢性支气管炎、首诊至CTPA诊断时间长、首诊至D-二聚体结果出现时间长是老年肺栓塞患者早期诊断延误的影响因素(P<0.05).结论 老年患者肺栓塞早期诊断延误率较高.高龄、合并心功能不全、合并冠心病、合并慢性支气管炎、首诊至CTPA诊断时间长、首诊至D-二聚体结果出现时间长是老年肺栓塞患者早期诊断延误的危险因素,应予以重视、早期识别及诊断.%Objective To investigate the associated factors of diagnostic delay of pulmonary embolism (PE) at an early stage among elderly patients. Methods The enrolled participants were 130 elderly patients with a final diagnosis of PE treated in Fuyang People's Hospital between January 2012 and July 2016. Of them, 68 timely underwent related examinations due to a initial diagnosis of suspected PE were assigned to the early diagnosis group, and other 62 did not due to a initial diagnosis of non-suspected PE were assigned to the early delay group. We compared their baseline and laboratory characteristics. The associated factors of diagnostic delay of PE at an early stage were analyzed using multivariate logistic regression. Results The rate of diagnostic delay of PE at an early stage among these elderly patients was 47.7% (62/130). Compared with those diagnosed at an early stage, patients with delayed diagnosis were older, and higher proportion of them were found with chest pain as the initial symptom, with coronary heart disease, chronic bronchitis or cardiac dysfunction, but lower proportion of them were identified with syncope, or edema of lower extremities as the initial symptom, and they were less likely to have risk factors such as a history of recent surgery/fracture, deep venous thrombosis, and long-term bedridden conditions (P<0.05). The distribution of gender, proportion of patients with chest tightness, asthma, cough and fever as the initial symptom, signs (body temperature, pulse, respiratory rate, systolic blood pressure, diastolic blood pressure), prevalence of hypertension, cerebral infarction, diabetes, and percentage of patients with the risk factor of tumor/ space-occupying lesion did not differ significantly between the two groups (P>0.05). Patients with delayed diagnosis demonstrated higher prevalence of ST-T wave abnormalities on an ECG, longer duration between timing of initial diagnosis and CTPA results reporting time, longer duration between timing of initial diagnosis and D-dimer test results reporting time, higher prevalence of S1Q3T3 pattern on an ECG, as well as higher prevalence of echocardiographic abnormalities compared with those with diagnosis at an early stage (P<0.05). Two groups showed no significant differences in the distribution of PE locations identified by CTPA (right pulmonary artery, left pulmonary artery, bilateral pulmonary arteries), levels of D-dimer, C-reactive protein and B-type natriuretic peptide, analysis results of arterial blood gas test (levels of pH, partial pressure of oxygen and partial pressure of carbon dioxide), levels of Troponin I, homocysteine, total cholesterol and low-density lipoprotein cholesterol (P>0.05). Multivariate Logistic regression analysis results indicated that age, cardiac insufficiency, coronary heart disease, chronic bronchitis, duration between timing of initial diagnosis and CTPA results reporting time , and duration between timing of initial diagnosis and D-dimer test results reporting time were the associated factors for diagnostic delay of PE at an early stage among elderly patients (P<0.05). Conclusion The rate of diagnostic delay of PE at an early stage among elderly patients was high. Older age, prevalence of cardiac insufficiency, coronary heart disease or chronic bronchitis, prolonged duration between timing of initial diagnosis and CTPA results reporting time, prolonged duration between timing of initial diagnosis and D-dimer test results reporting time were the risk factors for diagnostic delay of PE at an early stage among this population, which should be paid attention, and should be identified as early as possible.