中国全科医学 ›› 2024, Vol. 27 ›› Issue (32): 3987-3992.DOI: 10.12114/j.issn.1007-9572.2024.0047

• 论著 • 上一篇    下一篇

误诊为肺炎的中高危肺栓塞继发肺梗死患者临床特征及相关危险因素研究

吕广瑜1,2, 孙宛君3, 周倩倩1, 陈先梦1, 刘雪晗4, 胡晓文1,*()   

  1. 1.230001 安徽省合肥市,中国科学技术大学附属第一医院(安徽省立医院)呼吸与危重症医学科
    2.241000 安徽省芜湖市,皖南医学院研究生院
    3.243000 安徽省马鞍山市人民医院呼吸与危重症医学科
    4.230001 安徽省合肥市,中国科学技术大学附属第一医院(安徽省立医院)科研处
  • 收稿日期:2024-03-10 修回日期:2024-05-20 出版日期:2024-11-15 发布日期:2024-08-08
  • 通讯作者: 胡晓文

  • 作者贡献:

    吕广瑜进行文章的构思与设计,结果分析与解释,统计学处理及论文撰写;吕广瑜和孙宛君进行数据收集与整理;周倩倩、陈先梦、胡晓文进行研究的实施,论文的修订;刘雪晗负责论文统计学方法的设计及可行性分析;胡晓文对研究设计、质量控制进行指导和论文修改,对文章整体监督管理。

  • 基金资助:
    安徽省重点专科建设项目(2021szdzk05); 安徽省首届卫生健康杰出人才资助项目(0C6610183/202303-00141)

Clinical Characteristics and Risk Factors of Patients with Pulmonary Infarction Secondary to Intermediate and High-risk Pulmonary Embolism Misdiagnosed as Pneumonia

LYU Guangyu1,2, SUN Wanjun3, ZHOU Qianqian1, CHEN Xianmeng1, LIU Xuehan4, HU Xiaowen1,*()   

  1. 1. Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China/Anhui Province Hospital, Hefei 230001, China
    2. Graduate School, Wannan Medical College, Wuhu 241000, China
    3. Department of Pulmonary and Critical Care Medicine, Maanshan People's Hospital, Maanshan 243000, China
    4. Research Office, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China/Anhui Province Hospital, Hefei 230001, China
  • Received:2024-03-10 Revised:2024-05-20 Published:2024-11-15 Online:2024-08-08
  • Contact: HU Xiaowen

摘要: 背景 尽管近年来肺栓塞继发肺梗死的病例不断见诸报道,但该病的误诊仍较普遍,其中最常被误诊为肺炎,尤其是存在中高危风险患者,延迟诊断、未能及时接受治疗将会影响患者的预后。 目的 总结中高危肺栓塞继发肺梗死被误诊为肺炎患者的临床特征,分析相关危险因素,并构建早期诊断模型。 方法 回顾性收集中国科学技术大学附属第一医院2017—2023年确诊为中高危风险肺栓塞继发肺梗死的住院患者临床资料。分析患者误诊情况,根据诊断情况分为误诊组(曾误诊为肺炎离院回家)和对照组(门诊或急诊科首次就诊即正确诊断)。采用多因素二元Logistic回归分析探究中高危风险肺栓塞继发肺梗死被误诊为肺炎的影响因素,绘制受试者工作特征曲线(ROC曲线)分析各指标对中高危风险肺栓塞继发肺梗死被误诊为肺炎的预测价值,并采用Delong检验比较各ROC曲线下面积(AUC)。 结果 共纳入患者101例,其中70例中高危肺栓塞继发肺梗死患者被误诊为肺炎。2017—2023年中高危肺栓塞继发肺梗死患者被误诊为肺炎的发生率呈下降趋势(依次为100.0%、83.3%、74.1%、71.4%、63.2%、66.7%、50.0%,χ2趋势=6.672,P=0.010)。多因素二元Logistic回归分析结果显示,年龄≥60岁(OR=18.271,95%CI=4.373~76.339,P<0.001)、发热(OR=16.073,95%CI=3.510~73.786,P<0.001)、胸痛(OR=6.660,95%CI=1.571~28.233,P=0.010)和不伴有呼吸困难(OR=7.783,95%CI=2.049~30.249,P=0.003)是中高危风险肺栓塞继发肺梗死被误诊为肺炎的独立影响因素。经筛选得出,多变量联合模型=-6.624+0.095×年龄+2.510×发热+2.683×不伴有呼吸困难,联合模型预测中高危风险肺栓塞继发肺梗死被误诊为肺炎的AUC为0.880(95%CI=0.802~0.959),灵敏度为0.871,特异度为0.806。Delong检验结果显示,联合模型预测价值优于单因素指标如年龄(Z=2.771,P=0.006)、发热(Z=4.653,P<0.001)及不伴有呼吸困难(Z=4.014,P<0.001)。 结论 尽管2017—2023年中高危肺栓塞继发肺梗死患者被误诊为肺炎的比例有所降低,但当老年肺栓塞患者出现发热、胸痛并且不伴有呼吸困难时,临床医生应注意肺梗死与肺炎的鉴别诊断。

关键词: 肺梗死, 肺栓塞, 中高危风险, 误诊, 肺炎, 预测

Abstract:

Background

Although the number of case reports on pulmonary infarction (PI) secondary to pulmonary embolism (PE) is increasing in recent years, its misdiagnosis remains common, mainly as pneumonia. In patients with intermediate and high-risk pulmonary embolism, delays in diagnosis and timely treatment would lead to poor prognosis.

Objective

By analyzing the pneumonia-misdiagnosed cases of patients with PI, we summarized their clinical characteristics and related risk factors, and constructed a multivariate joint model to improve the accurate diagnosis rate at early stage.

Methods

This retrospective study included the hospitalized patients with pulmonary embolism at the First Affiliated Hospital of USTC from January 2017 to December 2023. In the group of pneumonia-misdiagnosed patients with intermediate to high-risk PI, we analyzed the clinical characteristics and compared the differences between the misdiagnosed groups and control group. Furthermore, using a multivariate Logistic regression analysis, we explored the independent predictive factors of the delayed diagnosis, analyze the predictive value of various indicators for the misdiagnosis by ROC curves, and compared the AUC values using Delong test.

Results

Among 101 cases of PI patients, 70 of them were misdiagnosed as pneumonia. From 2017 to 2023, the misdiagnosis rate gradually decreased in percentages of 100.0%, 83.3%, 74.1%, 71.4%, 63.2%, 66.7%, and 50.0%, respectively (χ2trend=6.672, P=0.010). Based on the results of multivariate Logistic regression analysis, the characteristics of over sixty-years-old age (OR=18.271, 95%CI=4.373-76.339, P<0.001), fever (OR=16.073, 95%CI=3.510-73.786, P<0.001), chest pain (OR=6.660, 95%CI=1.571-28.233, P=0.010) and non-dyspnea (OR=7.783, 95%CI=2.049-30.249, P=0.003) were independent predictive factors for the misdiagnosis. Therefore, a multivariate joint model was constructed as the following equation: Y=-6.624+0.095×A (factor of age) +2.510×F (factor of fever) +2.683×N (factor of non-dyspnea chest pain). The model indicated the PI misdiagnosis parameters as AUC under the curve (OR=0.880, 95%CI=0.802-0.959, P<0.001), sensitivity (0.871) and specificity (0.806). According to Delong's tests, the predictive values were superior to single-factor indicators of age (Z=2.771, P=0.006), fever (Z=4.653, P<0.001) and non-dyspnea chest pain (Z=4.014, P<0.001) .

Conclusion

Although the misdiagnosis rate of pulmonary infarction has decreased in recent years, clinicians should keep alert to the differential diagnosis of pulmonary infarction and pneumonia in elderly PE patients with symptoms of fever and non-dyspnea chest pain.

Key words: Pulmonary infarction, Pulmonary embolism, Intermediate and high-risk, Misdiagnosis, Pneumonia, Prediction

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