Plasma D-dimer Determination in the Diagnosis of Pulmonary Embolism

폐색전증의 진단에 있어 혈청 D-dimer 측정의 진단적 가치

Background: The diagnosis of pulmonary embolism (PE) based on clinical findings is often elusive and therefore requires confirmative diagnostic method. Pulmonary angiography, though the gold standard for the diagnosis of pulmonary embolism, is an invasive method and requires trained personnel and special equipment. Lung V/Q scan, on the other hand, is a noninvasive method but the diagnostic specificity and sensitivity arc not satisfactory in case that the results are either intermediate or low probability scan. Plasma D-dimer is generated when a thrombus is fibrinolysed by plasmin and is known to be increased in various thrombotic disorders. The aim of this study was to investigate the value of the determination of plasma D-dimer level in the diagnosis of pulmonary embolism. Methods: Pulmonary angiography was performed in 17 patients who were clinically suspected to have pulmonary embolism. 9 patients(PE, $56{\pm}13.4$ yrs, M:F=8:1) were diagnosed to have pulmonary embolism by pulmonary angiography. The control group were the 8 patients with negative pulmonary angiography and 13 orthopedic patients with no evidence of pulmonary embolism on scintigraphic and impedance plethysmographic studies(n=21) (non-PE, $54.5{\pm}11.1$ yrs, M:F=11:10). Plasma D-dimer was measured by latex agglutination method in study subjects and the results were analyzed according to the presence or absence of pulmonary embolism. Results: 1) The increased level of plasma D-dimer was more frequently observed in the patients with pulmonary embolism than in the controls(>0.5 mg/L, 8 in PE, 10 in non-PE; <0.5 mg/L, 1 in PE, 11 in non-PE, p=0.049). 2) The diagnostic value of plasma D-dimer level higher than 0.5 mg/L were as follows: sensitivity 88.9%(8/9), specificity 52.4%(11/21), positive predictive value 44.4%(8/18), and negative predictive value 91.7%(11/12). Conclusion: Plasma D-dimer determination showed high sensitivity and negative predictive value in the diagnosis of pulmonary embolism and is therefore thought to be useful in excluding the possibility of pulmonary embolism.

연구배경: 폐색전증의 진단에 있어 확전법인 폐동맥 조영술은 관혈적이고 임상에서의 제약이 있으며, 폐환기-관류주사는 비고확률 소견인 경우 진단적 민감도 및 특이도가 낮은 문제가 있다. 혈장 D-dimer는 섬유소분 해산물로 임상적으로 폐색전증이 의심되는 환자에서 증가되는 것이 알려져 있어 혈장 D-dimer의 측정이 폐색전증에 있어 어떤 진단적 가치가 있는지 알아보고자 하였다. 방법: 전향적 임상연구로 정상대조군 21예와 폐색전증 환자군 9예에서 latex agglutination법에 의해 혈장 D-dimer를 측정하고 폐동맥조영술 결과와 비교하였다. 결과: 1) 대조군 및 폐색전증군의 혈장 D-dimer치; 대조군의 혈장 D-dimer치는 21예중 0.5 mg/L 미만 11예, 0.5 mg/L 보다 높은 경우 10예 였고, 폐색전증군 9예중 0.5 mg/L 미만 1예, 0.5 mg/L 보다 8예로 혈장 D-dimer치가 0.5 mg/L 이상으로 증가된 양성율은 폐색전증군에서 대조군에 비해 유의하게 많았다(p=0.049). 2) 혈장 D-dimer치의 진단적 효용; 혈장 D-dimer치 0.5 mg/L를 cut-off으로 했을 때 폐색전증 진단의 민감도 88.9%(8/9), 특이도 52.4%(11/21), 양성예측치 44.4%(8/18) 및 음성 예측치 91.7%(11/12)였다. 결론: 폐색전증의 진단에 있어 D-dimer의 측정치가 cut-off(0.5 mg/L)치 이내인 경우 폐색전증의 존재 가능성은 매우 적을 것으로 사료되었다.