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目的 通过调查我国不同级别医院诊治肺栓塞(PE)的病例资料,了解我国不同级别医院诊治肺栓塞的状况,探讨在基层医院诊断PE的策略.方法 采用分层整群随机抽样方法,通过调查问卷形式,回顾性调查我国8个省市自治区20家不同级别医院提供的PE患者临床资料.问卷内容包括一般情况、基础病与诱因(危险因素)、临床表现、辅助检查结果、误诊疾病、诊断、治疗和转归等.纳入标准为:年龄≥18岁;已通过肺动脉造影、增强CT等手段确诊的患者;临床诊断PE需充分排除其他疾病的可能;无明显能进行抗凝或溶栓治疗的禁忌证,如活动性出血和近2个月内自发性颅内出血等.结果 (1)本组20家协作医院共提供302例PE患者的病例资料:三级医院11家,提供病例204例;二级医院9家,提供病例98例.(2)12余种危险因素中,深静脉血栓形成、创伤及外科术后所占比率位居前两位,分别为23.4%,16.2%;22种临床表现中,胸闷或呼吸困难、心悸、胸痛、呼吸急促、心率加快的发生率均在40%以上;在辅助检查中,血D-二聚体大于500μg/L、血清酶、肌酸激酶同工酶升高的比率分别为74.6%,50.1%,0%;心电图:窦性心动过速、V1～V6存在T波低平或倒置、ST段压低、完全或不完全右束支传导阻滞及典型SⅠQⅢTⅢ等发生的比率各为55.4%,35.7%,27.2%,26.9%及25.9%;胸部X线片:肺纹理增重、肺部阴影、胸腔积液、肺动脉段突出、右下肺动脉增宽、区域性肺野血管稀疏及肺不张等发生率分别为46.4%,36.1%,24.2%,24.2%,17.5%,9.3%及7.7%;超声心动图:肺动脉高压、右心室扩张、右心室壁运动降低及肺动脉内血栓影等发生的比率分别为66.7%,50.7%,16.4%及6.8%.(3)本组有55例(18.2%)患者初步误诊(66例次).其中误诊为冠心病28例次,肺炎11例次,占据了误诊疾病的前两位.(4)国内二级医院诊断PE多为依靠临床表现和辅助检查等临床综合方法进行诊断(占89.8%).三级医院一般选择增强CT(48.0%)、临床综合方法(22.1%)、核素肺通气/灌注扫描(12.3%)、肺动脉造影(10.8%)进行诊断.(5)二级医院与三级医院相比:采用溶栓治疗的患者比率为17.3%vs.14.7%(P＞0.05).抗凝治疗为63.3%vs.77.9%(P＜0.01).对症治疗为19.4%vs.5.4%(P＜0.01).出院后继续口服华法令至少3个月为(61.2%vs.76.0%,P＜0.01).本组患者中采用抗凝或溶栓治疗的干预组有效率高于未干预组(83.6%vs.23.3%,P＜0.01),病死率低于未干预组(9.0%vs.30.0%,P＜0.01).结论 PE具有多种危险因素及表现特点,特异性均不高,易误诊误治.目前我国二级医院诊治PE较三级医院尚有一定差距,二级医院诊断PE的方法主要为临床综合诊断,三级医院增强CT的使用率较高.进行有效干预可明显提高治疗效果.根据我国国情,规范基层医院诊治PE的方法有着重要的现实意义.“,”Objective To investigate the diagnosis and treatment of pulmonary embolism(PE)in hospitals of different medical levels and further explore the diagnostic strategy for PE in primary hospitals.Method The clinical data from twenty hospitals of different medical levels in 8 provisions of China were retrospectively investigated using stratified cluster random sampling method and questionnaire form during may 2001 to may 2008.The questionnaire included:the general situation,the underlying diseases and triggering factors(risk factors),clinical manifestations,examination findings,rate of misdiagnosis and correct diagnosis,treatment and prognosis.Inclusion criteria:age≥18 years,passed pulmonary angiography or enhanced CT to confirm the diagnosis of PE.The data was input the Epidata database.Comparison of the rate of count data used chi-square test.Results(1)A total of 302 collected from 20 hospitals including 11 tertiary hospitals(n = 204)and 9 second hospitals(n = 98).(2)Of 12 risk factors,deep vein thrombosis and surgical operation accounted for 23.4%,16.2%,respectively.Of 22 clinical manifestations,the incidences of chest tightness,dyspena,palpitations,chest pain,shortness of breath and tachycardia accounted for over 40%in all.Laboratory examinations showed the percentage of blood Ddimer over 500 μg/L was 74.6%and the percentages of serum enzyme and creatine kinase isoenzyme were 50.1%and 0%,respectively,on ECG,the incidence of sinus tachycardia,low or inverted T waves of V1 to V6 leads,ST segment depression,complete or incomplete right bundle branch block and typical SⅠ QⅢ TⅢ were 55.4%,35.7%,27.2%,26.9%and 25.9%,respectively.On chest X-ray,the incidence of increase in lung markings,the shadow of the lungs,pleural effusion,prominent pulmonary artery segment,right pulmonary artery widened,regional lung atelectasis and pulmonary blood vessels sparse were 46.4%,36.1%,24.2%,24.2%,17.5%,9.3%,and 7.7%,respectively.The echocardiography showed the incidence of pulmonary hypertension,right ventricular dilation,lower right ventricular wall motion and pulmonary artery thrombosis were 66.7%,50.7%,16.4%and 6.8%,respectively.(3)The misdiagnosis was made in 55(18.2%)of 66 patients.Of them,28 patients were misdiagnosed as coronary heart disease and 11 patients were misdiagnosed as pneumonia.(4)In the hospitals of secondary medical level the diagnosis depended mainly upon the clinical manifestions of patients and clinical examinations(89.8%).In the tertiary hospitals,the diagnosis of PE was made by using enhanced CT(48.0%),an integrated clinical approach(22.1%),pulmonary ventilation/perfusion scan (12.3%),and pulmonary angiography(10.8%).(5)In the tertiary and secondary hospitals,the percentages of thrombolytic therapy were 17.3%and 14.7%,respectively,(P＞0.05).The percentage of anticoagulant therapy is 63.3%and 77.9%(P＜0.01).The percentage of oral warfarin for at least 3 months were 61.2%and 76.0%(P＜0.01).(6)The anticoagulant or thrombolytic intervention showed higher therapeutic efficiency than the non-intervention(83.6%vs.23.3%,P＜0.01).The mortality of the therapeutic group was lower than that of non-intervention group(9.0%vs.30.0%,P＜0.01).Conclusions PE has no specific symptom and easily leads to misdiagnosis and mistreatment.The diagnosis of PE in the secondary hospitals depended? on general inspection,whereas in the tertiary hospitals,on enhanced CT.Effective intervention can significantly improve outcomes,and standardized guidelines of the diagnosis and treatment of PE should be set in our country.