RU2601661C1 - Method of clinical assessment of the probability of non-massive pulmonary artery thromboembolia in female patients taking combined oral contraceptives - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to clinical diagnostics. Following clinical signs are determined and appraised by points: two and more thromboembolia cardiac and/or respiratory and/or neurological symptoms typical for pulmonary artery - causeless cough, shortness of breath, feeling lack of air, heart rhythm disorder, syncopal condition of unknown genesis, cardialgia - such symptoms are awarded 3 points. If the medical history of a patient contains diseases that can be "masks" of non-massive pulmonary artery thromboembolia - pneumonia, pleuritis, pericarditis, neurocirculatory dystonia, bronchitis, chronic obstructive pulmonary disease - such diseases are awarded 2 points. Proved use of combined oral contraceptives is awarded 3 points. If the electrocardiogram of the patient shows the signs of pulmonary artery thromboembolia, 1 point is awarded. If X-ray examination shows the signs of non-massive pulmonary artery thromboembolia, 1 point is awarded. If doppler echocardiography shows the signs of right ventricular dysfunction, 2 points is awarded. Occurrence of chronic venous insufficiency and thrombophlebitis of veins of lower extremities after taking combined oral contraceptives is awarded 2 points. Hereditary or acquired hemostatic disorders hyperhomocysteinemia, antiphospholipid syndrome, detection of d-dimer marker of thrombosis, hypercoagulation syndrome, increase of thrombocyte aggregation are awarded 2 points. Smoking - 3 points. Presence of one or more risk factors - surgeries, catheterization of main and peripheral vessels, postoperative period, prolonged immobilization, bed rest, travelling by plane, nephrotic syndrome, malignant neoplasms, knee and hip joint prosthetics, injuries, burns, state accompanied by increase of blood viscosity, Crohn's disease, vasculitis, acute myocardial infarction, heart failure, endocarditis, heart rhythm disorders, diabetes mellitus, obesity - is awarded 2 points. Absence of any of the following clinical signs is awarded 0 points, then the total score is calculated. If the total score is more than 14, clinical probability of thromboembolia of pulmonary artery is high; if the total score of 7-13, clinical probability of thromboembolia of pulmonary artery is moderate; and if total score is less than 6, clinical probability of thromboembolia of pulmonary artery is low.

EFFECT: method enables more accurate detection of non-massive thromboembolism in female patients taking combined oral contraceptives.

1 cl, 2 dwg, 3 tbl

Description

The invention relates to medicine, namely internal medicine, specifically to methods for clinical determination of the likelihood of non-massive pulmonary thromboembolism in patients taking combined oral contraceptives (COCs).

Preparations for oral contraception were invented back in the 60s of the XX century, and since then have gained wide distribution as the most reliable and safe method of regulating fertility. This was largely due to aggressive commercial promotion by pharmaceutical companies and the misconception of doctors and the public about the safe use of these drugs for women. These drugs are prescribed to women extensively without proper preliminary examination; they can be bought at the pharmacy on the recommendation of the front desk workers or on their own, without a prescription.

Safety issues related to drug use continue to be key to clinical practice. The use of synthetic analogues of female sex hormones is considered a risk factor for acquired thrombophilia. Using them increases the risk of venous thromboembolic complications, including deep vein thrombosis and pulmonary embolism, and arterial thrombotic complications, including acute myocardial infarction and ischemic stroke [1, 2, 3, 4].

One of the most common but difficult to diagnose complications is non-massive pulmonary thromboembolism (PE). TELA is not only the most common cause of cardiovascular mortality, but also an important interdisciplinary problem, as it occurs in the practice of a doctor of any profile. The complexity of the diagnosis lies in the fact that non-massive pulmonary embolism often proceeds under the guise of various cardiac and respiratory diseases (sudden shortness of breath, which is regarded as a symptom of a pulmonary disease, “pleurisy”, frequent “pneumonia”, neurocirculatory dystonia, etc.). Unfortunately, non-surgical physicians are wary of non-massive PE, the assessment of the clinical probability of non-massive PE is difficult due to the low specificity and sensitivity of individual symptoms and objective examination data. Although assessing them together allows even before performing analyzes and instrumental examinations to divide patients into categories of clinical probability of pulmonary embolism. The determination of the clinical probability of non-massive pulmonary embolism, along with risk stratification, underlies the choice of a diagnostic algorithm and a comprehensive assessment of the results of diagnostic procedures.

A prerequisite for the development of the proposed method was the fact that not a single woman from the field of vision underwent any examination either before the appointment of COCs or during the administration of drugs. And to date, no protocol has been developed and adopted for the management of such patients.

In the existing practice of determining the likelihood of pulmonary embolism, a method using the Wells scale (2001) is known, with which the following indicators are evaluated in points: clinical symptoms of deep vein thrombosis of the lower extremities; Pulmonary embolism is more likely than other pathologies; tachycardia> 100 beats / min; immobilization or surgery over the past 3 days; history of deep vein thrombosis of the lower extremities or pulmonary embolism in history; hemoptysis; oncological pathology at the present time or up to 6 months old [5]. This scale is quite easy to use, but has several disadvantages. Firstly, it does not take into account some important clinical manifestations, for example, respiratory (shortness of breath, dissatisfaction with inspiration, sudden cough or bronchial obstructive syndrome), cardiac (chest pain, tachycardia) and neurological (dizziness, weakness, loss of consciousness) symptoms. Secondly, a low probability of another diagnosis is mentioned as a criterion. This criterion is not clear enough and serves as a source of errors of various kinds, while it is estimated by the maximum number of points, which increases the likelihood of making an erroneous decision. In addition, this method does not take into account the influence of factors such as taking combined oral contraceptives and analysis of changes according to routine data (radiography, electrocardiography, Doppler echocardiography) and laboratory examination methods.

There is also known a method for the diagnosis of thromboembolism of small branches of the pulmonary artery in patients with implanted VVI pacemakers (Patent No. 2257848, published on 10.08.2005 [6]), which consists in performing perfusion and ventilation lung scintigraphy upon presentation of complaints that cause low and medium clinical probability pulmonary embolism, characterized in that when detecting defects in perfusion of the lungs, anticoagulant therapy is prescribed and perfusion scans are repeated 5-6 days after its start tigrafiyu lungs, after which the percentage of scintillation counting in symmetrical areas of light and its increase in lesion side compared with the initial at least 10-15% diagnose thromboembolism small branches of the pulmonary artery. This method is designed to improve the accuracy and informativeness of the clinical determination of the probability of pulmonary embolism in a specific category of patients (with an implanted VVI pacemaker) and cannot be used for other categories of patients.

Closest to the proposed method is the Geneva scale (2006), where the following clinical data are also scored: age> 65 years, history of deep vein thrombosis of the lower extremities or pulmonary embolism in the anamnesis, surgery or fracture over the past month, suspected thrombosis deep veins of the lower extremities (pain in one limb), hemoptysis, tachycardia ≥95 beats / min, pain during palpation of a vein + edema of one limb. The clinical likelihood of pulmonary embolism is estimated by the total score.

However, this method has the following disadvantages: its scope is limited, since it includes general criteria for pulmonary embolism, without highlighting specific criteria for non-massive pulmonary embolism, which often proceeds under various masks. In addition, there are no specific criteria for the clinical determination of the likelihood of pulmonary embolism in young patients taking combined oral contraceptives. The criteria of the known method are not fully manifested in patients taking COCs, since age over 65 is an irrelevant factor, chronic venous insufficiency and deep vein thrombosis of the lower extremities develop already with COC, and not before the appointment (which is a contraindication to taking drugs), hemoptysis is also not a significant factor, since this symptom mainly occurs with pulmonary infarction, and non-massive PE is more often manifested by shortness of breath and dissatisfaction with the breath or outside apno appeared cough or BOS syndrome.

In addition, the disadvantage of these methods is the lack of assessment of paraclinical parameters (analysis of routine examination methods - ECG, Echocardiography, radiographs) used in the outpatient examination, potential congenital hemostasis disorders (antiphospholipid syndrome, hyperhomocysteinemia) are not evaluated and specific risk factor in young women, such as prolonged uncontrolled intake of oral contraceptives, which increases the risk of pulmonary embolism by 2–9 times [1, 2].

Thus, the identification of the clinical likelihood of pulmonary embolism by known methods in patients taking COCs does not allow a reliable verification of the diagnosis during further examination, since the first stage of diagnosis, the assessment of the clinical likelihood of pulmonary embolism, is complicated by the absence of the above criteria, and therefore the information content and accuracy of diagnosis are reduced with using known methods.

A new technical result is an increase in the accuracy and informativeness of the method for the clinical determination of the likelihood of non-massive pulmonary embolism, which would cover all the important and most common risk factors in young women of reproductive age who take combined oral contraceptives.

To achieve a new technical result in a method for clinical determination of the likelihood of non-massive pulmonary thromboembolism in patients taking combined oral contraceptives, including determining clinical signs and evaluating each in points and calculating a diagnostic indicator by their sum, the following clinical signs are determined and evaluated in points: two and cardiac and / or respiratory and / or neurological symptoms more typical for pulmonary thromboembolism - causeless cough, shortness of breath, a feeling of lack of air, heart rhythm disturbance, syncopal conditions of unclear origin, cardialgia - estimated at 3 points, the presence of a history of diseases that could be “masks” of non-massive pulmonary thromboembolism - pneumonia, pleurisy, pericarditis, neurocirculatory dystonia, bronchitis, chronic obstruction lungs - estimated at 2 points, the presence of the fact of taking combined oral contraception is estimated at 3 points, the appearance on the electrocardiogram of signs of pulmonary thromboembolism was evaluated dissolved in 1 point; radiological signs of non-massive pulmonary embolism are estimated at 1 point; the detection of doppler echocardiography signs of dysfunction of the right ventricle is estimated at 2 points; the appearance of chronic venous insufficiency and thrombophlebitis of the veins of the lower extremities after the start of taking combined oral contraceptives is estimated at 2 points; hereditary or acquired hemostasis disorders, hyperhomocysteinemia, antiphospholipid syndrome, identification of a marker of thrombosis of d-dimer, hypercoagulation syndrome, increased platelet aggregation are estimated at 2 points; smoking - 3 points; the presence of one or more risk factors - surgical interventions, catheterization of the main and peripheral vessels, the postoperative period, prolonged immobilization, bed rest, overflight, nephrotic syndrome, malignant neoplasms, prosthetics of the knee and hip joints, injuries, burns, conditions accompanied by an increase in blood viscosity, Crohn’s disease, vasculitis, acute myocardial infarction, heart failure, endocarditis, cardiac arrhythmias, diabetes mellitus, obesity - estimated at 2 alla; the absence of any of the listed clinical signs is estimated at 0 points, after which the total points are calculated and, if the total score is more than 14, the corresponding high is determined, with a total score of 7 to 13 - moderate, and with a total score of less than 6 - a low clinical likelihood of pulmonary embolism arteries.

The method is as follows.

Patients taking COCs have a history and complaints, examine the ECG, comparing it with previous ECG studies, conduct a thorough examination, including examination and palpation of the veins of the lower extremities, measure their circumferences at the level of the legs, hips, conduct routine clinical studies (general and biochemical analyzes blood). The detected signs are entered in the table in which scoring is carried out. Clinical signs are determined and each is scored, and a diagnostic indicator is calculated from their total. Symptoms are assessed (two or more cardiological and / or respiratory and / or neurological symptoms typical for pulmonary embolism - causeless cough, shortness of breath, feeling of lack of air, heart rhythm disturbance, syncopal conditions of unclear origin, cardialgia, evaluated at 3 points, physical data - the appearance of chronic venous insufficiency and thrombophlebitis of the veins of the lower extremities after the start of COC use are evaluated at 2 points, predisposing factors are hereditary hemostasis (hyperhomocysteinemia, antiphospholipid syndrome) or the marker of thrombosis of d-dimer, hypercoagulation syndrome, increased platelet aggregation is estimated at 2 points; the presence of one or more risk factors - surgical interventions, catheterization of the main and peripheral vessels, the postoperative period, prolonged immobilization, bed rest, overflight, nephrotic syndrome, malignant neoplasms , prosthetics of the knee and hip joints, injuries, burns, conditions accompanied by an increase in blood viscosity (thrombocytosis, true polycythemia), disease Crohn's disease, vasculitis, acute myocardial infarction, heart failure, endocarditis, cardiac arrhythmias, diabetes mellitus, obesity are estimated at 2 points, and clinical signs in the history of the disease, which could be “masks” of non-massive pulmonary embolism (pneumonia, pleurisy, pulmonary hypertension), are also determined , tricuspid regurgitation) is rated at 2 points; the fact of taking combined oral contraceptives in the previous 6 months is estimated at 3 points; in addition, smoking risk is separately assessed. It was established that smoking leads to multidirectional changes in platelet and plasma hemostasis in the form of hypercoagulation and a decrease in the level of physiological anticoagulants, in addition, it is a fairly common risk factor at the moment - 3 points; the absence of any of the listed clinical signs is estimated at 0 points, after which the total points are calculated and, with a total of more than 14 points, a high, from 7 to 13 points moderate and less than 6 points low clinical likelihood of pulmonary embolism is determined.

Determining the clinical likelihood of non-massive pulmonary embolism serves as the basis for further instrumental diagnosis of pulmonary embolism with the aim of confirming or excluding it. With moderate and high likelihood of pulmonary embolism, instrumental diagnostics may include the study of perfusion and ventilation of the lungs using perfusion ventilation scintigraphy, angiopulmonography, and spiral computed tomography of the lungs. The choice of further diagnostic tests depends on both the specific clinical conditions and the diagnostic capabilities of the clinic. With a low clinical likelihood of pulmonary embolism, the rejection of further diagnostic tests and antithrombotic therapy is safe for the patient.

Example 1

Patient X., 35 years old, was admitted to hospital with suspected myocarditis. Upon admission, she complained of severe shortness of breath during normal walking, a feeling of constant lack of air at rest, a sharp weakness, decreased performance, and dry unproductive cough. During the examination it was found out that over the past ten years she has taken the Yarina combined oral contraceptive without regularly examining the state of hemostasis and other systems and organs. During the administration of the drug, signs of chronic venous insufficiency appeared, swelling of the left lower limb appeared. On examination: moderate severity, pallor, oral cyanosis, BH - 20-24 / min (N-16). The percussion sound was not changed above the lungs, vesicular breathing, weakened in the middle-lower parts of the right, isolated dry rales. The boundaries of the relative dullness of the heart are normal, the tones are slightly muffled, the heart rate is 90 / min, the accent of the II tone above the pulmonary artery, a short systolic murmur at the apex and at Botkin's point. The abdominal organs are b / o, the right lowered kidney is palpated in a standing position. On legs, upon examination, signs of CVI, more on the left in the popliteal fossa.

On the electrocardiogram, signs of incomplete blockade of the right bundle branch block, overload of the right departments (this was not the case on the previous electrocardiogram), during the inpatient treatment, the patient was tested according to the proposed method, it was revealed that she had a high degree of clinical probability of pulmonary embolism (Table 2) : the total score for this patient is 14, which corresponds to the high probability of the occurrence of non-massive PE, and an additional examination was required to confirm or exclude this diagnosis.

In the hospital, she underwent an X-ray of the chest organs, on which no changes were detected, and lung scintigraphy with the conclusion that this scintigraphic picture most likely corresponds to pulmonary embolism of small S4 branches on the right (Fig. 1).

Unfortunately, this study was not taken into account by the attending physician, and at discharge she was diagnosed with Astheno-depressive syndrome due to the use of hormonal contraceptives. Sop. Chronic non-calculous cholecystitis, Art. remission. Nephroptosis on the left.

In the hospital, metabolic, antibacterial, antispasmodic therapy was carried out, it is recommended to cancel the combined oral contraceptive.

After discharge, the patient's condition did not improve. A second consultation was held at the cardiology department of the OKB. Based on the clinical picture, the history of prolonged and uncontrolled use of COCs, an electrocardiogram, lung scintigraphy with the identification of S4 hypoperfusion sites on the right, taking into account the absence of signs of pneumofibrosis in the area of hypoperfusion, as well as changes in the veins of the lower extremities, the patient was diagnosed with

Osn: Thromboembolism of small branches of the pulmonary artery in S4 on the right against the background of prolonged use of combined oral contraceptives.

Sop: Varicose veins of the lower extremities. Varicose veins of the small pelvis.

Based on the foregoing, the patient was hospitalized as an ambulance in the cardiology department of the OKB, where she was from 04/15/2011 to 05/06/2011, where the diagnosis was confirmed, antiplatelet and anticoagulant therapy was carried out. On the control scintigraphy performed after 7 months, no hypoperfusion sites were found, which indicates the absence of signs of pulmonary embolism (Fig. 2).

If, during the first inpatient treatment, the patient was tested according to the proposed method, it would be revealed that she has a high degree of clinical probability of pulmonary embolism (Table 2): the total score for this patient is 14, which corresponds to a high probability of non-massive pulmonary embolism and additional examination was required to confirm or exclude this diagnosis. Unfortunately, the relevance of this problem is underestimated, and research data are not very specific and can be informative in combination, especially in women receiving hormonal drugs. In this case, the doctor ignored the results of scintigraphy and did not take appropriate measures to clarify the diagnosis and further therapy.

Example 2

Patient Ch., 30 years old, applied for a consultative appointment with a cardiologist at a community clinic. Upon treatment, she complained of chest pain associated with breathing, a sudden dry cough during the last two months, shortness of breath with a light load, and constant dissatisfaction with the breath. From the anamnesis it is known that he takes combined oral contraceptives for more than 7 years. The drug was prescribed without a preliminary examination, regular monitoring for the time of admission was not carried out.

Objectively, the condition is relatively satisfactory, pallor of the skin is noted. Vesicular breathing, dry single rales on the left. The boundaries of the heart are not increased percussion, the rhythm is correct, the emphasis of the second tone over the pulmonary artery. On the hips and lower legs of both legs are signs of varicose veins.

The electrocardiogram shows signs of a pulmonary heart (high P wave in II, III. The amplitude of the R wave in V ₁ -V _{3 is} increased). Deviation of the electrical axis of the heart to the right. Incomplete blockade of the right bundle branch block.

X-ray focal and infiltrative changes were not detected. The pulmonary pattern is not reinforced, without deformation. The roots of the lungs are structural, not expanded. The shadow of the heart is not expanded across, the waist is smoothed. The contours of the diaphragm are even, clear. Sinuses are free.

Echocardiographic sizes of the cardiac cavities within normal values. The global contractile function of the left ventricle is not impaired. One gets the impression of asynchronism MZHP. Indirect signs of pancreatic overload. Increased SIJ. Valves without visible pathology.

Laboratory presence of lupus-type anticoagulants (lupus test) was detected.

Since the results of the studies do not allow a high degree of certainty to exclude pulmonary embolism, the patient was tested according to the proposed method. It was established that she has a moderate degree of clinical probability of pulmonary embolism (13 points), which confirms the correlation of the selected symptoms and the diagnosis (Table 3). It was decided to carry out perfusion-ventilation lung scintigraphy. Conclusion: general hypoperfusion of the left lung is noted. Against this background, there is an aperfusion of the region 4, 5, 6 of the broncho-pulmonary segments of the left lung. Signs of pulmonary embolism of small and medium branches on the left.

Based on the above data, the following diagnosis was made.

Main: Thromboembolism of the small and medium branches of the pulmonary artery on the left.

Complication: Subacute pulmonary heart.

Background: Antiphospholipid Syndrome? Varicose veins of the lower extremities. Chronic venous insufficiency of the 1st degree against the background of prolonged uncontrolled intake of oral contraceptives.

The following therapy was carried out in the hospital: fraxiparin 0.6 per day s / c, followed by oral cardiomagnyl, warfarin in the appropriate dosage, under the control of MHO. At discharge, the patient's condition was rated as satisfactory. It was recommended to repeat the lupus test after 6 weeks. On scintigrams performed after three months, normalization of perfusion of 6 broncho-pulmonary segments was noted, although hypoperfusion of 4, 5 broncho-pulmonary segments still persisted. In addition, a recommendation was given for repeated episodes of pulmonary embolism to contact the Federal Academic Center for Diagnostics and Treatment of Hemostasis Disorders at the Central Scientific Research Laboratory of Altai State Medical University, which was done a year later, since there was another episode of pulmonary embolism (9 months after the first episode of pulmonary embolism) .

A comprehensive study of the hemostatic system was carried out at the Center for Diagnostics and Treatment of Hemostasis Disorders, determining the level of lupus anticoagulant, screening disorders in the physiological anticoagulant system, platelet aggregation function, and plasma samples were taken and frozen to determine antibodies in phospholipids and serum homocysteine level. According to the results of these studies, the diagnosis was made:

Primary: Hematogenous thrombophilia due to primary antiphospholipid syndrome with circulating plasma lupus-type anticoagulants and antibodies to phospholipids. Moderate hyperhomocysteinemia. Heart attack pneumonia against the background of thromboembolism of small branches of the left lung.

Concomitant: Varicose disease of the lower extremities with the phenomena of XBH I. Uncontrolled administration of oral contraceptives.

The following treatment was recommended and carried out: plasmapheresis (10 sessions), sulodexide according to the scheme, mildronate according to the scheme, preductal MB, hepatotropic therapy.

As you can see, this patient has a complex combined pathology of the hemostatic system, which could be aggravated by the use of combined oral contraceptives. But since the woman did not undergo primary screening for pathology data and monitoring the state of the hemostasis system while taking the drug, this could provoke a vascular accident in the lungs.

The proposed criteria for determining the clinical likelihood of pulmonary embolism in patients taking combined oral contraceptives were selected based on the interpretation of data from a retrospective analysis of the patient’s case histories upon consultation or hospitalization in multidisciplinary hospitals of medical institutions for “mask diseases” under which hiding pulmonary embolism, as well as on the basis of clinical observation of patients with moderate and high clinical faith tnost PATE according to the proposed method.

The method is based on the analysis of clinical observation data. We analyzed 14 clinical cases in women from 29 to 50 years old, an average age of 36.57 ± 6.03 years, the average term for taking drugs was 6.14 ± 4.3 (from six months to 12 years of continuous use of the drug). At the same time, the time elapsed since the start of taking combined oral contraceptives was noted and compared with the time of the first occurrence of complaints during this period, the diagnoses and the degree of their validity, possible risk factors for pulmonary embolism in each patient, clinical and paraclinical examination methods were evaluated. The control group consisted of 10 women who did not take COCs and, accordingly, they did not have respiratory and cardiac complaints, laboratory indicators were normal. All indicators were entered into the database. To assess the contribution of each of the factors and their interaction, the non-parametric Chi-square criteria and Fisher's exact test were used, which made it possible to single out several working algorithms for determining the clinical probability of pulmonary embolism with various combinations of indicators and their scoring.

Of the 14 patients examined according to the proposed method, 9 showed a high probability of pulmonary embolism, 3 had a moderate probability of pulmonary embolism, and two had a low probability. In 8 out of 9 patients with a high probability of non-massive PE, the diagnosis was confirmed by electrocardiography, Doppler echocardiography, chest X-ray and ventilation perfusion scintigraphy. Moreover, the data of the radionuclide study were compared with the data of the x-ray picture. For one patient with a high probability of pulmonary embolism, the above studies were not performed. Also, in one patient with a moderate probability of pulmonary embolism, the diagnosis of pulmonary embolism was also confirmed by the above methods of research. The results of the studies showed that with a high and medium probability of clinical symptoms, the diagnosis of pulmonary embolism was confirmed in 9 out of 14 people.

A comparison group consisted of 10 women who did not take combined oral contraceptives; they did not have these complaints.

Thus, the proposed method allows with sufficient accuracy to diagnose the clinical likelihood of non-massive pulmonary embolism in patients taking combined oral contraceptives, which is important to improve the quality and life expectancy and conduct the most appropriate and timely diagnostic and therapeutic measures in this category of patients.

Information sources

1. Baillargeon J.P., McClish D.K., Essah P.A., Nestler J.E Association between the current use of low-dose oral contraceptives andcardiovascular arterial disease: a meta-analysis // J. Clin. Endocrinol. Metab. 2005. Vol. 90. P. 3863-3870.

2. Cardiovascular disease and steroid hormone contraception: technical report series. - Geneva: WHO, 1998.

3. Chan W.S., Ray J., Wai E.K. et al. Risk of stroke in women exposed to low-dose oral contraceptives: a critical evaluation of the evidence // Arch. Intern. Med. 2004. Vol. 164. P. 741-747.

4. Sidney S., Petitti D.B., Soff G.A. et al. Venous thromboembolic disease in users of low-estrogen combined estrogen-progestin oral contraceptives // Contraception. 2004. Vol. 70. P. 3-10.

5. Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ (2001). "Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer." Ann Intern Med 135 (2): 98-107. PMID 11453709.

6. A method for the diagnosis of non-massive thromboembolism of small branches of the pulmonary artery in patients with an implanted VVI pacemaker: US Pat. RF 2257848, A61B 6/00 / Tyukalova L.I., Posokhov I.N., Popov S.V., Krivonogov N.G., Vasilchenko E.E., Mileshina M.A .; applicants and patent holders: Tyukalova L.I., Posokhov I.N., Popov S.V., Krivonogov N.G., Vasilchenko E.E., Mileshina M.A. No. 2004103456/14; declared 02/05/2004; publ. 08/10/2005, Bull. No. 6.

7. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003 Jun 17; 107 (23 Suppl 1): I9-16.

a. http://circ.ahajournals.org/cgi/content/full/107/23_suppl_1/I-9

8. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008 Sep; 29 (18): 2276-315.

9. McGinn S, White PD (1935). "Acute cor pulmonale resulting from pulmonary embolism." J Am Med Assoc 104: 1473-80.

application

FIG. 1 Scintigraphy of patient X (example 1) with signs of pulmonary embolism of small S4 branches on the right.

FIG. 2 Control scintigraphy of patient X (example 1), performed after 7 months, on which no hypoperfusion sites were found, which indicates the absence of signs of pulmonary embolism.

Claims (1)

A method for the clinical determination of the likelihood of non-massive pulmonary thromboembolism in patients taking combined oral contraceptives, including determining clinical signs and evaluating each in points and calculating a diagnostic indicator by their sum, characterized in that the following clinical signs are determined and evaluated in points: two or more typical cardiac and / or respiratory and / or neurological symptoms for thromboembolism of the pulmonary artery - causeless cough, shortness of breath, feeling of lack of air, cardiac arrhythmias, syncopal conditions of unknown origin, cardialgia - estimated at 3 points, the presence of a history of diseases that could be "masks" of non-massive pulmonary embolism - pneumonia, pleurisy, pericarditis, neurocirculatory dystonia, bronchitis, chronic obstructive pulmonary disease - 2 points, the fact of taking combined oral contraceptives is estimated at 3 points, the appearance on the electrocardiogram of signs of pulmonary embolism is estimated at 1 point; X-ray signs of non-massive pulmonary embolism are estimated at 1 point; the detection of doppler echocardiography signs of dysfunction of the right ventricle is estimated at 2 points; the appearance of chronic venous insufficiency and thrombophlebitis of the veins of the lower extremities after the start of taking combined oral contraceptives is estimated at 2 points; hereditary or acquired hemostasis disorders, hyperhomocysteinemia, antiphospholipid syndrome, identification of a marker of thrombosis of d-dimer, hypercoagulation syndrome, increased platelet aggregation are estimated at 2 points; smoking - 3 points; the presence of one or more risk factors - surgical interventions, catheterization of the main and peripheral vessels, the postoperative period, prolonged immobilization, bed rest, overflight, nephrotic syndrome, malignant neoplasms, prosthetics of the knee and hip joints, injuries, burns, conditions accompanied by an increase in blood viscosity, Crohn’s disease, vasculitis, acute myocardial infarction, heart failure, endocarditis, cardiac arrhythmias, diabetes mellitus, obesity - estimated at 2 alla; the absence of any of the listed clinical signs is estimated at 0 points, after which the total points are calculated and, if the total score is more than 14, the corresponding high is determined, with a total score of 7 to 13 - moderate, and with a total score of less than 6 - a low clinical likelihood of pulmonary embolism arteries.

Images