患者和不大可能组二聚体阳性的患者接受CT肺血管照影(CTPA)(88%为多排CT)，
CT结果阴性者即排除PE，不再接受进一步检查。结果不大可能组和很可能组患者PE发生率分别为12.1%(95%CI，10.7%～13.5%)和37.1%(95%CI，34.2%～ 40.0%);不大可能组
二聚体阴性排除PE且未接受抗凝治疗的患者，3个月随访VTE发生率为
0.7%(95%CI，0.3%～1.4%);接受CTPA检查排除PE且未接受抗凝治疗的患者，3个月随访VTE发生率为1.3%(95%CI，0.7%～2.0%);确诊为PE接受抗凝治疗的患者3个月随访VTE发生率为3.0%。研究者认为结合两分类Wells评分法、
的诊断策略是安全有效。
二聚体和CT检查
研究者还建立了其他的PE临床可能性预测方法，如Geneva评分法〔26〕、改良 Geneva score评分法〔27〕、Pisa法〔28〕、Claudia 法〔29〕等等。一些研究比较了在PE诊断中不同预测方法的作用。Moores等〔30〕回顾性比较了Wells评分法和Geneva评分法。结果Wells评分为低、中、高三组PE发生率分别为15.3%(95%CI，9.5%～23.7%)、34.8%(95%CI，27.9%～42.4%)、47.2%(95%CI，32%～63%);Geneva评分低、中、高三组患者PE的发生率分别为26%(95%CI，13%～45%)、24%(95%CI，13%～38%)、60%(95%CI，31%～83%)。Moores等认为Wells评分法使用方便，对PE发生的危险分层有显着临床价值。Ollenberger等〔31〕利用PIOPED研究资料比较了Wells评分法和Geneva评分法，其中有27%患者因无血气分析结果而未进行Geneva评分。结果低、中、高三种PE发病率分别为17.4%、36.3%、55.4%(Wells)和18.4%、30.9%、43.7%(Geneva);两种方法的预测效果均取决于患者的来源，即门诊
患者显着优于住院患者，以手术住院患者预测效果最差。
Tamariz等〔32〕通过系统分析，认为Wells评分法(DVT评分和PE评分)在诊断
VTE时，有明确的临床实用价值。美国内科医师学院和美国家庭医师学会将Wells评分
法作为VTE诊断指南中预测VTE可能性的评估方法〔2〕。
因此，大量研究证明了Wells评分法在VTE疾病诊断策略上重要作用，如决定选择影像检查的具体种类、时间，提高影像检查的阳性率，并指导影像结果的判读，简化诊断流程，降低医疗费用等等。在我国如果能够在疑似VTE疾病的患者的诊断策略中
规范地使用Wells评分法，无疑在VTE疾病的诊治上能进一步同国际接轨。
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参考文献
1 Oger E.Incidence of venous thromboembolism：
Occidentale
〔J〕.Thromb Haemost，
2 Qaseem A，Snow V，Barry P，et al.Current diagnosis of venous thromboembolism in primary care：a clinical practice guideline from the American Academy of Family Physicians
and the American College of Physicians〔J〕.Ann Intern Med，
3 Wells PS，Hirsh J，Anderson DR，
thrombosis〔J〕.Lancet，
4 Wells PS，Hirsh J，Anderson DR，et al.A simple clinical model for the diagnosis of
：potential for an
improvement in the diagnostic process〔J〕.J Intern Med，
5 Wells PS，Anderson DR，Bormanis J，et al.Value of assessment of pretest probability of
osis in clinical management〔J〕.Lancet，
6 Wells PS，Anderson DR，Rodger M，
〔J〕.N Engl J Med，
7 Aschwanden M，Labs KH，Jeanneret C，et al
combined with structured clinical evaluation for the diagnosis of deep vein thrombosis〔J〕.J
Vasc Surg，
8 Kearon C，Ginsberg JS，Douketis J，et al.Management of suspected deep venous thrombosis in outpat
Med，
9 Dryjski M，
，Harris LM，et al.Evaluation of a screening protocol to exclude
〔J〕.Ann Intern
the diagnosis of deep venous thrombosis among emergency department patients〔J〕.J Vasc
Surg，
10 Cornuz J，Ghali WA，Hayoz D，et al.Clinical prediction of deep venous thrombosis using
〔J〕.Am
J Med，
11 Schutgens RE，Ackermark P，Haas FJ，
deep venous thrombosis〔J〕.Circulation，
12 Anderson DR，Kovacs MJ，Kovacs G，et al.Combined use of clinical assessment and
with suspected deep vein thrombosis(the EDITED study)〔J〕.J Thromb Haemost，
13 Goodacre S，Sutton AJ，Sampson
：the value of clinical assessment
in the diagnosis of deep venous thrombosis〔J〕.Ann Intern Med，
14 Wells PS，Owen C，Doucette S，et al.Does this patient have deep vein thrombosis〔J〕?
JAMA，
15 Oudega R，Hoes AW，Moons KG.The Wells rule does not adequately rule out deep
venous thrombosis in primary care patients〔J〕.Ann Intern Med，
16 Stevens SM，Ageno W.The Wells rule was not useful in ruling out deep venous
thrombosis in primary care setting〔J〕.Evid Based Med，2006;11(2):57.
17 Wells PS，Ginsberg JS，Anderson DR，et al.Use of a clinical model for the safe management of patients with suspected pulmonary embolism〔J〕. Ann Intern Med，
18 Celi A，Palla A，Petruzzelli S，et al.Prospective study of a standardized questionnaire to
improve clinical estimate of pulmonary embolism〔J〕. Chest，
19 Hoellerich VL，Wigton RS.Diagnosing pulmonary embolism using clinical findings
〔J〕.Arch Intern Med，
20 Wells PS，Anderson DR，Rodger M，et al.Derivation of a simple clinical model to categorize patients probability of pulmonary embolism：increasing the models utility with the
〔J〕.Thromb Haemost，
21 Righini M，Le Gal G，Perrier A，et al.Clinical probability assessment of pulmonary embolism by the Wells′ score：is the easiest the best〔J〕? J Thromb Haemost，
22 Buller HR，Agnelli G，Hull RD，et al.Antithrombotic therapy for venous thromboembolic
disease：the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
〔J〕.Chest，
.