郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY重新认识重新认识D D二聚体在心脏重症的二聚体在心脏重症的的临床价值的临床价值郑州大学附属洛阳中心医院心内科郑州大学附属洛阳中心医院心内科段卡丹段卡丹1教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY基本资料l女性，女性，7373岁，农民，因岁，农民，因“胸闷、心悸胸闷、心悸4 4年，再发伴胸痛年，再发伴胸痛1 1周，加重周，加重1212小小时时”于于2016-04-182016-04-18入院。入院。l4年前无明显诱因出现心悸、胸闷，至我科住院治疗，按年前无明显诱因出现心悸、胸闷，至我科住院治疗，按“冠心病冠心病 高高血压病血压病”予以药物治疗（具体不详）后症状缓解，出院后间断口服药予以药物治疗（具体不详）后症状缓解，出院后间断口服药物（具体不详）治疗，平时活动耐量差；物（具体不详）治疗，平时活动耐量差；l1 1周前于夜间周前于夜间休息休息时再次出现胸痛、胸闷、心悸，伴咽部发紧疼痛、牙时再次出现胸痛、胸闷、心悸，伴咽部发紧疼痛、牙痛症状，持续约数小时，无出汗、肩背痛，口服痛症状，持续约数小时，无出汗、肩背痛，口服“硝酸异山梨酯硝酸异山梨酯”后后症状逐渐缓解，后至我院门诊按症状逐渐缓解，后至我院门诊按“冠心病冠心病”予以予以“ 阿司匹林阿司匹林 单硝酸单硝酸异山梨酯异山梨酯”等药物治疗；等药物治疗；2教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY基本资料l12 2小时前休息时再次出现小时前休息时再次出现胸闷、呼吸困难、心悸，伴咽部发紧疼痛、胸闷、呼吸困难、心悸，伴咽部发紧疼痛、牙痛症状，持续不缓解，门诊以牙痛症状，持续不缓解，门诊以“ACSACS”收入；收入；l高血压史高血压史1010余年，最高血压余年，最高血压210/110mmHg210/110mmHg，平素口服，平素口服“左旋氨氯地平、左旋氨氯地平、替米沙坦替米沙坦”降压，血压控制尚可。特发性震颤病史降压，血压控制尚可。特发性震颤病史3 3年，主要表现为构年，主要表现为构音障碍，头部及双上肢不自主抖动，现未药物治疗。音障碍，头部及双上肢不自主抖动，现未药物治疗。 l月经史正常，个人史、家族史无特殊月经史正常，个人史、家族史无特殊3教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY体格检查体格检查lT38.3T38.3 P88 P88次分次分 R20 R20次分次分 BP 140 BP 14090mmHg 90mmHg l自主体位，构音障碍，头部及双上肢不自主抖动，唇发绀，自主体位，构音障碍，头部及双上肢不自主抖动，唇发绀，双肺呼吸双肺呼吸音粗，可闻及散在湿啰音，以右侧为著，音粗，可闻及散在湿啰音，以右侧为著，无胸膜摩擦音，无胸膜摩擦音，心界向左扩心界向左扩大，大，心率心率8888次次/ /分，心律齐，无杂音，无心包摩擦音，无异常血管征。分，心律齐，无杂音，无心包摩擦音，无异常血管征。腹柔软，腹柔软，右上腹有压痛，右上腹有压痛，MurphyMurphy征可疑阳性，征可疑阳性，肝脾肋下未及，肝脾肋下未及，双下肢双下肢轻度水肿，轻度水肿，神经系统检查（神经系统检查（）。）。 4教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY初步诊断初步诊断1.1.冠心病冠心病 急性冠脉综合征急性冠脉综合征 心力衰竭心力衰竭 心功能心功能IVIV级级2.2.肺栓塞？肺栓塞？3.3.心律失常心律失常 完全性左束支传导阻滞完全性左束支传导阻滞4.4.高血压高血压3 3级级 极高危组极高危组5.5.肺部感染肺部感染6.6.特发性震颤特发性震颤7.7.胆囊炎？胆囊炎？5教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY实验室检查血常规血常规 WBC 8.8710WBC 8.87109 9/L/L N 0.815 RBC 3.511012/L Hb106g/L PLT 175109/L 血气分析血气分析 PH 7.49 PCO2 20mmHg PO2 65mmHg HCO3- 15.2mmol/L BE -6.6 mmol/L 生化全项生化全项K+ 3.39mmol/L Ca+ 2.03mmol/L Na+ 134mmol/L Bun 4.3mmol/L Cr 49umol/l CRP135.6mg/ l 心肌坏死标记物心肌坏死标记物 cTnI 0.001ng/ml MYO 43.73ng/ml CK-MB 4 ng/ml BNP114.83pg/ml凝血功能凝血功能PT 14.3s INR 1.2 APTT 40.4s FIB 5.83g/L D-D 2562ng/ml 6教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY心电图心电图7教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY心脏彩超2016-04-18 2016-04-18 心脏彩超心脏彩超符合高血压心脏声像图改变符合高血压心脏声像图改变心肌运动增强并不协调心肌运动增强并不协调 主动脉瓣退行性病变并返流（少量）主动脉瓣退行性病变并返流（少量）二尖瓣后叶钙化并返流（少量）二尖瓣后叶钙化并返流（少量）三尖瓣返流三尖瓣返流 （少量）（少量）左室舒张功能减低左室舒张功能减低心包积液心包积液8教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY腹部及下肢彩超2016-04-18 2016-04-18 下肢腹部彩超下肢腹部彩超双下肢动脉内中膜增厚双下肢动脉内中膜增厚脂肪肝脂肪肝胆囊壁毛糙胆囊壁毛糙9教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY病情变化2016.4.192016.4.19号号04:3504:35呼吸困难加重，复查呼吸困难加重，复查l血气分析血气分析PH7.49PCO225mmHgPO260mmHgHCO3-19.1mmol/LBE-4.2mmol/L（呋塞米（呋塞米40mg 40mg ，低分子，低分子5000 5000 单位）单位）l凝血功能凝血功能 PT14.9sINR1.21APTT53.8sFIB7.1g/LD-D2843ng/mll心肌坏死标志物心肌坏死标志物cTnI0.031ng/ml10教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY 迟到的胸片迟到的胸片2016-04-182016-04-18胸片胸片 心影稍大心影稍大 11教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY进一步检查2016-04-12016-04-19 9 胸主动脉胸主动脉CTACTA肺动脉肺动脉CTACTAIIII型夹层动脉瘤型夹层动脉瘤心包积液心包积液 双肺散在感染双肺散在感染双侧胸膜增厚双侧胸膜增厚胸主动脉、左侧锁骨下动脉粥样硬化胸主动脉、左侧锁骨下动脉粥样硬化肺动脉肺动脉CTACTA未见明显栓塞未见明显栓塞12教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY经验教训经验教训l不典型的症状：血压不高，无典型胸痛；不典型的症状：血压不高，无典型胸痛；l先入为主的思想先入为主的思想：严重呼吸困难：严重呼吸困难+D+D二聚体明显升高；二聚体明显升高；l放过明确诊断的蛛丝马迹放过明确诊断的蛛丝马迹：胸痛、肌钙蛋白不高：胸痛、肌钙蛋白不高;BNP;BNP、心脏彩超、心脏彩超; ;高血压、高血压、 UCG UCG：主动脉增宽，主动脉瓣返流，胸片纵膈明显增宽。：主动脉增宽，主动脉瓣返流，胸片纵膈明显增宽。13教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY凝血和抗凝系统凝血和抗凝系统防止血凝纤溶系统发生出血正正常常状状态态血血液液流流动动病病理理情情况况功功能能增增强强血栓形成病病理理情情况况凝血系统出出血血时时正正常常状状态态功功能能增增强强止血功能14教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYD-dimer生成凝血系统纤溶系统内源性凝血外源性凝血凝血酶原凝血酶纤维蛋白原纤维蛋白单体FXIIIFXIIIa交联纤维蛋白纤溶酶原纤溶酶FDPX,Y,D,E 碎片X,Y,D,E碎片DD,DXD,DD/E,YXD等复合物15教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYD-2聚体的概念及意义聚体的概念及意义lD-D-二聚体是纤维蛋白单体经活化因子二聚体是纤维蛋白单体经活化因子IIIIII交联后，再经纤交联后，再经纤溶酶水解所产生的一种特异性降解产物；溶酶水解所产生的一种特异性降解产物；l增高或阳性见于继发性纤维蛋白溶解功能亢进；增高或阳性见于继发性纤维蛋白溶解功能亢进；l只要机体血管内有活化的血栓形成及纤维溶解活动，只要机体血管内有活化的血栓形成及纤维溶解活动，D-D-二聚二聚体就会升高。体就会升高。 16教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYD-dimer的动态改变的动态改变l研究报道血栓形成后研究报道血栓形成后1 1小时开始升高，半衰期小时开始升高，半衰期8 8小时，至小时，至15-2015-20天逐渐天逐渐恢复正常恢复正常11；l国内肺栓塞动物实验显示国内肺栓塞动物实验显示3030分钟开始升高，分钟开始升高，1-21-2小时达到高峰，至小时达到高峰，至1010天降至血栓前水平天降至血栓前水平22。lParent F,Matire S,meyer G,Dignosis value of D -dimer in patients with suspected pulmonary ambolism:Result from a multicentre outcome study. Thrombosis Research,2007.120:195-200l倪松示，贲素琴，施裕新，黄石兵、实验性肺血栓栓塞症血浆D-二聚体的动态研究【J】中华结合和呼吸杂志2003.26（12）:803-80417教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYD-二聚体升高的状态二聚体升高的状态 血栓性疾病 DIC 恶性肿瘤、白血病 外科手术后 肝脏疾病（爆发性肝炎、肝硬化、肝癌） 肾脏疾病（肾病综合征） 心脑血管疾病 溶栓治疗后 妊娠期 血栓性血小板减少性紫癜18教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY2014ESC2014ESC主动脉疾病指南中主动脉疾病指南中D D二聚体描述二聚体描述1.1.在临床低度可能的主动脉夹层患者，在临床低度可能的主动脉夹层患者，D-D-二聚体阴性可以认为排除夹二聚体阴性可以认为排除夹层（层（IIa,BIIa,B）；）；2.2.在临床中度可能的主动脉夹层患者，在临床中度可能的主动脉夹层患者，D-D-二聚体阳性则应考虑行进一二聚体阳性则应考虑行进一步检查步检查IIa,BIIa,B）；）；3.3.在临床高度可能的主动脉夹层患者，在临床高度可能的主动脉夹层患者，D-D-二聚体检查无额外意义，不二聚体检查无额外意义，不建议常规检查（建议常规检查（IIIIII，C C）；）；D-D-二聚体增加提示患主动脉夹层风险增加二聚体增加提示患主动脉夹层风险增加。19教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYl指南指出了指南指出了D-D-二聚体可以用于排除临床上患二聚体可以用于排除临床上患AADAAD可能性低的患者，但对中度和可能性低的患者，但对中度和高度可能患高度可能患AADAAD的患者无可奈何，没有指出的患者无可奈何，没有指出D-D-二聚体的诊断临界值二聚体的诊断临界值; ;l否累及升主动脉，以及是否出现并发症如休克、灌注不足和心包积液等，对否累及升主动脉，以及是否出现并发症如休克、灌注不足和心包积液等，对D-D-二聚体水平几乎没有影响，而年龄、症状出现间隔二聚体水平几乎没有影响，而年龄、症状出现间隔D-D-二聚体检测的时间和二聚体检测的时间和是否出现完全血栓型假腔（溃疡除外）对是否出现完全血栓型假腔（溃疡除外）对D-D-二聚体的水平有重要的影响。二聚体的水平有重要的影响。11Hazui, H., et al., Hazui, H., et al., Young adult patients with short dissection length andthrombosed false lumen without ulcer-Like projections are Young adult patients with short dissection length andthrombosed false lumen without ulcer-Like projections are liable to havefalse-negative results of D-dimer testing for acute aortic dissection based on aliable to havefalse-negative results of D-dimer testing for acute aortic dissection based on astudy of 113 cases. study of 113 cases. Circulation Journal, 2012. Circulation Journal, 2012. 7070(12): p. 1598-1601(12): p. 1598-160120教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY2014ESC2014ESC肺栓塞指南中肺栓塞指南中D D二聚体描述二聚体描述1 1、根据年龄调整的、根据年龄调整的、根据年龄调整的、根据年龄调整的D D D D二聚体界值：二聚体界值：二聚体界值：二聚体界值： 50505050岁以上的患者中，不再使用岁以上的患者中，不再使用岁以上的患者中，不再使用岁以上的患者中，不再使用500ug/L,500ug/L,500ug/L,500ug/L,定定定定义为：年纪义为：年纪义为：年纪义为：年纪10ug/L10ug/L10ug/L10ug/L；2.2.2.2.对于高危患者，强调尽早行对于高危患者，强调尽早行对于高危患者，强调尽早行对于高危患者，强调尽早行CTCTCTCT肺动脉造影（肺动脉造影（肺动脉造影（肺动脉造影（CTPACTPACTPACTPA）明确诊断，然后进行再灌）明确诊断，然后进行再灌）明确诊断，然后进行再灌）明确诊断，然后进行再灌注治疗，首选溶栓治疗（注治疗，首选溶栓治疗（注治疗，首选溶栓治疗（注治疗，首选溶栓治疗（BBBB）；）；）；）；3.3.3.3.非高危患者进一步分为高度和低中度临床可能性，对前者强调行非高危患者进一步分为高度和低中度临床可能性，对前者强调行非高危患者进一步分为高度和低中度临床可能性，对前者强调行非高危患者进一步分为高度和低中度临床可能性，对前者强调行CTPACTPACTPACTPA明确诊明确诊明确诊明确诊断，后者可先行断，后者可先行断，后者可先行断，后者可先行D-D-D-D-二聚体检查，对阳性患者进一步行二聚体检查，对阳性患者进一步行二聚体检查，对阳性患者进一步行二聚体检查，对阳性患者进一步行CTPACTPACTPACTPA（BBBB）。）。）。）。 21教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY恰当使用恰当使用 D- D- 二聚体检测可减少对不必要的影像学检查和辐射二聚体检测可减少对不必要的影像学检查和辐射22教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY妊娠患者的正式建议妊娠患者的正式建议l正常的正常的D-D-二聚体值在妊娠妇女中仍具有除外诊断的价值二聚体值在妊娠妇女中仍具有除外诊断的价值（IAIA）；）；l若若D-D-二聚体二聚体异常增高，应行下肢静脉加压超声，若发现近端异常增高，应行下肢静脉加压超声，若发现近端DVTDVT则需则需 抗凝治疗抗凝治疗（IBIB）；l若超声检查结果阴性，应进一步检查若超声检查结果阴性，应进一步检查， 胸片、胸片、CTCT血管造影等的辐射血管造影等的辐射 剂量均远低于对胎儿造成损伤的危险辐射剂量阈值，但仍应优先选择剂量均远低于对胎儿造成损伤的危险辐射剂量阈值，但仍应优先选择 肺同位素灌注显像肺同位素灌注显像（IIAIIA）。）。 23教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYD-D-二聚体急诊临床共识二聚体急诊临床共识D-D-D-D-二聚体检测的急诊临床应用分为两大部分：二聚体检测的急诊临床应用分为两大部分：二聚体检测的急诊临床应用分为两大部分：二聚体检测的急诊临床应用分为两大部分：1.1.1.1.与静脉血栓症相关的疾病与静脉血栓症相关的疾病与静脉血栓症相关的疾病与静脉血栓症相关的疾病如如如如APEAPEAPEAPE、DVTDVTDVTDVT、CVSTCVSTCVSTCVST；2.2.2.2.非静脉血栓症如非静脉血栓症如非静脉血栓症如非静脉血栓症如AADAADAADAAD、CVACVACVACVA、DICDICDICDIC、ACSACSACSACS、COPDCOPDCOPDCOPD。24教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY D-dimer D-dimer 急诊临床应用急诊临床应用l筛查高危的心脏筛查高危的心脏/ /大血管疾病（动脉和静脉）患者，降低医疗风险大血管疾病（动脉和静脉）患者，降低医疗风险; ;lSevre sepsis/DIC/CVSTSevre sepsis/DIC/CVST等疾病的危险分层。等疾病的危险分层。25教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYD-dimerD-dimer与急性冠脉综合征与急性冠脉综合征lACSACS患者的血栓多形成于中小动脉末端，而中小动脉口径较静脉细，血栓体患者的血栓多形成于中小动脉末端，而中小动脉口径较静脉细，血栓体积较小，继发性纤溶后血清中积较小，继发性纤溶后血清中D-D-二聚体含量相对较低。因此，与二聚体含量相对较低。因此，与PTEPTE、DVTDVT和和AADAAD患者相比，患者相比，ACSACS患者血浆中患者血浆中D-D-二聚体浓度的变化不明显二聚体浓度的变化不明显；l可作为溶栓再通的指标。可作为溶栓再通的指标。26教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY老调重弹老调重弹？ 或超乎想象的临床应用价值或超乎想象的临床应用价值! 27教育郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院郑州大学附属洛阳中心医院LUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITYLUOYANG CENTRAL HOSPITAL AFFILIATED TO ZHENGZHOU UNIVERSITY28教育