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Roadmap to final diagnosis
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Korean J Med. 2026;101(5):255-266. Published online October 1, 2026.
DOI: https://doi.org/10.3904/kjm.2026.101.5.255
- 호흡 곤란과 실신으로 내원한 환자에서 정맥혈전색전증의 진단
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우종신
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경희대학교 의과대학 경희대학교병원 심장내과
- A Diagnostic Roadmap for Venous Thromboembolism: Pulmonary Embolism and Deep Vein Thrombosis
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Jong Shin Woo
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Division of Cardiovascular, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
- Corresponding author: Jong Shin Woo ,Tel: +82-2-958-8170, Fax: +82-2-958-8160, Email: cardiodrwoo@gmail.com
- Received: June 22, 2026; Revised: August 23, 2026 Accepted: September 21, 2026.
- 증례: 79세 남자가 실신 후 응급실에 내원하였다. 의식 소실은 일시적이었고 내원 시 신경학적 결손은 뚜렷하지 않았으나 호흡 곤란과 전신 쇠약감을 호소하였다. 활력 징후는 혈압 156/78 mmHg, 심박수 85회/분, 호흡수 20회/분, 실내 공기 산소포화도 80%였으며, 비강 캐뉼라로 산소 5 L/min을 투여한 후 산소포화도는 96%로 유지되었다. 고혈압, 당뇨병 및 관상동맥질환의 과거력이 있었고 aspirin, amlodipine/atorvastatin, carvedilol, fimasartan, doxazosin 및 dapagliflozin/metformin 을 복용 중이었다.
심전도에서 ST분절 상승은 없었다. 고감도 트로포닌 I (high-sensitivity troponin I, hs-troponin I)은 28.6 pg/mL로 99백분위 상한 기준치(17.5 pg/mL)를 초과하였고, D-dimer는 >20 μg/mL (참고치 < 0.5 μg/mL), N-말단 B형 나트륨이뇨펩타이드(N-terminal pro-B-type natriuretic peptide, NT-proBNP)는 336 pg/mL, 젖산은 2.15 mmol/L, 추정 사구체여과율은 50.12 mL/min/1.73 m2였다. 폐동맥 컴퓨터단층혈관조영술에서 양측 주폐동맥과 양측 폐의 다발성 엽, 분절 폐동맥 가지를 침범하는 급성 폐색전증이 확인되었다. 심초음파에서는 우심실/좌심실 비 0.9, 삼첨판륜 수축기 이동거리(tricuspid annular plane systolic excursion, TAPSE) 15.9 mm, 우심실 분획면적 변화(right ventricular fractional area change, RVFAC) 18%, 추정 폐동맥 수축기압 43.8 mmHg였다. 하지 압박초음파에서는 양측 슬와정맥의 혈전이 확인되었다.
߽ɾ :정맥혈전색전증; 폐색전증; 심부정맥혈전증; D-이합체 검사; 진단 알고리즘; 임상 가능성
- Abstract
- Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), requires a structured diagnostic roadmap to prevent delayed diagnosis and unnecessary imaging. This review outlines a step-by-step approach from clinical suspicion to objective confirmation and early risk stratification. For suspected PE, hemodynamic stability is the initial branch point. Hemodynamically stable patients are evaluated using pretest probability tools and validated D-dimer strategies, including age-adjusted thresholds, YEARS, or clinical-probability-adjusted approaches such as PEGeD, followed by computed tomography pulmonary angiography when indicated. Pregnancy-adapted YEARS can reduce thoracic imaging in selected pregnant patients. For suspected DVT, the Wells score, D-dimer, and compression ultrasonography are applied sequentially. Once PE is confirmed, risk assessment should integrate clinical severity, right ventricular dysfunction, cardiac biomarkers, hemodynamic and respiratory compromise to guide management decisions. The final diagnosis should specify thrombus location and extent, risk category, provoking factors, and remaining diagnostic uncertainty. Standardizing this roadmap may reduce diagnostic delay and unnecessary imaging while linking diagnosis to appropriate disposition, monitoring, and follow-up.
Keywords :Venous thromboembolism, Pulmonary embolism, Deep vein thrombosis, D-dimer, Diagnostic algorithm, Clinical probability
