Chapter 1 introduces the topic of the thesis. In this thesis we investigated the management of pulmonary embolism (PE) at the interface of community and hospital based health care.
The chapter first describes the definition and epidemiology of PE. PE is a blood clot that blocks the main artery of the lung or one of its branches. It is the third most common cause of death from cardiovascular disease and results from a combination of hereditary and acquired risk factors.
The chapter then discusses the historical developments in diagnosing PE. Diagnosis of PE is a major challenge because patients often present with non‐specific symptoms. The invasive and labor intensive cathether guided pulmonary angiography has been the gold stadard reference test for PE for many years. Nowadays, probability estimation by using a clinical decision rule and laboratory‐based D‐Dimer testing, followd by CT‐scanning if indicated, is the routine protocol in patients suspected of PE in secondary care. The diagnostic strategy of assessing the probability of PE by a clinical decision rule and D‐dimer testing seems also ideal for primary care to decide which patients suspected of PE need to be referred to secondary care for further diagnostic work‐up. The chapter then goes on to report the rationale and aim of part I of this thesis ‘Diagnosing pulmonary embolism in primary care’. In the Netherlands, the primary care physician is commonly the first to encounter outpatients suspected of PE. In the Amsterdam Maastricht Utrecht Study on thromboEmbolism (AMUSE‐2) we investigated the accuracy and safety of the Wells clinical decision rule combined with point‐of‐care D‐dimer testing for excluding PE in primary care.
The next section of the chapter starts with the historical developments in the treatment of PE. Pateints with PE are usually treated with low molecular weight heparin for 5 to 10 days simultaneously with vitamin K antagonists (VKA). However, recently novel anticoagulant medication with a similar effcicacy as VKA has been developed and approved in many countries worldwide. The guidelines of the American College of Chest Physicians recommend to treat patients with a first provoked PE for 3 months, patients with a first episode of idiopathic PE at least 6 to 12 monhts and patients with two or more objectively documented PE indefintely. The chapter then describes the rational and aim of the second part of this thesis ‘Treatment of pulmonary embolism in secondary care’. The role of outpatient therapy in patients with PE is unclear and has been a matter of debate in literature. We investigated whether patients with hemodynamically stable PE could be safely treated out of the hospital and whether the Pulmonary Embolism Severity Index, a prognostic model for prediction of short‐term adverse outcomes, could help in the identification of appropriate patients for outpatient management.
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