BACKGROUND: The exact prevalence and etiology of exertional dyspnea in the clinical course of acute pulmonary embolism (PE) have not yet been established. METHODS: A large cohort of consecutive... Show moreBACKGROUND: The exact prevalence and etiology of exertional dyspnea in the clinical course of acute pulmonary embolism (PE) have not yet been established. METHODS: A large cohort of consecutive patients diagnosed with acute PE was subjected to a dyspnea questionnaire and invited for cardiopulmonary work-up including the 6-min walk test, spirometry and echocardiography. The prevalence, severity, determinants and underlying diseases of exertional dyspnea were evaluated. RESULTS: Of the registered 877 patients, 259 (30%) had died and 11 (1.3%) were excluded for geographical reasons. From the remaining 607 patients, 217 reported exertional dyspnea (36%; 95% CI 32-40%) 3.6 +/- 1.7 years after the PE. In 76% this dyspnea had developed or worsened after the acute PE. 421 patients completed the cardiopulmonary work-up. Cardiopulmonary comorbidity (OR 12; 95% CI 6.5-20), advanced age (OR 1.02 per year; 95% CI 1.01-1.03), higher BMI (OR 1.06 per kg/m(2); 95% CI 1.01-1.1) and a smoking history (OR 1.6; 95% CI 1.02-2.6) were identified as independent predictors of exertional dyspnea. A pre-defined dyspnea explaining diagnosis could be established in all patients with exertional dyspnea. In only 4 patients, this diagnosis was directly correlated to the acute PE. Increased severity of dyspnea was associated with decreased exercise performance (p < 0.001) and a higher number of dyspnea-related diagnoses (p < 0.001). CONCLUSION: Exertional dyspnea is a frequent symptom in the long term clinical course of acute PE. More severe dyspnea results in decreased exercise capacity and increased burden of cardiopulmonary comorbidity. This dyspnea is likely to be unrelated to the past thromboembolic event in the vast majority of patients. Show less
Abstract BACKGROUND: Studies evaluating the quality of life (QoL) in patients with a history of acute pulmonary embolism (PE) are not available, even though QoL is a key component of outcome of... Show moreAbstract BACKGROUND: Studies evaluating the quality of life (QoL) in patients with a history of acute pulmonary embolism (PE) are not available, even though QoL is a key component of outcome of medical care and a predictor of disease specific prognosis. METHODS: As part of a large follow-up study the Short Form-36 (SF-36) was presented to consecutive patients who had survived one or more episodes of acute PE. The results of all 9 subscales of the SF-36 were compared to sex and age adjusted Dutch population norms. Single and multivariate analyses were performed to identify independent determinants of the quality of life in our study population. RESULTS: The SF-36 was completed by 392 patients. Except for the subscale health change, patients had substantially lower QoL than population norms on all 8 remaining subscales. After multivariate analysis, the time interval between the last thromboembolic episode and study inclusion was inversely related to QoL, and significant determinants of poor QoL were prior PE, age, obesity, active malignancy and cardiopulmonary comorbid conditions. Regression models including all identified significant determinants proved to be quite modest predictors for QoL in the individual patient. Illness cognitions, coping mechanisms and self management behaviour might be additional important indicators of QoL in our study population but remain to be studied. CONCLUSION: We identified several PE- and non-PE related determinants of QoL in patients with a history of acute PE, which is impaired compared to sex and age adjusted population norms. QoL after acute PE should be studied more extensively and added as standard measure to outcome studies. Show less
Tan, M.; Velthuis, S.I.; Westerbeek, R.E.; Rooden, C.J. van; Meer, F.J.M. van der; Huisman, M.V. 2010
INTRODUCTION The Wells clinical decision rule (CDR) and D-dimer tests can be used to exclude pulmonary embolism (PE). We performed a meta-analysis to determine the negative predictive value (NPV)... Show moreINTRODUCTION The Wells clinical decision rule (CDR) and D-dimer tests can be used to exclude pulmonary embolism (PE). We performed a meta-analysis to determine the negative predictive value (NPV) of an "unlikely" CDR ( Show less
Klok, F.A.; Bijl, N. van der; Roos, A. de; Kroft, L.J.M.; Huisman, M.V. 2010
BACKGROUND: Even though quality of life (QoL) has become a key component of medical care, there is no instrument available that specifically measures QoL after pulmonary embolism (PE). Recently,... Show moreBACKGROUND: Even though quality of life (QoL) has become a key component of medical care, there is no instrument available that specifically measures QoL after pulmonary embolism (PE). Recently, the Pulmonary Embolism Quality of Life (PEmb-QoL) Questionnaire has been developed to address this gap. OBJECTIVE: To evaluate the validity of the PEmb-QoL questionnaire. METHODS: We distributed the PEmb-QoL questionnaire and the Short Form-36 (SF-36) questionnaire twice among consecutive subjects with a history of objectively confirmed acute PE. Internal consistency reliability, test-retest reliability, convergent validity and criterion validity, and correlations between the PEmb-QoL and clinical patient characteristics were assessed using standard-scale construction techniques. RESULTS: Ninety participants completed the questionnaires twice. Internal consistency was adequate (Cronbach's alpha 0.62-0.94), as well as test-retest reliability (intra-class correlation coefficients: 0.78-0.94). Furthermore, correlation between the PEmb-QoL questionnaire and the SF-36 questionnaire supported convergent validity. Age, obesity, cardiopulmonary comorbidity, centrally located PE and a family history of venous thromboembolism were shown to be independent determinants of disease-specific QoL. CONCLUSION: The PEmb-QoL questionnaire is a reliable instrument to specifically assess QoL following PE, which is helpful in the identification of patients with decreased QoL following acute PE. Show less
Background: Even though quality of life (QoL) has become a key component of medical care, there is no instrument available that specifically measures QoL after pulmonary embolism (PE). Recently,... Show moreBackground: Even though quality of life (QoL) has become a key component of medical care, there is no instrument available that specifically measures QoL after pulmonary embolism (PE). Recently, the Pulmonary Embolism Quality of Life (PEmb-QoL) Questionnaire has been developed to address this gap. Objective: To evaluate the validity of the PEmb-QoL questionnaire. Methods: We distributed the PEmb-QoL questionnaire and the Short Form-36 (SF-36) questionnaire twice among consecutive subjects with a history of objectively confirmed acute PE. Internal consistency reliability, test-retest reliability, convergent validity and criterion validity, and correlations between the PEmb-QoL and clinical patient characteristics were assessed using standard-scale construction techniques. Results: Ninety participants completed the questionnaires twice. Internal consistency was adequate (Cronbach's alpha 0.62-0.94), as well as test-retest reliability (intra-class correlation coefficients: 0.78-0.94). Furthermore, correlation between the PEmb-QoL questionnaire and the SF-36 questionnaire supported convergent validity. Age, obesity, cardiopulmonary comorbidity, centrally located PE and a family history of venous thromboembolism were shown to be independent determinants of disease-specific QoL. Conclusion: The PEmb-QoL questionnaire is a reliable instrument to specifically assess QoL following PE, which is helpful in the identification of patients with decreased QoL following acute PE. Show less
RATIONALE: There is a lack of information on the long-term prognosis of patients with acute pulmonary embolism (PE). OBJECTIVES: To assess the long-term risk for adverse events after PE. METHODS:... Show moreRATIONALE: There is a lack of information on the long-term prognosis of patients with acute pulmonary embolism (PE). OBJECTIVES: To assess the long-term risk for adverse events after PE. METHODS: Consecutive patients diagnosed with PE between January 2001 and July 2007, and patients in whom PE was ruled out from a previous study were followed until July 2008 for the occurrence of adverse clinical events: mortality, symptomatic recurrent venous thromboembolism, cancer, arterial cardiovascular events and chronic thromboembolic pulmonary hypertension. Hazard ratios (HR) for all endpoints and a combined endpoint were calculated and adjusted for potential confounders. MEASUREMENTS AND MAIN RESULTS: Three hundred eight patients with unprovoked, 558 with provoked, and 334 without PE were studied with a median follow-up period of 3.3 years. Patients with unprovoked PE had a lower overall risk for mortality than patients with provoked PE (HR, 0.59; 95% confidence interval [CI], 0.43-0.82), but a higher risk for nonmalignancy-related mortality (HR, 1.8; 95% CI, 1.3-2.5), recurrent venous thromboembolism (HR, 2.1; 95% CI, 1.3-3.1), cancer (HR, 4.4; 95% CI, 2.0-10), cardiovascular events (HR, 2.6; 95% CI, 1.5-3.8) and chronic thromboembolic pulmonary hypertension (1.5 vs. 0%). The risk for the combined endpoint did not differ between both groups (HR, 0.98; 95% CI, 0.82-1.1). Patients without PE had similar risks for malignancy and cardiovascular events than patients with provoked PE, but lower risks for the remaining outcomes. The fraction of both patients with provoked and unprovoked PE without events after 1 year was only 70% and decreased to fewer than 60% after 2 years and fewer than 50% after 4 years, whereas this latter was 84% for the control patients. CONCLUSIONS: The clinical course of acute PE is complicated by high rates of serious adverse events, which occur in half of the patients within 4 years. Show less
Kooiman, J.; Klok, F.A.; Mos, I.C.M.; Molen, A. van der; Roos, A. de; Sijpkens, Y.W.J.; Huisman, M.V. 2010
Background: Current guidelines in cardiovascular disease prevention advocate the use of carotid ultrasound measurements for risk stratification. Carotid abnormalities (plaques or increased intima... Show moreBackground: Current guidelines in cardiovascular disease prevention advocate the use of carotid ultrasound measurements for risk stratification. Carotid abnormalities (plaques or increased intima-media thickness (IMT)) are associated with high risk of coronary and peripheral artery disease. An office-based measurement by clinicians would considerably broaden the clinical applicability of carotid ultrasound. In the present study we have assessed the accuracy of ultrasound detection of carotid plaques and intima-media thickness by trained internists in a routine outpatient setting. Methods and results: Carotid ultrasound was performed in 112 vascular outpatients by internists, after a six-week training period. The internists' results were independently compared to the reference standard, consisting of carotid ultrasound performed in a specialized vascular laboratory. Sensitivity and specificity were calculated for plaque detection and IMT determination. The mean time required to perform the scans on the outpatient department was 7.3 min (range 4.5 to 16.7 min). A high level of accuracy for detecting plaques (sensitivity 78.5%; specificity 93.6%) was achieved. Identifying abnormal IMT had lower sensitivity but adequate specificity of 46.7% and 87.6%, respectively. Conclusions: In conclusion, our findings demonstrate that clinicians can be trained well enough in six weeks to accurately and efficiently detect carotid plaques in an outpatient setting. IMT abnormalities were less accurately detected in the office-based approach and may require a specialized vascular laboratory. (C) 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Show less
Klok, F.A.; Bijl, N. van der; Eikenboom, H.C.J.; Rooden, C.J. van; Roos, A. de; Kroft, L.J.M.; Huisman, M.V. 2010
