Diagnostiek VTE: 1 e of 2 e lijn?

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1 Diagnostiek Diagnostiek VTE: 1 e of 2 e lijn? Dr. Geert-Jan Geersing huisarts Universitair Medisch Centrum Utrecht Julius Center for Health Sciences and Primary Care

2 Longembolie en de huisarts Iedereen verwijzen? G.J. Geersing, M.D. PhD. huisarts Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde Stollingsdag 2014

3 Amuse 2005 It s serious! 2

4 Gemiste diagnose? BMJ 1949

5 Hoe gaat dat momenteel? Archives of Internal Medicine 2008

6 VTE zal toenemen!

7 Het eenvoudige deel van de diagnostiek.

8 Kans op PE na negatieve spiraal CT. R. Quiroz et.al. JAMA 2005

9 Overdiagnostiek? Slechts PE bij 10-15%! Neemt af Beslisregels!

10 Wells PE beslisregel

11 D-dimeer bepaling Degradatie product van fibrine Hoge sens / lage spec

12 Beslisregel en negatieve D-dimeer W. Lucassen and G.J. Geersing Ann Int Med 2011

13 Beslisregel en negatieve D-dimeer PE veilig uitgesloten in 1 op de 3 patiënten W. Lucassen and G.J. Geersing Ann Int Med 2011

14 De huisarts.

15 Point of Care (p.o.c.) D-dimer test: Simplify * * Clearview Simplify, Inverness Medical, Bedford, UK

16 Excluded patients N = 64 VKA or LMWH use N = 28 Pregnant N = 15 Age < 18 years N = 3 Unable to follow-up N = 18 Patients suspected of PE N = 662 Study patients N = 598 LOW RISK HIGH RISK Wells score <2 N = 237 Wells score 4 N = 422 Wells score > 4 N = 176 Reference: Spiral CT N = 70 V/Q scan N = 11 US N = 5 3 m f-up only N = 151 Reference: Spiral CT N = 131 V/Q scan N = 14 DSA N = 3 US N = 9 3 m f-up only N = 265 Reference: Spiral CT N = 101 V/Q scan N = 7 DSA N = 2 US N = 9 3 m f-up only N = 57 POC DD negative: POC DD positive: POC DD negative: POC DD positive: N = 168 N = 69 N = 272 N = 150 VTE positive N=2 Failure rate = 1.2 % Efficiency = 28 % VTE positive N=5 VTE positive N=4 VTE positive N=17 Failure rate = 1.5 % Efficiency = 45 % VTE positive N=52 Hence, confirmed VTE in around 1 in 3 patients

17 Excluded patients N = 64 VKA or LMWH use N = 28 Pregnant N = 15 Age < 18 years N = 3 Unable to follow-up N = 18 Patients suspected of PE N = 662 Study patients N = 598 LOW RISK HIGH RISK Wells score <2 N = 237 Reference: Spiral CT N = 70 V/Q scan N = 11 US N = 5 3 m f-up only N = 151 Wells score 4 N = 422 Reference: Spiral CT N = 131 V/Q scan N = 14 DSA N = 3 US N = 9 3 m f-up only N = 265 Wells score > 4 N = 176 Reference: Spiral CT N = 101 V/Q scan N = 7 DSA N = 2 US N = 9 3 m f-up only N = 57 POC DD negative: N = 168 POC DD negative: N = 272 POC DD positive: N = 150 VTE positive N=2 Failure rate = 1.2 % Efficiency = 28 % VTE positive N=4 Failure rate = 1.5 % Efficiency = 45 % VTE positive N=17 VTE positive N=52 Hence, confirmed VTE in around 1 in 3 patients

18 Excluded patients N = 64 VKA or LMWH use N = 28 Pregnant N = 15 Age < 18 years N = 3 Unable to follow-up N = 18 Patients suspected of PE N = 662 Study patients N = 598 LOW RISK HIGH RISK Wells score <2 N = 237 Reference: Spiral CT N = 70 V/Q scan N = 11 US N = 5 3 m f-up only N = 151 Wells score 4 N = 422 PE veilig uitgesloten in de eerste lijn. Reference: Spiral CT N = 131 V/Q scan N = 14 DSA N = 3 US N = 9 3 m f-up only N = 265 Wells score > 4 N = 176 Reference: Spiral CT N = 101 V/Q scan N = 7 DSA N = 2 US N = 9 3 m f-up only N = 57 POC DD negative: N = 168 POC DD positive: N = 69 POC DD negative: N = 272 VTE positive N=2 Failure rate = 1.2 % Efficiency = 28 % VTE positive N=5 VTE positive N=4 Failure rate = 1.5 % Efficiency = 45 % VTE positive N=52 Hence, confirmed VTE in around 1 in 3 patients

19 Thuis behandeling volgende stap?

20 Overdiagnostiek PE? R. Soylemes Wiener et.al. Arch Int Med 2011

21 Spiraal CT toch niet zo makkelijk

22 Discussie Diagnostiek PE = rol voor de huisarts PE = vaak gemiste diagnose Spiraal CT = eenvoud Spiraal CT = risico op overdiagnostiek Bottom line: We weten wat we moeten doen, maar weten we ook bij wie?