1. Managing suspected pulmonary embolism in primary care Referral for all? G.J. Geersing, M.D. PhD. Julius Center for Health Sciences and Primary Care EPCCS workshop WONCA 2014

2. Today’s presentation Background Diagnosing PE Overdiagnosing PE

3. Start with a patient Doctor, I took the nighttrain to Lisbon, and now after arrival I started to experience some shortness of breath, it’s more than usual and doesn’t seem to respond to my usual salbutamol … Male, 64 years old. Mild COPD (used to smoke). DVT after travelling to New York, 10 years ago. RR 140/70, pols 110/min r.a. Lungs: normal, no signs of infection/bronchitis. What should we do? Refer him?

4. Background venous thromboembolism

5. It’s serious!

6. Missing VTE BMJ 1949

7. Missing VTE today? Archives of Internal Medicine 2008

8. VTE disease of the elderly

9. Diagnosing PE, the easy part.

10. Risk of PE after a negative CT-scan R. Quiroz et.al. JAMA 2005

11. Refer all patients? At least you don’t miss a case of potentially fatal pulmonary embolism!

12. Overutilization of healthcare? Referral has low yield. Even decreased over recent years…  Solution: development of clinical decision rules

13. Clinical Decision Rule by Wells

14. Additional D-dimer testing; introduced in the ’90s D-dimer degradation product of fibrin. Rule-out test.

15. Combination of CDR and D-dimer testing W. Lucassen and G.J. Geersing Ann Int Med 2011

16. Combination of CDR and D-dimer testing W. Lucassen and G.J. Geersing Ann Int Med 2011 Combination of a low score on the clinical decision rule and a negative D-dimer test safely excludes PE in about 1 in every 3 patients.

17. How does this work in Primary Care?

18. The AMUSE-2 study Diagnostic validation study Patients suspected of acute PE All patients referred Point-of-care D-dimer test applied

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

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

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

22. Patients suspected of PE N = 662 Study patients N = 598 Excluded patients N = 64 VKA or LMWH use N = 28 Pregnant N = 15 Age < 18 years N = 3 Unable to follow-up N = 18 Reference: Spiral CT N = 70 V/Q scan N = 11 US N = 5 3 m f-up only N = 151 POC DD negative: N = 168 VTE positive N=2 Failure rate = 1.2 % Efficiency = 28 % LOW RISK HIGH RISK Wells score <2 N = 237 Wells score ≤ 4 N = 422 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 Reference: Spiral CT N = 131 V/Q scan N = 14 DSA N = 3 US N = 9 3 m f-up only N = 265 POC DD positive: N = 69 POC DD negative: N = 272 VTE positive N=4 Failure rate = 1.5 % Efficiency = 45 % VTE positive N=52 Hence, confirmed VTE in around 1 in 3 patients VTE positive N=5 Using a low score on the Wells score combined with a negative D-dimer is both safe and efficient in primary care for ruling-out acute PE.

23. Our patient is still waiting Doctor, I took the nighttrain to Lisbon, and now after arrival I started to experience some shortness of breath, it’s more than usual and doesn’t seem to respond to my usual salbutamol … Male, 64 years old. Mild COPD (used to smoke). DVT after travelling to New York, 10 years ago. RR 140/70, pols 110/min r.a. Lungs: normal, no signs of infection/bronchitis. Wells score = 3.0  D-dimer negative: PE ruled-out  D-dimer positive: refer for PE

24. Overdiagnosis of pulmonary embolism? R. Soylemes Wiener et.al. Arch Int Med 2011

25. Diagnosing PE, maybe not the easy part?!