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M H Prins

Publications and source records attributed to M H Prins.

At least 19 recordsLinked to original sources
PubMed2007

Antithrombotic drug prescription in atrial fibrillation and its rationale among general practitioners, internists and cardiologists in The Netherlands--The EXAMINE-AF study. A questionnaire survey.

The objective of the EXAMINE-AF study was to record and compare antithrombotic treatment in patients with atrial fibrillation (AF) in daily clinical practice of general practitioners, internists and cardiologists in the Netherlands. Eighty-six general practitioners, 93 internists and 99 cardiologists responded to postal questionnaires and enrolled 1596 patients: 365, 351 and 880 respectively. A cardiologist was indicated to be the main treating physician for AF in 82% of all patients; current antithrombotic treatment was initiated in 80% by a cardiologist. Of all patients, 84% were at high risk for stroke and therefore were eligible for oral anticoagulation treatment, but only 64% actually received this. Cardiologists instituted appropriate antithrombotic treatment best, compared with general practitioners and internists (70% vs. 58% and 55%; p < 0.001). Positive predictive factors for oral anticoagulation prescription were previous stroke/transient ischaemic attack (OR, 2.31; 95% CI, 1.33-4.02) and heart failure (OR, 1.72; 95% CI, 1.23-2.42). Contraindications for oral anticoagulation (OR, 0.46; 95% CI, 0.32-0.68), treatment by a general practitioner (OR, 0.29; 95% CI, 0.20-0.42) or internist (OR, 0.24; 95% CI, 0.15-0.39) were important factors for withholding treatment. Antithrombotic treatment in AF patients is well instituted in primary and secondary care in the Netherlands. Cardiologists play a key role in the diagnosis and management of the majority of AF patients, even in those regularly attending other physicians. Factors for oral anticoagulation prescription are heart failure, physician specialty and contraindications. Availability of guidelines seems instrumental for application of appropriate antithrombotic treatment.

Adolescent↗
PubMed2006

Cost-effectiveness of early detection and treatment of ocular hypertension and primary open-angle glaucoma by the ophthalmologist.

PURPOSE: To determine the most cost-effective case-finding strategy for the ophthalmologist to detect and treat ocular hypertension (OH) and primary open-angle glaucoma (POAG) at an early stage to prevent blindness. DESIGN: A Markov cost-effectiveness simulation model. METHODS: Three case-finding strategies are analysed and compared. The simulated cohort consists of all initial patients of at least 40 years old visiting an ophthalmic practice. All patients undergo ophthalmoscopy, but tonometry is routinely performed to: (1) all initial patients, (2) high-risk patients only, or (3) no one. The population characteristics are based on data of 1000 initial patients. Transition probabilities are taken from the literature. The (direct) costs of diagnosis and treatment represent those for the Netherlands. The time-horizon of the model is 20 years. An annual discount rate of 4% is used. MAIN OUTCOME MEASURES: Costs, proportion of patients becoming blind, years of blindness. RESULTS: The costliest strategy (1) leads to least blindness. The incremental cost-effectiveness ratio, which shows extra costs per year of vision saved in comparison to the cheapest strategy (3), is lower for strategy (1) than for strategy (2). It amounts to euro1707, not including extra costs due to blindness (eg associated with the use of disability facilities). When such costs exceed euro1707 per patient per year, which is most likely, then strategy (1) becomes cost saving. CONCLUSION: It is most cost-effective to routinely perform tonometry to all initial ophthalmic patients to prevent blindness due to glaucoma.

Adult↗
PubMed2006

Which factors are associated with the application of reperfusion therapy in ST-elevation acute coronary syndromes?. Lessons from the Euro Heart Survey on Acute Coronary Syndromes I.

BACKGROUND/AIMS: A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy. METHODS: From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy. RESULTS: A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI. CONCLUSION: Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.

Aged↗
PubMed2006

Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication.

BACKGROUND: Although exercise therapy is considered to be of significant benefit to people with leg pain (intermittent claudication), almost half of those affected do not undertake any exercise therapy. OBJECTIVES: To evaluate the effects of supervised versus non-supervised exercise therapy on the maximal walking time or distance for people with intermittent claudication. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialized Register (last searched November 2005) and the Cochrane Central Register of Controlled Trials (CENTRAL) database in The Cochrane Library (last searched Issue 4, 2005). In addition, we handsearched the reference lists of relevant articles for additional trials. There was no restriction on language of publication. SELECTION CRITERIA: Randomized and controlled clinical trials comparing supervised exercise programs with non-supervised exercise programs for people with intermittent claudication. DATA COLLECTION AND ANALYSIS: Two authors (BB and EMW) independently selected trials and extracted data. One author (BB) assessed trial quality and this was confirmed by a second author (MP). For all continuous outcomes we extracted the number of participants, the mean differences, and the standard deviation. If data were available, the standardized mean difference was calculated using a fixed-effect model. MAIN RESULTS: We identified twenty-seven trials, of which 19 had to be excluded because the control group received no exercise therapy at all. The remaining eight trials involved a total of 319 male and female participants with intermittent claudication. The follow up ranged from 12 weeks to 12 months. In general, the supervised exercise regimens consisted of three exercise sessions per week. All trials used a treadmill walking test as one of the outcome measures. The overall quality of the included trials was good, though the trials were all small with respect to the number of participants, ranging from 20 to 59. Supervised exercise therapy showed statistically significant and clinically relevant differences in improvement of maximal treadmill walking distance compared with non-supervised exercise therapy regimens, with an overall effect size of 0.58 (95% confidence interval 0.31 to 0.85) at three months. This translates to a difference of approximately 150 meters increase in walking distance in favor of the supervised group. AUTHORS' CONCLUSIONS: Supervised exercise therapy is suggested to have clinically relevant benefits compared with non-supervised regimens, which is the main prescribed exercise therapy for people with intermittent claudication. However, the clinical relevance has not been demonstrated definitely and will require additional studies with a focus on the improvements in quality of life.

Directly Observed Therapy↗
PubMed2006

Duration of treatment with vitamin K antagonists in symptomatic venous thromboembolism.

BACKGROUND: Currently, the most frequently used secondary treatment for patients with venous thromboembolism is vitamin K antagonists targeted at an INR of 2.5 (range 2.0 to 3.0). However, based on the continuing risk of bleeding and uncertainty regarding the risk of recurrent venous thromboembolism, there is discussion on the proper duration of treatment with vitamin K antagonists for these patients. Recently, several studies were published in which the risk and benefits of different durations of oral anticoagulants were compared in patients with venous thromboembolism. OBJECTIVES: The objective of this review was to evaluate efficacy and safety of different durations of treatment with vitamin K antagonists in patients with symptomatic venous thromboembolism. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2005). The Specialised Register is constructed from electronic searches of MEDLINE (from inception to October 2005) and EMBASE (inception to October 2005) and through handsearching relevant journals. In addition, we also contacted colleagues for details of trials. The last searches were carried out on 11 October 2005. SELECTION CRITERIA: Randomized controlled clinical trials comparing different durations of treatment with vitamin K antagonists in patients with symptomatic venous thromboembolism. DATA COLLECTION AND ANALYSIS: Two reviewers (BH and MP) extracted the data and assessed the quality of the trials independently. MAIN RESULTS: Eight studies with a total of 2994 patients were included. A consistent reduction in the risk of recurrent events was observed during prolonged treatment with vitamin K antagonists (OR 0.18; 95% CI 0.13 to 0.26) independent of the period elapsed since the index thrombotic event. A 'rebound' phenomenon, i.e. an excess of recurrences shortly after cessation of the prolonged treatment was not observed (OR 1.24; 95% CI 0.91 to 1.69). In addition, a substantial increase in bleeding complications was found during the entire period after randomization (OR 2.62; 95% CI 1.48 to 4.61). AUTHORS' CONCLUSIONS: In conclusion, this meta-analysis shows that treatment with vitamin K antagonists reduces the risk of recurrent venous thromboembolism for as long as it is used. However, the absolute risk of recurrent venous thromboembolism declines over time, while the risk for major bleeding remains. Thus, the efficacy of vitamin K antagonist administration decreases over time since the index event.

Anticoagulants↗
PubMed2006

A simple diagnostic strategy in hospitalized patients with clinically suspected pulmonary embolism.

OBJECTIVES: Diagnostic strategies in patients with suspected pulmonary embolism have been extensively studied in outpatients; their value in hospitalized patients has not been well established. Our aim was to determine the safety and clinical utility of a simple diagnostic strategy in hospitalized patients with suspected pulmonary embolism. DESIGN: Prospective management study. SETTING: Twelve teaching hospitals (five academic, seven general hospitals). SUBJECT: A total of 605 hospitalized patients with clinically suspected pulmonary embolism. All patients completed the study. INTERVENTIONS: First the clinical decision rule (CDR)-score was calculated. An unlikely CDR-score in combination with a normal D-dimer excluded pulmonary embolism. All other patients underwent helical computed tomography (CT). CT either diagnosed or excluded pulmonary embolism, in which case anticoagulants were started or withheld. All patients were instructed to report symptoms of venous thrombosis. Objective tests were performed to confirm venous thromboembolism. The primary outcome was the incidence of symptomatic venous thrombosis during 3-month follow-up. RESULTS: The combination of an unlikely CDR-score and a normal D-dimer excluded pulmonary embolism in 60 patients (10% of all patients); no venous thromboembolic event occurred during follow-up (0%; 95% CI 0-6.7%). CT excluded pulmonary embolism in 380 patients; during follow-up venous thromboembolism occurred in five patients (1.4%; 95% CI 0.4-3.1%). CONCLUSIONS: An unlikely CDR-score in combination with a normal D-dimer appears to exclude pulmonary embolism safely in hospitalized patients. Before clinical implementation it is important this safety is confirmed by others. CT testing was obviated in only 10% of patients. CT can safely exclude pulmonary embolism in hospitalized patients.

Algorithms↗
PubMed2006

Venous thromboembolism and the risk of subsequent symptomatic atherosclerosis.

BACKGROUND: Recently, we reported an association between asymptomatic carotid atherosclerosis and venous thromboembolism (VTE) of unknown origin. We hypothesized that patients with VTE of unknown origin would be at a higher risk of developing symptomatic atherosclerosis than patients with VTE induced by known risk factors. METHODS: To examine this hypothesis, we studied 1,919 consecutive patients followed prospectively after their first VTE episode. The primary outcome was non-fatal and fatal symptomatic atherosclerotic disease in patients with VTE of unknown origin as compared to those with secondary VTE. An independent committee assessed all study outcomes, and adjusted hazard ratios (HR) were calculated using the Cox's proportional hazards model. RESULTS: After a median follow-up of 48 and 51 months, respectively, at least one symptomatic atherosclerotic complication was detected in 160 of the 1,063 patients (15.1%) with VTE of unknown origin, and in 73 of the 856 (8.5%) with secondary VTE. After adjusting for age and other risk factors of atherosclerosis, the HR for symptomatic atherosclerotic complications in patients with VTE of unknown origin compared to those with secondary VTE was 1.6 (95% confidence intervals; CI: 1.2-2.0). When the analysis was restricted to patients without previous symptomatic atherosclerosis, the HR became 1.7 (95% CI: 1.1-2.4). CONCLUSIONS: Patients with VTE of unknown origin have a 60% higher risk of developing symptomatic atherosclerotic disease than do patients with secondary venous thrombosis.

Aged↗
PubMed2005

Management studies using a combination of D-dimer test result and clinical probability to rule out venous thromboembolism: a systematic review.

BACKGROUND: While the number of patients with suspected venous thromboembolism (VTE) referred to hospital emergency units increases, the proportion in whom the diagnosis can be confirmed is decreasing. A more efficient but safe diagnostic strategy is needed. OBJECTIVE: To evaluate the safety of withholding anticoagulant therapy in patients suspected of VTE based on a diagnostic work-up that combines a clinical decision rule (CDR) with a D-dimer test result without performing additional diagnostic tests. PATIENTS/METHODS: We searched Medline (January 1996-December 2004)-related articles and reference lists of studies in English for prospective clinical studies that managed consecutive patients suspected of VTE and used a D-dimer assay combined with an explicit CDR or implicit clinical judgment. RESULTS: We identified 11 studies in which 6837 consecutive outpatients suspected of VTE were included. In the combined management studies, the overall rate of thromboembolic events was nine out of 2056 patients (0.44 %, 95% CI 0.2%-0.83%) in whom anticoagulants were withheld based on the D-dimer result and a low clinical score. Similar results were obtained with qualitative and quantitative D-dimer tests and with different decision rules. The rate of exclusion varied between 30% and 50% and was highest with a low incidence of VTE among those referred. CONCLUSION: Withholding anticoagulant treatment in patients suspected of VTE on the basis of a work-up consisting of a low clinical probability combined with either a qualitative or quantitative D-dimer test result is safe.

Decision Support Techniques↗
PubMed2005

Once versus twice daily LMWH for the initial treatment of venous thromboembolism.

BACKGROUND: In the initial treatment of venous thromboembolism (VTE) low molecular weight heparin (LMWH) is administered once or twice daily. A once daily treatment regimen is more convenient for the patient and may optimise home treatment. However, it is not clear whether a once daily treatment regimen is as safe and effective as a twice daily treatment regimen. OBJECTIVES: To compare the efficacy and safety of once daily versus twice daily administration of LMWH. SEARCH STRATEGY: We identified trials through searching the Specialised Register of the Cochrane Peripheral Vascular Diseases Group (last searched April 2005), the Cochrane Central Controlled Trials Register (CENTRAL) (last searched Issue 2, 2005), handsearches of relevant journals, checking cross-references and through personal communication with experts. SELECTION CRITERIA: Randomised clinical trials in which LMWH given once daily is compared to LMWH given twice daily for the initial treatment of venous thromboembolism. DATA COLLECTION AND ANALYSIS: Two authors assessed trials for inclusion and extracted data independently. MAIN RESULTS: Five studies were included with a total of 1508 participants. The pooled data showed a statistically non-significant difference in recurrent venous thromboembolism between the two treatment regimens (OR 0.82, 0.49 to 1.39). A comparison of major haemorrhagic events (OR 0.77, 0.40 to 1.45) and mortality (OR 1.14, 0.62 to 2.08) also showed a statistically non-significant difference between the two treatment regimens. AUTHORS' CONCLUSIONS: Once daily treatment with LMWH is as effective and safe as twice daily treatment with LMWH. However, the 95% confidence interval implies that there is a possibility that the risk of recurrent VTE might be higher when people are treated once daily. Hence, the decision to treat a person with a once daily regimen will depend on the evaluated balance between increased convenience and the potential for a lower efficacy.

Anticoagulants↗
PubMed2005

The development and implementation of a regional network of physiotherapists for exercise therapy in patients with peripheral arterial disease, a preliminary report.

BACKGROUND: Exercise therapy (ET) is the main conservative and proven effective treatment of patients with intermittent claudication. Currently, the most frequent exercise prescription is a single 'go home and walk' advise, without supervision or follow-up. There is no evidence to support the efficacy of this advise and compliance is known to be low. Therefore, a systematic approach was used to guarantee quality and standardisation of treatment, optimal guideline adherence and improved of inter-professional communication between vascular surgeons and physiotherapists. In this preliminary report we would like to outline the steps taken for the development and implementation of the Network Exercise Therapy Parkstad. METHODS: In October 2003 all 59 regional physiotherapy practices were invited to attend a symposium regarding ET in a physiotherapeutic setting. Attending physiotherapists interested in providing ET and willing to follow a certified course on ET, were asked to register. Three tastk groups were formed to accomplish the set targets: Exercise therapy education, Exercise therapy implementation and continuity, and Inter-professional communication in the Parkstad region. RESULTS: In total 27 physiotherapists, from 22 different practices followed the educational program and are now trained and accredited to provide ET according to the guideline of the Royal Dutch Society for Physiotherapy. A web-based database was designed to contain information on disease specific items provided by the vascular surgery department, and aspects with respect to ET registered by the physiotherapist. The information is regularly updated and available online. Access to the database is restricted to vascular surgeons and physiotherapists in the network. The secondary purpose of the database is to register essential benchmark data for future analysis of ET in a physiotherapeutic setting in the Netherlands and to enable physiotherapists continuous feedback on patient performance. A triage system was developed to detect patients with a compromised cardiac history. This group receives ET at the in-hospital department of revalidation with the possibility of immediate consultation of a cardiologist in case of cardiac complications or even CPR. CONCLUSION: The Network Exercise Therapy Parkstad of supervised ET is the first initiative in the Netherlands to provide ET close to the patient's home environment. With the implementation of supervised ET in an outpatient physiotherapeutic setting for all eligible patients with symptomatic PAD, the access to care has been improved. A web-based communication system provides physiotherapists and vascular surgeons with all the necessary and continues updated patient information. Future research, currently in progress, will investigate the therapeutic benefits and cost-effectiveness of exercise therapy in a physiotherapeutic setting.

Ambulatory Care↗
PubMed2005

Antiplatelet and anticoagulant drugs for prevention of restenosis/reocclusion following peripheral endovascular treatment.

BACKGROUND: Peripheral arterial disease (PAD) is frequently treated by balloon angioplasty. Restenosis/reocclusion of the dilated segments occurs often depending on length of occlusion, lower leg outflow, stage of disease and presence of cardiovascular risk factors. To prevent reocclusion, patients are treated with antithrombotic agents. OBJECTIVES: To determine whether any antithrombotic drug is more effective in preventing reocclusion after peripheral endovascular treatment, compared to another antithrombotic drug, no treatment, placebo, or other vasoactive drugs. SEARCH STRATEGY: We searched the Cochrane Peripheral Vascular Diseases Group's trials register (last searched April 2004), the Cochrane Central Register of Controlled trials (CENTRAL Issue 2, 2004), MEDLINE and EMBASE (last searched June 2004). SELECTION CRITERIA: Randomised trials were categorised as A (double or single blinded) or B (not blinded). Participants included patients with symptomatic PAD treated by endovascular revascularisation of the pelvic or femoropopliteal arteries. Interventions were anticoagulant, antiplatelet or other vasoactive drug therapy compared with no treatment, placebo, or any other vasoactive drug. Clinical endpoints were re-obstruction, amputation, death, myocardial infarction, stroke and major bleeding. DATA COLLECTION AND ANALYSIS: Details of the number of randomised patients, treatment, study design, study category, allocation concealment and patient characteristics were extracted. Analysis was based on intention-to-treat data. To examine the effects of binary outcomes such as amputation and major bleeding, odds ratios were computed using a fixed effect model. The 95% confidence intervals of the effect sizes were calculated. MAIN RESULTS: A 60% reduction of recurrent obstruction was found with aspirin (ASA) 330 mg combined with dipyridamol (DIP) as compared to placebo at 12 months follow-up. At six months following endovascular treatment, a positive effect on patency was found with 50 to 100 mg ASA combined with DIP (n = 356). However, this was not significant. ASA/DIP tended towards showing a superior effect on patency after femoropopliteal angioplasty compared with VKA at three, six, and twelve months. Periinterventional treatment with LMWH in femoropopliteal obstructions resulted in significantly lower restenosis/reocclusion rates than with unfractionated heparin. AUTHORS' CONCLUSIONS: Aspirin 50 to 300 mg started prior to femoropopliteal endovascular treatment appears to be the most effective and is safe. Clopidogrel might be an alternative, but data are lacking. Abciximab might be a useful adjunctive for high risk patients with long segmental femoropopliteal interventions. Low molecular weight heparin seems to be more effective in preventing reocclusion or restenosis than unfractionated heparin.

Angioplasty, Balloon↗
PubMed2005

Definition of the post-thrombotic syndrome, differences between existing classifications.

BACKGROUND: Accepted diagnostic criteria exist for the diagnosis of deep vein thrombosis (DVT). However, no uniform definition for the diagnosis and treatment of the post-thrombotic syndrome (PTS) exists. We examined the various definitions of PTS that are used and their relationships with invasive venous pressure measurement. METHODS: Patients who had previously suffered a documented DVT underwent clinical evaluation of both lower limbs in which we used five clinical definitions to grade PTS. We included the definition of Widmer, the CEAP classification, the venous clinical severity score (also without compression therapy), and the definitions according to Prandoni and Brandjes in the evaluation. We compared all the clinical scoring systems with invasive ambulatory venous pressure measurement. RESULTS: In total 124 patients were enrolled in whom both legs were evaluated. Thirteen patients had previously suffered bilateral DVT and nine patients had had an ipsilateral recurrent DVT. In the limbs with DVT, 10 (7%) to 29 (21%) were defined as severe PTS, compared to 0-4 (4%) in the control legs. Mild-to-moderate PTS in the DVT legs ranged from 23 to 49%, compared to 13-34% in the control legs. Overall the presence of any PTS in the DVT legs varied from 30% (VCS without compression) to 66% (Brandjes). The scoring systems of Brandjes and VCS showed a tendency towards more legs to be defined as severe PTS. Absolute frequencies of PTS in DVT legs were highest for the classifications according to Widmer, Prandoni and Brandjes. Differences in proportions of any PTS calculated between DVT and control legs varied from 18 to 39%, while odds ratios varied between 2.2 and 5.2 for the different definitions. The CEAP classification and definition of Brandjes show a moderate relation to Widmer, kappa=0.53 and 0.52, respectively. The VCS shows in all comparisons a poor correlation (kappa 0.22-0.41). Prandoni has a moderate correlation with most definitions (kappa 0.40-0.44). CONCLUSION: All clinical definitions of PTS were highly associated with the reference standard of ambulatory venous pressure, with higher AVPs observed in the more severely affected groups. The ability of the scoring systems to discriminate between DVT and control legs as well as the observed prevalence of PTS differed substantially. In part this is due to the considerable overlap in AVP in the different clinical groups, reflecting the fact that our reference standard has substantial deficiencies. No clear advantage was found in any one system of classification over the rest.

Bandages↗
PubMed2005

Elevated levels of FVIII:C within families are associated with an increased risk for venous and arterial thrombosis.

Elevated levels of coagulation factor VIII:C (FVIII:C) are associated with an increased risk for venous and arterial thromboembolism. Whether relatives of patients with elevated levels of FVIII:C are also at increased risk for thrombotic disease is unknown. The objective was to determine the annual incidences of both venous and arterial thrombotic events in first-degree relatives of patients with elevated levels of FVIII:C and venous thromboembolism (VTE) or premature atherosclerosis. A retrospective study with 584 first-degree relatives of 177 patients with elevated levels of FVIII:C was performed. The level of FVIII:C was determined and relatives with elevated and normal levels of FVIII:C were compared. Of the participants, 40% had elevated levels of FVIII:C. The annual incidence of a first episode of VTE was 0.34% and 0.13% in relatives with elevated levels of FVIII:C and those with normal levels, respectively [OR 3.7 (95% CI 1.9-7.5)]. The absolute annual incidence in the youngest age group with elevated levels of FVIII:C was 0.16% (0.05-0.37) and gradually increased to 0.99% (0.40-2.04) in those older than 60 years of age, although the odds ratios were not statistically significant. The annual incidences of a first arterial thrombotic event were 0.29% and 0.14% in relatives with and without elevated levels of FVIII:C, respectively [OR 3.1 (1.4-6.6)]. In particular the risks for a first myocardial infarction [OR 4.3 (1.0-18.1); P =0.046] and a first peripheral arterial thrombosis [OR 8.6 (1.6-47.6)] were increased. Within families of patients with elevated levels of FVIII:C and VTE or premature atherosclerosis, 40% of their first-degree relatives has elevated levels of FVIII:C as well, and they are at increased risk for both VTE and arterial thrombosis as compared with their relatives with normal levels.

Adolescent↗
PubMed2005

Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphy.

BACKGROUND: Spiral computed tomography (CT) has emerged as a potentially conclusive diagnostic test to exclude pulmonary embolism (PE) in patients with non-high probability scintigraphy and is already widely used-sometimes as the sole primary diagnostic test in the diagnosis of suspected PE. Its true sensitivity and specificity has, however, not been evaluated previously in a large cohort of consecutive patients. METHODS: In a multicenter prospective study 627 consecutive patients with clinically suspected PE were studied. Patients with normal perfusion scintigraphy were excluded from further analysis. Single-detector spiral CT scanning and ventilation scintigraphy were then performed in all patients to diagnose PE, while pulmonary angiography was performed as the gold standard. The only exceptions were those patients who had both a high-probability VQ scan and a CT scan positive for PE: these patients were considered to have PE and did not undergo additional pulmonary angiography. All imaging tests were read by independent expert panels. RESULTS: Five hundred and seventeen patients were available for complete analysis. The prevalence of PE was 32%. Spiral CT correctly identified 88 of 128 patients with PE, and 92 of 109 patients without PE, for a sensitivity and specificity of 69%[95% confidence interval (CI) 63-75] and 84% (95% CI 80-89), respectively. The sensitivity of spiral CT was 86% (95% CI 80-92) for segmental or larger PE and 21% (95% CI 14-29) in the group of patients with subsegmental PE. CONCLUSION: The overall sensitivity of spiral CT for PE is too low to endorse its use as the sole test to exclude PE. This holds true even if one limits the discussion to patients with larger PE in segmental or larger pulmonary artery branches. We conclude that, in patients with clinically suspected PE and an abnormal perfusion scintigraphy, single-slice detector spiral CT is not sensitive enough to be used as the sole test to exclude PE.

Adult↗
PubMed2005

Relation between quality of anticoagulant treatment and the development of the postthrombotic syndrome.

BACKGROUND: About 30% of patients with an episode of adequately treated deep venous thrombosis (DVT) develop the postthrombotic syndrome (PTS) within 2 years. During treatment with vitamin K antagonists (VKA) patients spend only 60% of time between an International Normalized Ratio (INR) of 2.0 and 3.0. We hypothesized that patients who spend a large amount of their time beneath this range will have an increased risk of the PTS. OBJECTIVE: To investigate the relation between the quality of anticoagulant therapy with VKA and the risk of the development of the PTS. METHODS: The time spent beneath the therapeutic range was calculated for patients with a first episode of DVT, who were treated with VKA for at least 3 months. At follow-up assessments for a maximum of 5 years, presence and severity of signs and symptoms of PTS were recorded. RESULTS: A total of 244 patients, with a median duration of follow-up of 4.9 years were included for analysis. Of these, 81 patients (33%) developed the PTS. The multivariate model showed that patients who spend more than 50% of their time beneath an INR level of 2.0 are at higher risk for PTS [odds ratio (OR): 2.71, 95% CI: 1.44-5.10]. CONCLUSIONS: Low quality treatment with VKA, which is a common condition, is related to the occurrence of the PTS in patients with DVT. Strategies aimed at improving the quality of long-term anticoagulation might have the potential to reduce the incidence of this complication.

Aged↗
PubMed2005

Medical management of peripheral arterial disease.

Whether symptomatic or not, peripheral arterial disease (PAD), atherosclerosis in the arteries of the lower extremities, is a common disorder in the general population. The prevalence increases with age and under the influence of vascular risk factors. The most classic symptomatic expression of PAD is intermittent claudication. However, the majority of patients with PAD is asymptomatic or has leg symptoms other than classic intermittent claudication. Both symptomatic and asymptomatic subjects with PAD have increased mortality rates, mainly due to cardiovascular and cerebrovascular expressions of atherosclerotic disease. This review focuses on the current available medical therapies for PAD, including risk-factor modification and antiplatelet therapies, as well as strategies for symptomatic relief in both patients with intermittent claudication and patients with critical limb ischemia. In general, risk factor modification and antiplatelet therapy is essential in all patients with PAD to prevent systemic atherosclerotic complications. Furthermore, for symptomatic relief exercise therapy is the main intervention while pharmacological treatment should be only complementary. In patients with critical limb ischemia, when revascularization therapy is not possible, an attempt should be made to avoid amputation with conservative treatment using analgesics, vasodilators and/or anticoagulants. In case of an acute onset of critical limb ischemia, thrombolysis is indicated.

Anticoagulants↗