Citation
Nijkeuter, M. (2007, June 7). The diagnostic management of suspected pulmonary
embolism. Department of Internal Medicine and Endocrinology, Faculty of Medicine,
Leiden University. Retrieved from https://hdl.handle.net/1887/12097
Version: Corrected Publisher’s Version
License: Licence agreement concerning inclusion of doctoral thesis in the
Institutional Repository of the University of Leiden
The Diagnostic Management of Suspected
Pulmonary Embolism
Roche Diagnostics BV, Glaxo Smith Kline, Actelion, Astra Zeneca
The Diagnostic Management of Suspected
Pulmonary Embolism
Proefschrift
ter verkrijging van
de graad van Doctor aan de Universiteit Leiden, op gezag van Rector Magnificus prof.mr. P.F. van der Heijden,
volgens besluit van het College voor Promoties te verdedigen op donderdag 7 juni 2007
klokke 15 uur
door
Mathilde Nijkeuter geboren te Groningen
in 1977
Prof. Dr. J.A. Romijn Prof. Dr. K.F. Rabe Prof. Dr. A. de Roos
Prof. Dr. G. Palareti (S. Orsola-Malpighi University Hospital, Bologna, Italië) Dr. F.W.G. Leebeek (Erasmus University Medical Centre, Rotterdam)
Step into this room and dance hoose, loose
Pull out your arsenal And Dance
This is the floor, these are the rules, these are the moves This is the room in which we dance
Close the floor, say you will Dance
Madrugada, "The Nightly Disease"
Aan mijn moeder
Contents
Chapter 1. General introduction and outline of this thesis Chapter 2. Diagnostic methods in pulmonary embolism
Chapter 3. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography (the Christopher-study)
Chapter 4. Excluding pulmonary embolism by non-imaging tests; the effect of varying cut-off levels of a clinical decision rule and D-dimer test on safety and clinical utility
Chapter 5. The distribution of subsegmental pulmonary emboli in multi- and single- detector row computed tomography
Chapter 6. The natural course of pulmonary embolism; clinical outcome and risk factors in a large prospective cohort study
Chapter 7. Excluding clinically suspected recurrent pulmonary embolism: a diagnostic challenge
Chapter 8. Resolution of thrombo-emboli in patients with acute pulmonary embolism
Chapter 9. Diagnosing pulmonary embolism in pregnancy: rationalizing fetal radiation exposure in radiological procedures
Chapter 10. Diagnostic management of deep vein thrombosis and pulmonary embolism in pregnancy
Chapter 11. Summary and conclusions Samenvatting
Curriculum Vitae List of Publications List of Co-authors List of Abbreviations
originate as venous thrombi. He stated: “The detachment of larger or smaller fragments from the end of the softening thrombus which are carried along by the current of blood and driven into remote vessels. This gives rise to the very frequent process on which I have bestowed the name of Embolia”. The term “pulmonary emboli” was born.
Pulmonary embolism is a potentially fatal disease of which early recognition and institution of anticoagulant treatment can prevent mortality. Due to the diversity and aspecificity of signs and symptoms of pulmonary embolism, varying from asymptomatic pulmonary embolism to haemodynamic instability and shock, clinical recognition is notoriously inaccurate. Post- mortem studies have shown that the majority of cases of pulmonary embolism detected were not diagnosed prior to deatz2. Therefore, to demonstrate or refute the diagnosis, objective diagnostic tests are mandatory in patients with a clinical suspicion of PE.
It has only been since forty years that a diagnosis of PE can be objectively diagnosed and physicians need not rely solely on their clinical judgement of the presence or absence of PE.
In 1963, Williams and Sasahara published a landmark study of pulmonary angiography as a diagnostic tool in diagnosing PE3;4. The armamentarium has been expanded with the introduction of perfusion scintigraphy in 1964 and ventilation scintigraphy in 19685;6. The major concerns leading to a continued search for better diagnostic tools were the invasiveness and consequently complications of pulmonary angiography as well as the high percentage (40-60%) of non-conclusive ventilation perfusion (VQ) scans.
A promising diagnostic tool, of which the first clinical report appeared in 1992, is helical computed tomography (CT)7. This method provides a series of images of the thorax in the transverse plane enabling to view all intra-thoracic structures. In order to visualize the pulmonary arteries, it requires intravenous injection of iodinated contrast agent via an antecubital vein during scanning. Helical CT has clear advantages, i.e. direct visualisation of thrombus as an intra-luminal filling defect, the possibility of making an alternative diagnosis, a rapid scanning time (less than 30 seconds), wide availability and excellent inter-observer agreement8;9. The percentage of inconclusive CT scans is low, but radiation exposure is higher compared to ventilation-perfusion scintigraphy. Moreover, allergic reactions to contrast agents
