Paul L. den Exter

Bio: Paul L. den Exter is an academic researcher from Leiden University Medical Center. The author has contributed to research in topics: Pulmonary embolism & Medicine. The author has an hindex of 14, co-authored 39 publications receiving 1465 citations. Previous affiliations of Paul L. den Exter include Leiden University.

Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study

Abstract: RESULTS Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 μg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 μg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 μg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 μg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE Compared with a fixed D-dimer cutoff of 500 μg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01134068

Risk of Recurrent Venous Thromboembolism and Mortality in Patients With Cancer Incidentally Diagnosed With Pulmonary Embolism: A Comparison With Symptomatic Patients

Abstract: Purpose The routine use of modern computed tomography scanners has led to an increased detection of incidental pulmonary embolism (PE), in particular in patients with cancer. The clinical relevance of these incidental findings is unknown. Patients and Methods In this retrospective cohort study, oncology patients in whom PE was objectively proven between 2004 and 2010 and anticoagulant treatment was started, were included. Fifty-one patients with incidental PE and 144 with symptomatic PE were observed for 1 year to compare the risks of recurrent venous thromboembolism (VTE), bleeding complications, and mortality. Kaplan-Meier and Cox survival analyses were performed. Results Incidental and symptomatic patients did not differ with respect to mean age, sex, cancer type and stage, and risk factors for VTE. As a result from evolving treatment guidelines, approximately half of the patients in both groups received long-term treatment with vitamin K antagonists in stead of currently recommended low-molecular-weig...

Wells Rule and D-Dimer Testing to Rule Out Pulmonary Embolism A Systematic Review and Individual-Patient Data Meta-analysis

Abstract: Background: The performance of different diagnostic strategies for pulmonary embolism (PE) in patient subgroups is unclear. Purpose: To evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted D-dimer testing overall and in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and age 75 years or older. Data Sources: MEDLINE and EMBASE from 1 January 1988 to 13 February 2016. Study Selection: 6 prospective studies in which the diagnostic management of PE was guided by the dichotomized Wells rule and quantitative D-dimer testing. Data Extraction: Individual data of 7268 patients; risk of bias assessed by 2 investigators with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool. Data Synthesis: The proportion of patients in whom imaging could be withheld based on a "PE-unlikely" Wells score and a negative D-dimer test result (efficiency) was estimated using fixed (50 years) D-dimer thresholds; their 3-month incidence of symptomatic venous thromboembolism (failure rate) was also estimated. Overall, efficiency increased from 28% to 33% when the age-adjusted (instead of the fixed) D-dimer threshold was applied. This increase was more prominent in elderly patients (12%) but less so in inpatients (2.6%). The failure rate of age-adjusted D-dimer testing was less than 3% in all examined subgroups. Limitation: Post hoc analysis, between-study differences in patient characteristics, use of various D-dimer assays, and limited statistical power to assess failure rate. Conclusion: Age-adjusted D-dimer testing is associated with a 5% absolute increase in the proportion of patients with suspected PE in whom imaging can be safely withheld compared with fixed D-dimer testing. This strategy seems safe across different high-risk subgroups, but its efficiency varies.

Wells Rule and D-Dimer Testing to Rule Out Pulmonary Embolism

Abstract: This review contributes new information on use of the Wells rule with D-dimer testing to make decisions about imaging in patients with suspected pulmonary embolism.

Heart Disease and Stroke Statistics—2013 Update A Report From the American Heart Association

Abstract: Author(s): Go, Alan S; Mozaffarian, Dariush; Roger, Veronique L; Benjamin, Emelia J; Berry, Jarett D; Borden, William B; Bravata, Dawn M; Dai, Shifan; Ford, Earl S; Fox, Caroline S; Franco, Sheila; Fullerton, Heather J; Gillespie, Cathleen; Hailpern, Susan M; Heit, John A; Howard, Virginia J; Huffman, Mark D; Kissela, Brett M; Kittner, Steven J; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Magid, David; Marcus, Gregory M; Marelli, Ariane; Matchar, David B; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Mussolino, Michael E; Nichol, Graham; Paynter, Nina P; Schreiner, Pamela J; Sorlie, Paul D; Stein, Joel; Turan, Tanya N; Virani, Salim S; Wong, Nathan D; Woo, Daniel; Turner, Melanie B; American Heart Association Statistics Committee and Stroke Statistics Subcommittee

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

Abstract: ACS : acute coronary syndrome AMPLIFY : Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-line Therapy aPTT : activated partial thromboplastin time b.i.d. : bis in diem (twice daily) b.p.m. : beats per minute BNP : brain natriuretic peptide BP : blood pressure CI : confidence interval CO : cardiac output COPD : chronic obstructive pulmonary disease CPG : Committee for Practice Guidelines CRNM : clinically relevant non-major CT : computed tomographic/tomogram CTEPH : chronic thromboembolic pulmonary hypertension CUS : compression venous ultrasonography DSA : digital subtraction angiography DVT : deep vein thrombosis ELISA : enzyme-linked immunosorbent assay ESC : European Society of Cardiology H-FABP : heart-type fatty acid-binding protein HIT : heparin-induced thrombocytopenia HR : hazard ratio ICOPER : International Cooperative Pulmonary Embolism Registry ICRP : International Commission on Radiological Protection INR : international normalized ratio iPAH : idiopathic pulmonary arterial hypertension IVC : inferior vena cava LMWH : low molecular weight heparin LV : left ventricle/left ventricular MDCT : multi-detector computed tomographic (angiography) MRA : magnetic resonance angiography NGAL : neutrophil gelatinase-associated lipocalin NOAC(s) : Non-vitamin K-dependent new oral anticoagulant(s) NT-proBNP : N-terminal pro-brain natriuretic peptide o.d. : omni die (every day) OR : odds ratio PAH : pulmonary arterial hypertension PE : pulmonary embolism PEA : pulmonary endarterectomy PEITHO : Pulmonary EmbolIsm THrOmbolysis trial PESI : pulmonary embolism severity index PH : pulmonary hypertension PIOPED : Prospective Investigation On Pulmonary Embolism Diagnosis PVR : pulmonary vascular resistance RIETE : Registro Informatizado de la Enfermedad Thromboembolica venosa RR : relative risk rtPA : recombinant tissue plasminogen activator RV : right ventricle/ventricular SPECT : single photon emission computed tomography sPESI : simplified pulmonary embolism severity index TAPSE : tricuspid annulus plane systolic excursion Tc : technetium TOE : transoesophageal echocardiography TTR : time in therapeutic range TV : tricuspid valve UFH : unfractionated heparin V/Q scan : ventilation–perfusion scintigraphy VKA : vitamin K antagonist(s) VTE : venous thromboembolism Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate. A great number of Guidelines have …

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS)

Abstract: Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.