How is atrial fibrillation detected in everyday healthcare? Results of a Dutch cohort study.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia with serious potential consequences when left untreated. For timely treatment, early detection is imperative. We explored how new AF is detected in patients aged ≥ 65 years in Dutch healthcare. METHODS: The study cohort consisted of 9526 patients from 49 Dutch general practices in the usual-care arm of the Detecting and Diagnosing Atrial Fibrillation study. We automatically extracted data from the electronic medical records and reviewed individual records of patients who developed AF. Patient selection started in 2015, and data collection ended in 2019. RESULTS: We included 258 patients with newly diagnosed AF. In 55.0% of the patients, the irregular heartbeat was first observed in general practice and in 16.3% in the cardiology department. Cardiologists diagnosed most cases (47.3%), followed by general practitioners (GPs; 33.7%). AF detection was triggered by symptoms in 64.7% of the patients and by previous stroke in 3.5%. Overall, patients aged 65-74 years more often presented with symptoms than those aged ≥ 75 years (73.5% vs 60.6%; p = 0.042). In 31.5% of the patients, AF was diagnosed incidentally ('silent AF'). Silent-AF patients were on average 2 years older than symptomatic-AF patients. GPs less often diagnosed silent AF than symptomatic AF (21.0% vs 39.0%; p = 0.008), whereas physicians other than GPs or cardiologists more often diagnosed symptomatic AF than silent AF (34.6% vs 11.9%; p < 0.001). Most diagnoses were based on a 12-lead electrocardiogram (93.8%). CONCLUSION: Diagnosing AF is a multidisciplinary process. The irregular heartbeat was most often detected by the GP, but cardiologists diagnosed most cases. One-third of all newly diagnosed AF was silent.

Correction to: How do Dutch general practitioners detect and diagnose atrial fibrillation? Results of an online case vignette study.

Following publication of the original article [1], the authors opted to remove the authors full name from.

Interpretations of and management actions following ECGs in programmatic cardiovascular care in primary care: A retrospective dossier study.

BACKGROUND: The usefulness of routine electrocardiograms (ECGs) in cardiovascular risk management (CVRM) and diabetes care is doubted. OBJECTIVES: To assess the performance of general practitioners (GPs) in embedding ECGs in CVRM and diabetes care. METHODS: We collected 852 ECGs recorded by 20 GPs (12 practices) in the context of CVRM and diabetes care. Of all abnormal (n = 265) and a sample of the normal (n = 35) ECGs, data on the indications, interpretations and management actions were extracted from the corresponding medical records. An expert panel consisting of one cardiologist and one expert GP reviewed these 300 ECG cases. RESULTS: GPs found new abnormalities in 13.0% of all 852 ECGs (12.0% in routinely recorded ECGs versus 24.3% in ECGs performed for a specific indication). Management actions followed more often after ECGs performed for specific indications (17.6%) than after routine ECGs (6.0%). The expert panel agreed with the GPs' interpretations in 67% of the 300 assessed cases. Most often misinterpreted relevant ECG abnormalities were previous myocardial infarction, R­wave abnormalities and typical/atypical ST-segment and T­wave (ST-T) abnormalities. Agreement on patient management between GP and expert panel was 74%. Disagreement in most cases concerned additional diagnostic testing. CONCLUSIONS: In the context of programmatic CVRM and diabetes care by GPs, the yield of newly found ECG abnormalities is modest. It is higher for ECGs recorded for a specific reason. Educating GPs seems necessary in this field since they perform less well in interpreting and managing CVRM ECGs than in ECGs performed in symptomatic patients.

How do Dutch general practitioners detect and diagnose atrial fibrillation? Results of an online case vignette study.

BACKGROUND: Detection and treatment of atrial fibrillation (AF) are important given the serious health consequences. AF may be silent or paroxysmal and remain undetected. It is unclear whether general practitioners (GPs) have appropriate equipment and optimally utilise it to detect AF. This case vignette study aimed to describe current practice and to explore possible improvements to optimise AF detection. METHODS: Between June and July 2017, we performed an online case vignette study among Dutch GPs. We aimed at obtaining at least 75 responses to the questionnaire. We collected demographics and asked GPs' opinion on their knowledge and experience in diagnosing AF. GPs could indicate which diagnostic tools they have for AF. In six case vignettes with varying symptom frequency and physical signs, they could make diagnostic choices. The last questions covered screening and actions after diagnosing AF. We compared the answers to the Dutch guideline for GPs on AF. RESULTS: Seventy-six GPs completed the questionnaire. Seventy-four GPs (97%) thought they have enough knowledge and 72 (95%) enough experience to diagnose AF. Seventy-four GPs (97%) could order or perform ECGs without the interference of a cardiologist. In case of frequent symptoms of AF, 36-40% would choose short-term (i.e. 24-48 h) and 11-19% long-term (i.e. 7 days, 14 days or 1 month) monitoring. In case of non-frequent symptoms, 29-31% would choose short-term and 21-30% long-term monitoring. If opportunistic screening in primary care proves to be effective, 83% (58/70) will support it. CONCLUSIONS: Responding GPs report to have adequate equipment, knowledge, and experience to detect and diagnose AF. Almost all participants can order ECGs. Reported monitoring duration was shorter than recommended by the guideline. AF detection could improve by increasing the monitoring duration.

Interpretations of and management actions following electrocardiograms in symptomatic patients in primary care: a retrospective dossier study.

BACKGROUND: The electrocardiogram (ECG) has become a popular tool in primary care. The clinical value of the ECG depends on the appropriateness of the indication and the interpretation skills of the general practitioner (GP). OBJECTIVES: To describe the use of electrocardiography in primary care and to assess the performance of GPs in interpreting ECGs and making subsequent management decisions. METHODS: Three hundred ECGs, recorded during daily practice in symptomatic patients by 14 GPs who regularly perform electrocardiography, were selected. Corresponding data of the indications, interpretations and subsequent management actions were extracted from the associated medical records. A panel consisting of an expert GP and a cardiologist reviewed the ECGs and specified their agreement with the findings and actions of the study GPs. RESULTS: The most common indications were suspicion of a rhythm abnormality (43.7%), ischaemic heart disease (42.7%) and patient reassurance (14.3%). The study GPs interpreted 53.3% of the ECGs as showing no (new or acute) abnormality, whereas supraventricular rhythm disorders (12.3%), conduction disorders (7.7%) and repolarisation disorders (7.0%) were the most frequently reported pathological findings. Overall, the expert panel disagreed with the interpretations of the study GPs in 16.2% of cases, and with the GPs' management actions in 11.7%. Learning goals for GPs performing electrocardiography could be formulated for acute coronary syndrome, rhythm disorders, pulmonary embolism, reassurance, left ventricular hypertrophy and premature ventricular complexes. CONCLUSION: GPs who feel competent in electrocardiography performed well in the opinion of the expert panel. We formulated various learning objectives for GPs performing electrocardiography.

Competence of general practitioners in requesting and interpreting ECGs - a case vignette study.

BACKGROUND: Performing electrocardiography is common in general practice, but the quality of indication setting and diagnostic accuracy have been disputed. OBJECTIVES: To assess the competence of general practitioners (GPs) in their decision-making process with regard to recording and interpreting an electrocardiogram (ECG) and evaluating the relevance of the result for management. METHODS: An online case vignette survey was performed among GPs and cardiologists (in 2015). Nine cases describing situations for which Dutch clinical guidelines recommend or advise against recording an ECG were presented. In each case, the participant had to make choices on recording an ECG, interpreting it, and using the result in a management decision. The reference standard for each ECG diagnosis was set by the expert author team. RESULTS: Fifty GPs who interpret ECGs themselves, eight GPs who do not and 12 cardiologists completed the survey. Adherence to guidelines recommending an ECG was high for suspected atrial fibrillation, suspected arrhythmia present during consultation, including bradycardia, but much lower for progressive heart failure and stable angina. Diagnostic accuracy of GPs was best in atrial fibrillation (96%), sick sinus syndrome (85%) and old myocardial infarction (82%), but poor in left anterior fascicular block (16%) and incomplete right bundle branch block (10%). GPs often acknowledged the low relevance of the results of a non-indicated ECG. CONCLUSION: GPs do not fully adhere to Dutch cardiovascular guidelines on indications for recording ECGs. Diagnostic accuracy was high for atrial fibrillation, sick sinus syndrome and old myocardial infarction and poor for left anterior fascicular block and incomplete right bundle branch block.

Current practice of Dutch cardiologists in detecting and diagnosing atrial fibrillation: results of an online case vignette study.

INTRODUCTION: Detection of atrial fibrillation (AF) is important given the risk of complications, such as stroke and heart failure, and the need for preventive measures. Detection is complicated because AF can be silent or paroxysmal. Describing current practice may give clues to improve AF detection. The aim of this study was to describe how cardiologists currently detect AF. METHODS: Between December 2014 and May 2015, we sent Dutch cardiologists an online questionnaire. Firstly, we asked which tools for detection of AF their department has. Secondly, we presented six case vignettes related to AF, in which they could choose a diagnostic tool. Thirdly, we compared the results with current guidelines. RESULTS: We approached 90 cardiology departments and 48 (53%) completed the questionnaire. In asymptomatic patients with risk factors according to CHA2DS2-VASc, 40% of the cardiologists would screen for AF. In patients with signs or symptoms of AF, all but one cardiologist would start a diagnostic process. In both vignettes describing patients with non-frequent symptoms, 46% and 54% of the responders would use short-term (i. e. 24- or 48-hour) electrocardiographic monitoring, 48% and 27% would use long-term (i. e. 7 day, 14 day or one month) monitoring. In both cases describing patients with frequent symptoms, 85% of the responders would use short-term and 15% and 4% long-term monitoring. CONCLUSION: Dutch cardiologists have access to a wide variety of ambulatory arrhythmia monitoring tools. Nearly half of the cardiologists would perform opportunistic screening. In cases with non-frequent symptoms, monitoring duration was shorter than recommended by NICE.

[How much do patients and health professionals (really) know? The surplus value of a home visit to the patient with polypharmacy by the practice nurse, to support medication reviews in primary care]. / Wat weten de patiënt en zijn hulpverlener: de meerwaarde van een huisbezoek door de praktijkondersteuner bij de medicatiebeoordelingen van patiënten met polyfarmacie in de eerste lijn.

BACKGROUND: Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse. RESEARCH QUESTIONS: What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist? METHOD: Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use. RESULTS: Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%. CONCLUSIONS: Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.

Benefits of an open access echocardiography service: a Dutch prospective cohort study.

BACKGROUND: Open access echocardiography has been evaluated in the United Kingdom, but hardly in the Netherlands. The echocardiography service of the SHL-Groep in Etten-Leur was set up independently from the regional hospitals. Cardiologists not involved in the direct care of the participating patients evaluated the echocardiograms taken by ultrasound technicians. AIMS: We estimated the reduction in the number of referrals to regional cardiologists, the adherence of the general practitioners (GPs) to the advice of the evaluating cardiologist, GPs' opinion on the benefit of the echocardiography service and GPs' adherence to the diagnostic protocol advocated in the Dutch clinical guideline for heart failure. METHODS: A prospective cohort study was performed. Patients were included from April 2011 to April 2012 (N = 155). Data from application forms (N = 155), echocardiography results (N = 155) and telephone interviews with GPs (N = 138) were analysed. RESULTS: GPs referred less patients to the cardiologist than they would have done without echocardiography available (92 % vs. 34 %, p < 0.001). They treated more patients by themselves (62 % vs. 10 %, p < 0.001). Most GPs (81 %) followed the advice presented on the echocardiogram result. Most GPs (82 %) found the service had clinical benefit for the patient. Sixty two percent of echocardiography requests met the criteria of the Dutch clinical guideline for heart failure. CONCLUSION: Open access echocardiography saved referrals to the cardiology department, saved time, and enabled GPs to treat more patients by themselves. Adherence to diagnostic guidelines for heart failure was suboptimal.

Primary prevention of cardiovascular diseases in general practice: mismatch between cardiovascular risk and patients' risk perceptions.

OBJECTIVE: Guidelines on primary prevention of cardiovascular disease (CVD) emphasize identifying high-risk patients for more intensive management, but patients' misconceptions of risk hamper implementation. Insight is needed into the type of patients that general practitioners (GPs) encounter in their cardiovascular prevention activities. How appropriate are the risk perceptions and worries of patients with whom GPs discuss CVD risks? What determines inappropriate risk perception? METHOD: Cross-sectional study in 34 general practices. The study included patients aged 40 to 70 years with whom CVD risk was discussed during consultation. After the consultation, the GPs completed a registration form, and patients completed a questionnaire. Correlations between patients' actual CVD risk and risk perceptions were analyzed. RESULTS: In total, 490 patients were included. In 17% of the consultations, patients were actually at high risk. Risk was perceived inappropriately by nearly 4 in 5 high-risk patients (incorrect optimism) and by 1 in 5 low-risk patients (incorrect pessimism). Smoking, hypertension, and obesity were determinants of perceiving CVD risk as high, whereas surprisingly, diabetic patients did not report any anxiety about their CVD risk. Men were more likely to perceive their CVD risk inappropriately than women. CONCLUSION: In communicating CVD risk, GPs must be aware that they mostly encounter low-risk patients and that the perceived risk and worry do not necessarily correspond with the actual risk. Incorrect perceptions of CVD risk among men and patients with diabetes were striking.

Open access echocardiography is feasible in the Netherlands.

OBJECTIVES: In an urban region in the Netherlands, general practitioners (GPs) were offered an open access echocardiographic service. We report the outcomes of the first two years of this project. METHODS: GPs were given a course on the indications and restrictions for diagnostic referral as well as the interpretation of echocardiographic results. Indications were restricted to `dyspnoea', `cardiac murmur' and `peripheral oedema'. A uniform request form was developed, using ticking boxes for quick completion. The echocardiogram was performed within one week after the request. Results were interpreted by the cardiologist according to the criteria of the Dutch, European and American Societies of Echocardiography. RESULTS: Sixty GPs from 43 general practices participated, covering a practice population of 130,000 persons. During a period of 24 months, 198 patients were referred. Only 1.5% of the workload of the echocardiography department was due to requests from GPs. The GPs kept well to the agreements on indications for echocardiography (91% approved reasons). An abnormal echocardiographic outcome was found in 53% of all patients. For `cardiac murmur' this was 52%, for `dyspnoea' 63%, and for `peripheral oedema' 58%. Left ventricular dysfunction was present in 49 patients (25%); diastolic dysfunction was present in most of them (39 patients, 19%). Systolic dysfunction (LVEF < 40%) was found in 19 patients (10%). Twenty patients (10%) appeared to have relevant aortic or mitral valve disease. CONCLUSION: GPs did not overuse the open access echocardiographic service; they possibly used it conservatively. To prevent underdiagnosis of left ventricular dysfunction, diagnostic strategies in which electrocardiogram, NT-pro-BNP and echocardiography are combined, should be developed.

[What do older patients on polypharmacy know about their prescribed drugs?]. / Wat weten ouderen met polyfarmacie van hun pillen?

OBJECTIVE: To identify factors associated with appropriate knowledge about the indications for drugs prescribed to older patients on polypharmacy. DESIGN: Cross-sectional study. METHOD: In a primary care setting, patients aged 60 years and over who were taking five or more prescribed drugs simultaneously were asked about their medication by conducting home interviews and postal questionnaires. Multiple logistic regression analysis was used to evaluate the association between medication knowledge and explanatory variables such as medication use, sex, age, residential status and educational level. RESULTS: Seven hundred and fifty-four participants, mean age 73.2 years, reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients were able to recall the indication for each of their prescribed drugs. Variables that were negatively associated with correct reporting of all indications were: taking many prescribed drugs (≥ 10 vs. ≤ 5 drugs: odds ratio (OR) 0.05), age 80 years or over (vs. 60-69 years: OR 0.47) and male sex (vs. females: OR 0.53). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11). We did not find an association with educational level. CONCLUSION: Among older patients using five or more prescribed drugs, there was little understanding of the indications for their drugs, especially among patients taking the highest number of drugs, patients aged 80 years or over, and men. Patients living independently with a partner were more knowledgeable than others.

Regional differences in cardiovascular risk factor profile cannot fully explain differences in cardiovascular morbidity in the Netherlands: a comparison of two urban areas.

BACKGROUND: Our objective was to investigate whether a region in the south of the Netherlands (Heerlen/Kerkrade) had a high burden of cardiovascular disease in comparison with a nearby region (Maastricht) and the average Dutch population, respectively. We also wanted to determine if there are interregional differences in cardiovascular risk factor profile. DESIGN: Cross-sectional study. METHODS: Data from a nationwide registry (CBS) were used to analyse cardiovascular mortality in the two regions and the average in the Netherlands. Data from a primary care morbidity registration network (RNH) were used to compare cardiovascular morbidity and cardiovascular risk factors in both regions. A standardisation procedure was carried out for age and sex. Data were analysed using logistic regression analyses. RESULTS: The overall cardiovascular mortality rate was higher in the Heerlen/Kerkrade region (7.8 per thousand) compared with Maastricht (6.1 per thousand, OR=1.3, 95% CI 1.2-1.5) and the average in the Netherlands (5.7 per thousand). Similarly, most cardiovascular morbidity rates for Heerlen/Kerkrade were more elevated compared with the RNH overall and with Maastricht. Prevalence rates of risk factors such as diabetes mellitus (7.2%, OR=1.5, 95% CI 1.3-1.7) and overweight (10.8%, OR= 2.0, 95% CI 1.8-2.2) were significantly higher in the Heerlen/Kerkrade region compared with Maastricht. There were no differences with regard to hypertension (15.2%, OR=1.0, 95% CI 0.9-1.1). CONCLUSION: Heerlen/Kerkrade is indeed a region with a high burden of cardiovascular disease. Differences in morbidity between Heerlen/Kerkrade and Maastricht cannot be fully explained by differences in cardiovascular risk factor profile.

Qualitative point-of-care D-dimer testing compared with quantitative D-dimer testing in excluding pulmonary embolism in primary care.

BACKGROUND: General practitioners can safely exclude pulmonary embolism (PE) by using the Wells PE rule combined with D-dimer testing. OBJECTIVE: To compare the accuracy of a strategy using the Wells rule combined with either a qualitative point-of-care (POC) D-dimer test performed in primary care or a quantitative laboratory-based D-dimer test. METHODS: We used data from a prospective cohort study including 598 adults suspected of PE in primary care in the Netherlands. General practitioners scored the Wells rule and carried out a qualitative POC test. All patients were referred to hospital for reference testing. We obtained quantitative D-dimer test results as performed in hospital laboratories. The primary outcome was the prevalence of venous thromboembolism in low-risk patients. RESULTS: Prevalence of PE was 12.2%. POC D-dimer test results were available in 582 patients (97%). Quantitative test results were available in 401 patients (67%). We imputed results in 197 patients. The quantitative test and POC test missed one (0.4%) and four patients (1.5%), respectively, with a negative strategy (Wells ≤ 4 points and D-dimer test negative) (P = 0.20). The POC test could exclude 23 more patients (4%) (P = 0.05). The sensitivity and specificity of the Wells rule combined with a POC test were 94.5% and 51.0% and, combined with a quantitative test, 98.6% and 47.2%, respectively. CONCLUSIONS: Combined with the Wells PE rule, both tests are safe to use in excluding PE. The quantitative test seemed to be safer than the POC test, albeit not statistically significant. The specificity of the POC test was higher, resulting in more patients in whom PE could be excluded.

Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study.

OBJECTIVE: Asymptomatic peripheral arterial occlusive disease (PAOD) is a common atherosclerotic disorder among the elderly population. Scarce data are available on the risk of nonfatal and fatal cardiovascular diseases in these subjects. We investigated cardiovascular morbidity and mortality of asymptomatic PAOD subjects. STUDY DESIGN AND SETTING: A sample of 3649 subjects (40-78 years of age) was selected in collaboration with 18 general practice centers and followed up after the initial screening (mean follow-up time 7.2 years). Asymptomatic PAOD was determined by means of the ankle-brachial pressure index (ABPI). Main outcome measures were nonfatal cardiovascular events and mortality. RESULTS: Cox proportional hazard models showed that asymptomatic PAOD was significantly associated with cardiovascular morbidity (hazard ratio [HR] 1.6, 95% confidence interval [CI] 1.3-2.1), total mortality (HR 1.4, 95% CI 1.1-1.8), and cardiovascular mortality (HR 1.5, 95% CI 1.1-2.1). CONCLUSION: Asymptomatic PAOD is a significant predictor of cardiovascular morbidity and mortality. In high-risk subjects, measurement of the ABPI provides valuable information on future cardiovascular events.

[Summary of the practice guideline 'Peripheral vascular disease' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Perifeer arterieel vaatlijden' (eerste herziening) van het Nederlands Huisartsen Genootschap.

Peripheral vascular disease is a manifestation of atherosclerosis and may occur with or without signs or symptoms. The local prognosis is worse with signs or symptoms. The concomitant atherosclerosis in heart and brain is responsible for long-term morbidity and mortality. Absence of signs and symptoms almost excludes peripheral vascular disease, but for the diagnosis an ankle-brachial index is mandatory. This implies a protocol in general practice. Treatment of peripheral vascular disease consists of advice on cardiovascular risk factors, stopping smoking, walking exercises, and foot care. For peripheral vascular disease, anti-thrombotic medication is advised.

Development and validation of an ankle brachial index risk model for the prediction of cardiovascular events.

BACKGROUND: The ankle brachial index (ABI) is related to risk of cardiovascular events independent of the Framingham risk score (FRS). The aim of this study was to develop and evaluate a risk model for cardiovascular events incorporating the ABI and FRS. DESIGN: An analysis of participant data from 18 cohorts in which 24,375 men and 20,377 women free of coronary heart disease had ABI measured and were followed up for events. METHODS: Subjects were divided into a development and internal validation dataset and an external validation dataset. Two models, comprising FRS and FRS + ABI, were fitted for the primary outcome of major coronary events. RESULTS: In predicting events in the external validation dataset, C-index for the FRS was 0.672 (95% CI 0.599 to 0.737) in men and 0.578 (95% CI 0.492 to 0.661) in women. The FRS + ABI led to a small increase in C-index in men to 0.685 (95% CI 0.612 to 0.749) and large increase in women to 0.690 (95% CI 0.605 to 0.764) with net reclassification improvement (NRI) of 4.3% (95% CI 0.0 to 7.6%, p = 0.050) and 9.6% (95% CI 6.1 to 16.4%, p < 0.001), respectively. Restricting the FRS + ABI model to those with FRS intermediate 10-year risk of 10 to 19% resulted in higher NRI of 15.9% (95% CI 6.1 to 20.6%, p < 0.001) in men and 23.3% (95% CI 13.8 to 62.5%, p = 0.002) in women. However, incorporating ABI in an improved newly fitted risk factor model had a nonsignificant effect: NRI 2.0% (95% CI 2.3 to 4.2%, p = 0.567) in men and 1.1% (95% CI 1.9 to 4.0%, p = 0.483) in women. CONCLUSIONS: An ABI risk model may improve prediction especially in individuals at intermediate risk and when performance of the base risk factor model is modest.

Common alternative diagnoses in general practice when deep venous thrombosis is excluded.

BACKGROUND: In patients initially suspected of deep venous thrombosis (DVT) the diagnosis can be confirmed in approximately 10 to 30% of cases. For the majority of patients this means that eventually an alternative diagnosis is assigned. OBJECTIVE: To assess the frequency distribution of alternative diagnoses and subsequent management of patients in primary care after initial exclusion of DVT. In addition, assess the value of ultrasound examination for the allocation of alternative diagnoses. METHODS: Data were recorded by general practitioners alongside a diagnostic study in primary care in the Netherlands (AMUSE). Additional data were retrieved from a three-month follow-up questionnaire. A descriptive analysis was performed using these combined data. RESULTS: The most prevalent diagnoses were muscle rupture (18.5%), chronic venous insufficiency (CVI) (14.6%), erysipelas/cellulitis (12.6%) and superficial venous thrombosis (SVT) (10.9%). Alternative diagnoses were based mainly on physical examination; ultrasound examination (US) did not improve the diagnostic yield for the allocation of alternative diagnoses. In about 30% of all cases, a wait and see approach was used (27 to 41%). During the three-month follow-up nine patients were diagnosed with venous thromboembolic disease, three of which occurred in patients with the working diagnosis of SVT (p=0.026). CONCLUSIONS: We found that after exclusion of DVT in general practice a wait and see policy in the primary care setting is uneventful for almost one third of patients, but with the alternative diagnosis of SVT, patients may require closer surveillance since we found a significant association with thrombosis in these patients.

[Thrombophlebitis of the leg: diagnosis and treatment by the general practitioner]. / Tromboflebitis van het been: diagnostiek en behandeling door de huisarts.

We reviewed the literature for the association between superficial vein thrombosis (SVT) and venous thromboembolism (VTE) and for evidence of treatment of SVT with low-molecular-weight heparin (LMWH). There is some evidence for an association between SVT and VTE. This association seems stronger for proximal SVT as compared with distal SVT. In general practice, the absolute risk of VTE with or after SVT is low, approximately 3%. There is evidence that treatment of SVT with LMWH may have a beneficial effect on its course. NSAIDs have a similar effect. There is indirect evidence that LMWH is effective in the prevention of VTE, if the treatment is continued for more than 4 weeks. In case of a proximal SVT, we suggest an ultrasound examination be carried out and LMWH treatment given if the diagnosis is confirmed; in other cases, NSAIDs can be considered.

Age is an independent risk factor for left atrial dysfunction: results from an observational study.

Introduction. The degenerative changes of myocardial tissue are thought to influence left atrial (LA) function. Changes of left atrial function are generally due to changes in left ventricle (LV) compliance. But valvular dysfunction and hypertension as comorbidity cannot be ignored. Women have a different clinical profile compared with men concerning the risk of heart failure. We investigated the influence of increasing age and gender corrected for comorbidity, on left atrial function.Methods. Using an open access echocardiography database, supplemented with additional LA function measurements, we defined three different LA function parameters. Odds ratios (OR) were calculated to reproduce the relation between age, gender and LA function. The association between age, gender and LA function was estimated, and corrected for comorbid conditions as valve disease, high blood pressure and LV dysfunction, using logistic regression.Results. Higher age was positively correlated with increased LA volume, decreased ejection fraction and increased LA kinetic energy. Age per decade increase, corrected for comorbidity, resulted in an increased risk of LA dysfunction (OR between 1.5 and 1.9). Gender had little influence on LA function parameters except for LA maximal volume. Men had a significantly larger LA maximal volume compared with women. Conclusions. In this open access echocardiography database, increasing age was correlated with LA dysfunction. Age per decade increase, corrected for comorbid conditions such as mitral and aortic valve disease, hypertension and heart failure, is an independent risk factor for LA dysfunction. The gender influence on LA dysfunction seems to be limited. (Neth Heart J 2010;18:243-7.).