Balancing risks in thromboembolic disease

Abstract

In this thesis, several balancing acts regarding the diagnosis, prognosis, and treatment of patients with thromboembolic disease were explored and analyzed. First, regarding diagnosis, the risks of over- and underdiagnosis should be balanced. The prevalence of diagnostic delay, which can be seen as underdiagnosis, was systematically reviewed in patients with pulmonary embolism and the delay was on average 6.3 days. Second, to better balance the risk between thromboembolism and bleeding, we need to be able to predict these risks accurately. This thesis showed that existing bleeding risk models, including an internally validated updated model, were not able to accurately predict bleeding in patients with cancer using anticoagulants. Only age and a history of bleeding appeared to contribute to the prediction of bleeding. Our updated model can be used as a starting point for further model updating. Third, integrated care for patients with atrial fibrillation (AF) can be a possible solution for improving the balance of risks. It was shown that all AF patients benefit from integrated care in primary care, yet the absolute effect of integrated care was the greatest in patients with the highest all-cause mortality. Finally, for improving the balancing of risks in patients with thromboembolic disease, we need to assure the correct prescription of anticoagulants. The DUTCH-AF registry will evaluate guideline non-adherence and the association with adverse events, such as bleeding. Using data from this registry we showed that males and females with new AF differ in age, comorbidities, AF pattern, symptoms, and disease management in the first year. These findings are building blocks for more individualized sex-specific AF care, but also for further research on sex differences in AF patients.