Wells' Criteria for DVT

id

362

full_title

Wells' Criteria for DVT

short_title

Wells' Score for DVT

med_description

Calculates risk of DVT based on clinical criteria.

description

The Wells’ Criteria for DVT Objectifies risk of deep vein thrombosis (DVT) based on clinical findings.

keywords

deep vein thrombosis, DVT, Rule out DVT, PE, VTE, d-dimer positive, wells dvt, wells criteria, wells deep, wells deep vein, wells deep vein thrombosis wells embolism, wells thrombosis, wells vte, wells calc, wells dvt calc, wells r/o, wells rule out, wells clinical signs, wells criteria for deep vein thrombosis, wells rule out dvt, wells rule out deep vein, wells rule out thrombosis, wells r/o dvt, wells r/o vte

complaint

[ "Extremity Edema", "Extremity Pain" ]

formula

Addition of the selected points: Note: there are a few versions of the criteria with minor differences based on the study; this set is the most widely validated, based onWells 2003.

evidence

• Wells' Criteria were derived from a number of studies by Wells et al (Wells 1995, Wells 1997, Wells 2003) in an attempt to stratify risk of DVT in symptomatic outpatients, since at the time, the clinical diagnosis of DVT was thought to be inaccurate, leading to widespread overuse of confirmatory imaging.
• Wells 2003 took 1,096 outpatients with concern for DVT and randomized them into two groups after applying Wells’ Criteria for DVT. 520 were the control and had an ultrasound, 562 were tested with a d-dimer. If the dimer was positive these patients also received an US. If negative no US was performed. 16% of the control group and 15.5 percent of the test group had DVT or PE resulting in overall incidence of 15.7%.
• Of the 520 control patients, 279 were considered DVT unlikely, and 241 were DVT likely. 16 (5.7%) of the unlikely patients had DVT or PE. In the control group overall, 6 (1.4%) patients who had been initially ruled out had a diagnosis of DVT on 3 month follow-up.
• Of the 562 patients in the d-dimer group, 315 were considered unlikely and 247 considered likely to have DVT. 71 (28.7%) of the likely group had DVT. 38.8 percent of the unlikely group had a negative d-dimer and did not undergo further testing. 2 of these patients (0.4%) had confirmed DVT on 4 and 14 d follow-up. The negative predictive value of d-dimer was 96.1%.
• This algorithm was then supported by Scarvelis and Wells in 2006 (Scarvelis 2006).
• A systematic review (Wells 2006) was performed in 2006 which evaluated 14 studies with 8239 patients that used the Wells score to predict risk of DVT and evaluated for incidence of DVT in association with moderate or high sensitivity d-dimer. This has been utilized by the American College of Chest physicians to provide guidelines for the evaluation of DVT.

measurements

[]

information

Interpretation:

refrences

{ "Clinical Practice Guidelines": [ { "href": "https://pubmed.ncbi.nlm.nih.gov/30482764/", "text": "Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226-3256." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/34352278/", "text": "Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for vte disease: second update of the chest guideline and expert panel report. Chest. 2021;160(6):e545-e608." }, { "href": "https://pubmed.ncbi.nlm.nih.gov/32374563/", "text": "Venous Thromboembolic Diseases: Diagnosis, Management and Thrombophilia Testing. National Institute for Health and Care Excellence (NICE); 2023." } ], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/7752753", "text": "Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-30." }, { "href": "https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)08140-3/fulltext", "text": "Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/14507948", "text": "Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/16403932", "text": "Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. 2006 Jan 11;295(2):199-207. Review." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/22315267", "text": "Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson M.D., Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/25985219", "text": "Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med. 2015 Jul;175(7):1112-7. doi: 10.1001/jamainternmed.2015.1687." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/17060659", "text": "Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006 Oct 24;175(9):1087-92. Review. Erratum in: CMAJ. 2007 Nov 20;177(11):1392." } ], "Validations": [] }

pearls

The Wells’ Criteria for Deep Vein Thrombosis (DVT) are used to stratify patients by their risk of DVT.

• There is an overall low prevalence of DVT in cases with low (<25%) clinical suspicion patients.
• The Wells score inherently incorporates clinical gestalt with a minus 2 score for alternative diagnosis more likely.
• Sequelae from DVT include pulmonary embolism (PE) and pulmonary hypertension, which have an associated mortality of 1-8%.
• Anticoagulation is the mainstay treatment for DVT with its own associated risks of bleeding.

usecase

The Wells’ DVT Criteria can be used in the outpatient and emergency department setting. By risk stratifying to low risk (Wells’ Score <2) and a negative d-dimer the clinician can exclude the need for ultrasound (US) to rule out DVT.

reasons

Traditional testing for DVT involved multiple lower extremity US which are associated with time and cost. Utilization of the Wells’ DVT criteria can determine those patients who are overall unlikely to have a DVT. Further testing with d-dimer can safely rule out DVT without the need for US.

next_advice

• As with all clinical decision aids, the Wells’ DVT criteria is meant to aid clinical decision making and not force management.
• The Wells’ DVT criteria should only be applied after a detailed history and physical is performed.
• The Wells’ DVT criteria should only be applied to those patients who have been deemed at risk for DVT. If there is no concern for DVT, then there is no need for risk stratification.

next_actions

• No decision rule should trump clinical gestalt. High suspicion for DVT should warrant imaging regardless of Wells score.
• The Wells’ Criteria for DVT is utilized for the workup of DVT. The presence of DVT is critical to the evaluation of possible PE, and if PE is on the differential, alternative decision aids such as the Wells’ PE or PERC Rule should be entertained.

next_management

Patients can be divided into “DVT unlikely” and “DVT likely” groups based on Wells score. An additional moderate risk group can be added based on the sensitivity of the d-dimer being used.

• A score of 0 or lower is associated with DVT unlikely with a prevalence of DVT of 5%.
  • These patients should proceed to d-dimer testing:
    • A negative high or moderate sensitivity d-dimer results in a probability <1 % and no further imaging is required.
    • A positive d-dimer should proceed to US testing.
      • A negative US is sufficient for DVT rule out.
      • A positive US is concerning for DVT; strongly consider treatment with anticoagulation.

• A score of 1-2 is considered moderate risk with a pretest probability of 17%.*
  • These patients should proceed to high-sensitivity d-dimer testing (moderate sensitivity d-dimer is not sufficient).
    • A negative high-sensitivity d-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1%.
    • A positive high sensitivity d-dimer should proceed to US testing.
      • A negative US is sufficient for ruling out DVT.
      • A positive US is concerning for DVT, strongly consider treatment with anticoagulation.

• A score of 3 or higher suggests DVT is likely. Pretest probability 17-53%.
  • All DVT likely patients should receive US.
  • D-dimer testing should be utilized to help risk-stratify these DVT-likely patients.
    • In DVT likely patients with negative d-dimer:
      • A negative US is sufficient for ruling out DVT, consider discharge.
      • A positive US should be concerning for DVT, strongly consider treatment with anticoagulation.
    • In DVT likely patients with a positive d-dimer:
      • A positive US should be concerning for DVT, strongly consider treatment with anticoagulation.
      • A negative US is still concerning for DVT. A repeat US should be performed within 1 week for re-evaluation.

*Group should only undergo d-dimer testing for rule out without ultrasonography if a high-sensitivity d-dimer is being used.

diseases

[ "Deep Venous Thrombosis" ]

instructions

• Note: The Wells' Score is less useful in hospitalized patients (Silveira PC, 2015).
• There are a few versions of this criteria with minor differences based on the study; this set is the most widely validated, based on Wells 2003.

published

2022-04-21T20:29:17.346Z

purpose

[ "Diagnosis" ]

search_terms

[ "well’s", "dvt", "wells", "deep vein thrombosis score", "wells score", "wells dvt", "wells vte" ]

seo

{ "keywords_en": "deep vein thrombosis, DVT, Rule out DVT, PE, VTE, d-dimer positive, wells dvt, wells criteria, wells deep, wells deep vein, wells deep vein thrombosis wells embolism, wells thrombosis, wells vte, wells calc, wells dvt calc, wells r/o, wells rule out, wells clinical signs, wells criteria for deep vein thrombosis, wells rule out dvt, wells rule out deep vein, wells rule out thrombosis, wells r/o dvt, wells r/o vte", "meta_description_en": "The Wells’ Criteria for DVT Objectifies risk of deep vein thrombosis (DVT) based on clinical findings." }

specialty

[ "Cardiology", "Emergency Medicine", "Family Practice", "Geriatrics", "Hematology and Oncology", "Hospitalist Medicine", "Internal Medicine", "Orthopedics", "Primary Care", "Surgery (General)" ]

departments

[ "Cardiac", "Hematologic" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 1750, "short_title_en": "Geneva Score (Revised)", "slug": "geneva-score-revised-pulmonary-embolism" }, { "calcId": 10125, "short_title_en": "Villalta Score", "slug": "villalta-score-post-thrombotic-syndrome-pts" }, { "calcId": 115, "short_title_en": "Wells' Score for PE", "slug": "wells-criteria-pulmonary-embolism" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "cardiology", "hematology" ]

cleaned_use

[ "The Wells’ DVT Criteria can be used in the outpatient and emergency department setting. By risk stratifying to low risk (Wells’ Score <2) and a negative d-dimer the clinician can exclude the need for ultrasound (US) to rule out DVT." ]

pub

true