Wells' Criteria for Pulmonary Embolism

id

115

full_title

Wells' Criteria for Pulmonary Embolism

short_title

Wells' Score for PE

med_description

Objectifies risk of pulmonary embolism.

description

The Wells’ Criteria for Pulmonary Embolism objectifies risk of pulmonary embolism (PE).

keywords

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

complaint

[ "Chest Pain", "Cough", "Palpitations", "Shortness of Breath" ]

formula

Addition of the selected points:

evidence

• The original Wells study was performed on cohorts where prevalence of PE was high: approximately 30%. Two further emergency department studies validated this tool with a 9.5%-12% PE prevalence.
• The largest study demonstrated risk stratification with:
  • Low score of 0-1 having a 1.3% prevalence.
  • Moderate score of 2-6 having a 16.2% prevalence.
  • High score of >6 having a 37.5% prevalence.
• The Christopher study divided the Wells scoring system into 2 categories:
  • A score of 4 or less was defined as “PE unlikely” and tested with a d-dimer.
  • A score of 5 or more was defined as “PE likely” and went straight to CTA
• Overall Incidence of PE was 12.1% in the “unlikely” group vs. 37.1% in the “likely” group.
• If dimer was negative no further testing was performed.
• If dimer was positive the patient went to CTA.
• 20.4% of all patients who went to CTA had a diagnosis of PE.
• In the “PE unlikely” group, those with a negative dimer and discharged to home had an incidence of missed PE on 3 month follow up of 0.5% .

measurements

[]

information

Score interpretation:

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/11453709", "text": "Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. PubMed PMID: 11453709." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/16403929", "text": "van Belle A, Buller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA : the journal of the American Medical Association. Jan 11 2006;295(2):172-179." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/15520710", "text": "Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004 Nov;44(5):503-10. PubMed PMID: 15520710." } ], "Validations": [] }

pearls

The Wells’ Criteria risk stratifies patients for pulmonary embolism (PE), and has been validated in both inpatient and emergency department settings. Its score is often used in conjunction with d-dimer testing to evaluate for PE.

• There must first be a clinical suspicion for PE in the patient (this should not be applied to all patients with chest pain or shortness of breath, for example).
• Wells' can be used with either 3 tiers (low, moderate, high) or 2 tiers (unlikely, likely). We recommend the two tier model as this is supported by ACEP’s 2011 clinical policy on PE. (See Next Steps)
  • Wells’ is often criticized for having a “subjective” criterion in it (“PE #1 diagnosis or equally likely”)
• Wells’ is not meant to diagnose PE but to guide workup by predicting pre-test probability of PE and appropriate testing to rule out the diagnosis.

usecase

The Wells’ Criteria risk stratifies patients for pulmonary embolism (PE) and provides an estimated pre-test probability. The physician can then chose what further testing is required for diagnosing pulmonary embolism (I.E. d-dimer or CT angiogram).

reasons

The Wells’ Score has been validated multiple times in multiple clinical settings.Physicians have a low threshold to test for pulmonary embolism.The score is simple to use and provides clear cutoffs for the predicted probability of pulmonary embolism.The score aids in potentially reducing the number of CTAs performed on low-risk PE patients. Physicians have a low threshold to test for pulmonary embolism. The score is simple to use and provides clear cutoffs for the predicted probability of pulmonary embolism. The score aids in potentially reducing the number of CTAs performed on low-risk PE patients.

next_advice

• Some advocate using the Wells’ score over clinician gestalt to predict who is low-risk and then applying the PERC rule to stop workup for PE.
• As with all clinical decision aids, the physician must first have a suspicion of the diagnosis before attempting to apply the Wells criteria.
• The original intent of this tool was to determine who was low risk enough to rule out testing with a d-dimer.
• Age adjusted d-dimer cutoffs have been validated for use in patients over 50 years in low risk patients (rGeneva “not high” or Wells’ low). If using the appropriate d-dimer assay consider calculating the age adjusted d-dimer cutoff of: Age (years) x 10 µg/L = cutoff (for patients > 50 years).
• While both two and three tier models are accepted, guidelines appear to favor the two tier model which utilizes only the high sensitivity d-dimer and more conservative risk stratification; “intermediate” risk patients are thought to be still too high risk to be evaluated without further risk stratification.

next_actions

• Given the next generation d-dimer high sensitivity but low specificity (approx 50%), patients who are considered high risk should be ruled out with CTA.
• Never delay resuscitative efforts for diagnostic testing, especially in the unstable patient.
• History and exam should always be performed prior to diagnostic testing.

next_management

Three Tier Model

• Patient is determined to be low risk (<2 points:1.3% incidence PE): consider d-dimer testing to rule out Pulmonary embolism. Alternatively consider a rule-out criteria such as PERC.
  • If the dimer is negative consider stopping workup.
  • If the dimer is positive consider CTA.
• Patient is determined to be moderate risk (score 2-6 points, 16.2% incidence of PE): consider high sensitivity d-dimer testing or CTA.
  • If the dimer is negative consider stopping workup.
  • If the dimer is positive consider CTA.
• Patient is determined to be high risk (score >6 points: 37.5% incidence of PE): consider CTA. D-dimer testing is not recommended.

Two Tier Model

• Patient risk is determined to be “PE Unlikely” (0-4 points, 12.1% incidence of PE): consider high sensitivity d-dimer testing.
  • If the dimer is negative consider stopping workup.
  • If the dimer is positive consider CTA.
• Patient risk is determined to be “PE Likely” (>4 points, 37.1% incidence of PE): consider CTA testing.

diseases

[ "Pulmonary Embolism" ]

instructions

published

2022-04-21T20:28:57.283Z

purpose

[ "Diagnosis" ]

search_terms

[ "well's", "wells", "pe", "pulmonary embolism", "pre-test", "PE pre-test", "pre-test probability" ]

seo

{ "keywords_en": "pulmonary embolism, PE, Rule out PE, DVT, VTE, d-dimer positive, wells pe, wells criteria, wells pulmonary, wells embolism, wells pulmonary embolism, wells calc, wells pe calc, wells r/o, wells rule out, wells clinical signs, wells criteria for pulmonary embolism, wells rule out PE , wells rule out embolism, wells rule out pulmonary embolism, wells rule out thrombosis, wells r/o dvt, wells r/o vte", "meta_description_en": "The Wells’ Criteria for Pulmonary Embolism objectifies risk of pulmonary embolism (PE)." }

specialty

[ "Cardiology", "Critical Care", "Emergency Medicine", "Hematology and Oncology", "Hospitalist Medicine", "Internal Medicine", "Pulmonology", "Surgery (General)" ]

departments

[ "Cardiac", "Hematologic", "Respiratory" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 1750, "short_title_en": "Geneva Score (Revised)", "slug": "geneva-score-revised-pulmonary-embolism" }, { "calcId": 347, "short_title_en": "PERC Rule", "slug": "perc-rule-pulmonary-embolism" }, { "calcId": 10343, "short_title_en": "Altitude-Adjusted PERC Rule", "slug": "altitude-adjusted-perc-rule" } ]

ismed

true

section

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

cleaned_departments

[ "cardiology", "hematology", "pulmonology" ]

cleaned_use

[ "The Wells’ Criteria risk stratifies patients for pulmonary embolism (PE) and provides an estimated pre-test probability. The physician can then chose what further testing is required for diagnosing pulmonary embolism (I.E. d-dimer or CT angiogram)." ]

pub

true