Deep vein thrombosis assessment of clinical probability and risk scores

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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Kashish Goel, M.D.; Justine Cadet; Rim Halaby, M.D. [3]

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Overview

In a patient with suspected deep vein thrombosis (DVT), establishing a pre-test probability helps in early risk stratification and appropriate use of laboratory tests and imaging modalities. Many pretest probability scoring systems are proposed for use in primary care patients, such as Wells score, Hamilton score, and AMUSE score; however, the most studied of them is Wells score.[1][2] When combined with pretest probability, ultrasonography and D-dimer tests are most useful in the diagnosis of DVT.

The Constans score can help diagnose DVT of the upper extremity.[3]

Wells Score

Calculation of Wells Score for DVT

The Wells score is the most widely used tool to assess pre-test probability of DVT. It includes 9 clinical questions, with the score ranging from -2 to 8. Pretest probability guides the interpretation of test results. It includes risk factors and examination findings.[4]

Wells score calculator for DVT

Variables Score
Active cancer with either palliative therapy or treatment that is either ongoing or within the prior 6 months 1
Patient was recently bedridden for at least 3 days
OR Major surgery in the prior 12 weeks necessitating general or regional anesthesia
1
Recent plaster immobilization, paresis or paralysis of the lower extremities 1
Tenderness that is localized is the distribution of the deep veins 1
Leg is entirely swollen 1
Discrepancy of ≥ 3 cm in calf circumference 1
Pitting edema in the symptomatic leg 1
Presence of collateral superficial non varicose veins 1
There is an alternative diagnosis as likely as DVT -2

Interpretation of Wells Score for DVT

Score Pretest probability[4]
≥3 High (Prevalence of DVT - 75%)
1 or 2 Moderate (Prevalence of DVT - 17%)
0 or less Low (Prevalence of DVT - 3%)

Limitations of Wells score

  • The accuracy of the Wells rule, though useful in secondary and tertiary care centers, has not been properly validated for use in primary care patients with the suspicion of DVT.[5]
  • The performance of the Wells score was decreased when evaluating elderly patients, patients with a prior DVT, or patients having other comorbidities. These results may be equivalent to what is found in a primary care setting.[6][7] Also, it should be highlighted that Wells criteria is an additional tool to diagnosis rather than being a stand-alone test.

Modified Wells Criteria

Calculation of the Modified Wells Score for DVT

The modified Wells score includes 10 clinical questions, with the score ranging from -2 to 9. The clinical questions in the modified Wells score are similar to the Wells score with the exception of one added clinical question regarding a previous DVT which has been given a score of 1.

Modified Wells score calculator for DVT

Variables Score[8]
Active cancer with either palliative therapy or treatment that is either ongoing or within the prior 6 months 1
Patient was recently bedridden for at least 3 days
OR Major surgery in the prior 12 weeks necessitating general or regional anesthesia
1
Recent plaster immobilization, paresis or paralysis of the lower extremities 1
Tenderness that is localized is the distribution of the deep veins 1
Leg is entirely swollen 1
Calf is swollen for 3 cm or move compared to the other calf 1
Pitting edema in the symptomatic leg 1
Presence of collateral superficial non varicose veins 1
Previous DVT 1
There is an alternative diagnosis as likely as DVT -2

Interpretation of the Modified Wells Score for DVT

Score Pretest probability[8]
≥2 DVT is likely (Prevalence of DVT or PE - 28%)
<2 DVT is unlikely (Prevalence of DVT or PE - 6%)

AMUSE Score

Calculation of the AMUSE Score

The AMUSE score includes clinical variables in addition to the results of a qualitative D-dimer test to evaluate the need to proceed with ultrasonography among patients with suspected DVT. The study of the AMUSE score was designed for the primary care setting.

AMUSE score calculator

Variables Score[9]
Male 1
Active malignancy in the previous 6 months 1
Surgery in the previous 1 month 1
Absence of leg trauma 1
Hormonal contraceptive intake 1
Collateral leg veins distention 1
Discrepancy of ≥ 3 cm in calf circumference 2
Elevated D-dimer concentration 6

Interpretation of the AMUSE Score

Score Pretest probability[9]
≤3 Not high suspicion of DVT: Should not proceed with ultrasonography
≥4 High suspicion of DVT: Should proceed with ultrasonography

Limitations of the AMUSE Score

The study of the AMUSE score was not randomized. In addition, the follow up for the detection of missed thrombotic disease was based on clinical evaluation. Moreover, the design of the study that investigated the AMUSE score targeted the primary care setting.

HAMILTON Score

Calculation of HAMILTON Score

HAMILTON score calculator

Variables Score[1]
Active malignancy in the previous 6 months 2
Lower limb plaster immobilization 2
The emergency department physician has an elevated clinical suspicion of DVT in the absence of other possible alternative diagnoses 2
Bed rest for more than 3 days
OR
Recent surgery in the previous 4 weeks
1
Male 1
Discrepancy of ≥ 3 cm in calf circumference 1
Erythema 1

Interpretation of HAMILTON Score

Score Pretest probability[1]
≤2 Unlikely probability of DVT
≥3 Likely probability of DVT

The combination of a HAMILTON score ≤2 and a negative D-dimer excludes DVT with a negative predictive value of 99%.[1]

QThrombosis

Shown below is a list of the variables included in the QThrombosis score.[10] To calculate the risk prediction click here.

Age
Body mass index
Cigarette smoking (non-smoker; ex-smoker; light, moderate, or heavy smoker)
Townsend deprivation score
Varicose veins
Congestive heart failure
Rheumatoid arthritis
Chronic kidney disease
Inflammatory bowel disease
Cancer
Hospital admission within the last 12 months
Hip fracture or hip surgery (or both) within the last 12 months
Current use of antipsychotic drugs
Current use of tamoxifen
Current use of hormone replacement therapy
Use of antiplatelets
Cardiovascular disease(stroke, transient ischemic attack, or coronary artery disease)
Atrial fibrillation
Asthma
Chronic obstructive pulmonary disease
Family history of venous thromboembolism

References

  1. 1.0 1.1 1.2 1.3 Subramaniam RM, Chou T, Heath R, Allen R (2006). "Importance of pretest probability score and D-dimer assay before sonography for lower limb deep venous thrombosis". AJR Am J Roentgenol. 186 (1): 206–12. doi:10.2214/AJR.04.1398. PMID 16357403. Retrieved 2011-12-22. Unknown parameter |month= ignored (help)
  2. van der Velde EF, Toll DB, Ten Cate-Hoek AJ, Oudega R, Stoffers HE, Bossuyt PM, Büller HR, Prins MH, Hoes AW, Moons KG, van Weert HC (2011). "Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients". Ann Fam Med. 9 (1): 31–6. doi:10.1370/afm.1198. PMC 3022042. PMID 21242558. Retrieved 2011-12-22.
  3. van Es N, Bleker SM, Di Nisio M, Kleinjan A, Beyer-Westendorf J, Camporese G; et al. (2016). "Improving the diagnostic management of upper extremity deep vein thrombosis". J Thromb Haemost. doi:10.1111/jth.13536. PMID 27732764.
  4. 4.0 4.1 Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L; et al. (1997). "Value of assessment of pretest probability of deep-vein thrombosis in clinical management". Lancet. 350 (9094): 1795–8. doi:10.1016/S0140-6736(97)08140-3. PMID 9428249.
  5. Oudega R, Hoes AW, Moons KG (2005). "The Wells rule does not adequately rule out deep venous thrombosis in primary care patients". Ann. Intern. Med. 143 (2): 100–7. PMID 16027451. Retrieved 2011-12-22. Unknown parameter |month= ignored (help)
  6. Goodacre S, Sutton AJ, Sampson FC (2005). "Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis". Ann. Intern. Med. 143 (2): 129–39. PMID 16027455. Retrieved 2011-12-22. Unknown parameter |month= ignored (help)
  7. Qaseem A, Snow V, Barry P, Hornbake ER, Rodnick JE, Tobolic T, Ireland B, Segal J, Bass E, Weiss KB, Green L, Owens DK (2007). "Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians". Ann Fam Med. 5 (1): 57–62. doi:10.1370/afm.667. PMC 1783928. PMID 17261865. Retrieved 2011-12-22.
  8. 8.0 8.1 Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J; et al. (2003). "Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis". N Engl J Med. 349 (13): 1227–35. doi:10.1056/NEJMoa023153. PMID 14507948. Review in: ACP J Club. 2004 May-Jun;140(3):67
  9. 9.0 9.1 Büller HR, Ten Cate-Hoek AJ, Hoes AW, Joore MA, Moons KG, Oudega R; et al. (2009). "Safely ruling out deep venous thrombosis in primary care". Ann Intern Med. 150 (4): 229–35. PMID 19221374.
  10. Hippisley-Cox J, Coupland C (2011). "Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study". BMJ. 343: d4656. doi:10.1136/bmj.d4656. PMC 3156826. PMID 21846713. line feed character in |title= at position 12 (help)

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