Deep vein thrombosis assessment of clinical probability and risk scores: Difference between revisions
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Revision as of 00:54, 29 May 2014
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.; Assistant Editor(s)-In-Chief: Justine Cadet
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Overview
In a patient with suspected DVT, establishing 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, like the Wells score, Hamilton score , and AMUSE score. [1][2] When combined with pretest probability, ultrasonography and D-dimer tests are most useful in a diagnosis for DVT.
Pretest Probability
Wells Score
The Wells score is the most widely used tool to assess pre-test probability. It includes 10 clinical questions, with the score ranging from -2 to 9. Pretest probability guides the interpretation of test results. It includes risk factors and examination findings.
Wells score calculator for DVT
| Variable | Wells Score[3][4] |
|---|---|
| Active cancer (treatment within last 6 months or palliative) | 1 |
| Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) | 1 |
| Collateral superficial veins (non-varicose) | 1 |
| Pitting edema (confined to symptomatic leg) | 1 |
| Swelling of entire leg | 1 |
| Localized pain along distribution of deep venous system | 1 |
| Paralysis, paresis, or recent cast immobilization of lower extremities | 1 |
| Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 12 weeks | 1 |
| Previously documented DVT | 1 |
| Alternative diagnosis at least as likely | - 2 |
Interpretation
- High probability: ≥ 3 (Prevalence of DVT - 53%)
- Moderate probability: 1-2 (Prevalence of DVT - 17%)
- Low probability: ≤ 0 (Prevalence of DVT - 5%)
A modified scoring system stratifies the patients as likely (≥ 2, 28% prevalence) or unlikely (< 2, 6% prevalence) based on the score of 2.
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.
References
- ↑ 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) - ↑ 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.
- ↑ Wells PS, Anderson DR, Bormanis J; 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.
- ↑ Wells PS, Anderson DR, Rodger M; 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. Unknown parameter
|month=ignored (help) - ↑ 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) - ↑ 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) - ↑ 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.