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A study of modified Wells score for pulmonary embolism and age-adjusted D-dimer values in patients at risk for deep venous thrombosis

PE is one of the biggest masqueraders in medicine and a preventable cause of death; therefore, early diagnosis is of paramount importance while simultaneously avoiding the risks of unnecessary testing. The combined strategy using modified Wells score and age-adjusted D-dimer cut-off value has 100% sensitivity and NPV and can be used to safely exclude PE in in-patients.

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 Wells Score for Pulmonary Embolism (PE)

“The recommendations from our analysis represent a significant departure from current practice. Implementing the policies we advocate could result in increased D-dimer testing. However, our analysis indicates that when patients present with signs and symptoms suggestive of PE and warranting a history, exam, vital signs, 12-lead ECG, and chest x-ray, using the D-dimer in accordance with the guidelines from our analysis is part of a cost-effective diagnostic strategy. Moreover, the policies we advocate would likely lead to decreased numbers of imaging tests, particularly in Low and Moderate Wells category patients. Future work will need to validate these results in a prospective clinical trial prior to the delivery of clinical recommendations.”

Articles of Interest

Impact of implementation of the Simplified Wells Criteria on referrals for pulmonary embolism

The study emphasized the importance of determining a pretest clinical probability for PE.

Investigation of a suspected Pulmonary Embolus [PE]: The Wells PE Score

The Wells PE Score is used to evaluate a patient with a suspected PE to establish the probability that this is likely or unlikely. The results of the Wells Score will guide additional investigations and management.

Is all well with the Wells score?

Note: there have been multiple revisions of both the Wells criteria for DVT and the Wells criteria for Pulmonary Embolisms. Be sure to stay up-to-date with any amendments to the Wells score methods.

PERCs of the Wells Score

The WELLS score was created by Philip Steven Wells in 1995 to risk stratify patients for PE and was further developed over the next few years into two different models... The most important thing to remember is that these decision rules do not replace clinical judgment. The PERC rule requires a clinical suspicion of <15% before it can be applied; it should no tbe applied to all patients in whom you are considering PE. Similarly, the WELLS score is not meant to be used on all patients with chest pain or dyspnea; you must first have a genuine clinical suspicion for PE. Furthermore, these tools do not force you to order any diagnostic testing. A positive PERC is not an indication for ordering a d-dimer, and a high-risk WELLS score does not necessarily mean you must order a CTPA.

The Legend score synthesizes Wells, PERC, Geneva, D-dimer and predicts acute pulmonary embolism prior to imaging tests

What this study adds - A new model termed Legend score comprising active cancer, D-dimer
1000 ng/mL, DVT symptoms and/or signs, previous VTE history, and surgery, trauma, or immobilization in the past month has yielded excellent diagnostic efficiency with good safety and more reduction of unnecessary imaging tests than Wells+DD, PERC+DD, Geneva+DD, or YEARS+DD, in the pretest prediction of acute PE prior to imaging tests.

Values of the Wells and Revised Geneva Scores Combined with D-dimer in Diagnosing Elderly Pulmonary Embolism Patients

In conclusion, for elderly cases, the Wells score appeared to be a more accurate rule, with which could reduce the rate of misdiagnosis and avoid unnecessary tests; D-dimer is of greater value in excluding PE when combined with Wells score or revised Geneva score.

Wells Score for DVT Diagnosis

The Wells score for the diagnosis of a DVT. The Wells score is the most widely used clinical decision tool for the diagnosis of deep vein thrombosis (DVT). This tool risk-stratifies patients into 'low', 'intermediate' and 'high' risk categories for DVT, based on a point system. A score of less than two indicates low risk, and above two indicates intermediate/high risk.

Wells’ Score + D-dimer to Rule Out PE

Bottom Line - Wells’ criteria and D-dimer can be used to safely exclude PE in patients with a low pre-test probability and negative D-dimer.

Resources

Simplified Wells Score

This is a large study based on the Wells Score. It creates a simplified version of the Wells rule that is easier to follow and should be easier to apply in clinical situations. It is also a larger external validation of the Wells Score. It may be applied in adult inpatient and outpatients with confidence. The study found that using the Simplified Wells Score, a patient with a score of ≤1 and a negative D dimer has an extremely low probability of PE and an alternative diagnosis should be sought. In addition, the PERC rule may be used with patients with a score of ≤1 to determine who should have a D dimer and who require no further testing for PE.

Wells score

Objectifies risk of pulmonary embolism. The model should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. it should not be applied to all patients with chest pain or dyspnea or to all patients with leg pain or swelling.

Wells score Two Level

Two-level Wells score tables and algorithms for diagnosis...

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