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    Wells' Criteria for DVT

    Calculates Wells' Score for risk of DVT.
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    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.
    When to Use
    Pearls/Pitfalls
    Why 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.

    The Wells’ Deep Vein Thrombosis (DVT) Criteria risk stratify patients for 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.

    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.

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    Result:

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    Next Steps
    Evidence
    Creator Insights

    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 than there is no need for risk stratification.

    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 a diagnostic 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.

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

    Critical 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.

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    Dr. Phil Wells
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