Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis

Abstract

Objective To assess the accuracy of the Wells rule for excluding deep vein thrombosis and whether this accuracy applies to different subgroups of patients.Design Meta-analysis of individual patient data. Data sources Authors of 13 studies (n=10 002) provided their datasets, and these individual patient data were merged into one dataset.Eligibility criteria Studies were eligible if they enrolled consecutive outpatients with suspected deep vein thrombosis, scored all variables of the Wells rule, and performed an appropriate reference standard.Main outcome measures Multilevel logistic regression models, including an interaction term for each subgroup, were used to estimate differences in predicted probabilities of deep vein thrombosis by the Wells rule. In addition, D-dimer testing was added to assess differences in the ability to exclude deep vein thrombosis using an unlikely score on the Wells rule combined with a negative D-dimer test result.Results Overall, increasing scores on the Wells rule were associated with an increasing probability of having deep vein thrombosis. Estimated probabilities were almost twofold higher in patients with cancer, in patients with suspected recurrent events, and (to a lesser extent) in males. An unlikely score on the Wells rule (≤1) combined with a negative D-dimer test result was associated with an extremely low probability of deep vein thrombosis (1.2%, 95% confidence interval 0.7% to 1.8%). This combination occurred in 29% (95% confidence interval 20% to 40%) of patients. These findings were consistent in subgroups defined by type of D-dimer assay (quantitative or qualitative), sex, and care setting (primary or hospital care). For patients with cancer, the combination of an unlikely score on the Wells rule and a negative D-dimer test result occurred in only 9% of patients and was associated with a 2.2% probability of deep vein thrombosis being present. In patients with suspected recurrent events, only the modified Wells rule (adding one point for the previous event) is safe.Conclusion Combined with a negative D-dimer test result (both quantitative and qualitative), deep vein thrombosis can be excluded in patients with an unlikely score on the Wells rule. This finding is true for both sexes, as well as for patients presenting in primary and hospital care. In patients with cancer, the combination is neither safe nor efficient. For patients with suspected recurrent disease, one extra point should be added to the rule to enable a safe exclusion.

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study

“…Primary disease was classified into four categories: cancer bearing,6 infection,7 trauma,8 and others. These primary diseases were considered to affect the ED assessment because each is associated with positive D‐dimer results 6, 7, 8. Death during hospitalization was considered to indicate a severe disorder and was treated as a confounder for both variables and outcomes.…”

“…In the differential diagnosis for the positive D‐dimer, we defined D‐dimer‐related diseases as DVT or pulmonary embolism,6, 10 aortic dissection,11 disseminated intravascular coagulopathy,12 and others. Documentation data were collected in a sentence, and two authors, D.T.…”

Impact of Hormone Therapy Linked to Wells Prediction Score in the Diagnosis of Deep Vein Thrombosis in Women Submitted to Vascular Ultrasound

“…A Tabela 1 detalha o escore de Wells para TVP em pacientes sintomáticos. A reprodutibilidade e o desempenho do escore foram amplamente pesquisados, sendo o escore aplicado especialmente na avaliação de TVP em atendimentos ambulatoriais [8][9][10] .…”

Current challenges in diagnostic imaging of venous thromboembolism

“…To start with, the use of clinical decision rules in combination with D-dimer assays has not been evaluated in large cohorts for this specific clinical setting. [6][7][8] Furthermore, it has been shown that ultrasound abnormalities persist in ;80% of patients 3 months and in 50% of patients 1 year after initial DVT diagnosis, despite adequate anticoagulation. 9 Because a sonographer cannot determine whether incompressibility of a specific vein segment is caused by a new DVT or residual thrombosis, the usefulness of CUS in a patient with suspected ipsilateral recurrent DVT is questionable.…”