Deep vein thrombosis assessment of clinical probability and risk scores: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
Line 178: Line 178:
{|style="background:white" border="1"
{|style="background:white" border="1"
|-
|-
|Age
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Age
|-
|-
|Body mass index
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Body mass index
|-
|-
|Smoking status (non-smoker; ex-smoker; light, moderate, or heavy smoker)
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Smoking status (non-smoker; ex-smoker; light, moderate, or heavy smoker)
|-
|-
|Townsend deprivation score
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Townsend deprivation score
|-
|-
|Varicose veins  
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Varicose veins  
|-
|-
|Congestive cardiac failure
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Congestive cardiac failure
|-
|-
|Rheumatoid arthritis
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Rheumatoid arthritis
|-
|-
|Chronic renal disease
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Chronic renal disease
|-
|-
|Inflammatory bowel disease
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Inflammatory bowel disease
|-
|-
|Cancer:(lung, gastrointestinal, pancreas, renal, breast, prostate, other)
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Cancer:(lung, gastrointestinal, pancreas, renal, breast, prostate, other)
|-
|-
|Recent hospital admission
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Recent hospital admission
|-
|-
|Recent hip fracture or hip surgery (or both)
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Recent hip fracture or hip surgery (or both)
|-
|-
|Current use of [[antipsychotic]] drugs:(none, atypical, typical)
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Current use of [[antipsychotic]] drugs:(none, atypical, typical)
|-
|-
|Current use of [[tamoxifen]]
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Current use of [[tamoxifen]]
|-
|-
|Current use of [[hormone replacement therapy]]: (none, equine or non-equine hormone replacement therapy)
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Current use of [[hormone replacement therapy]]: (none, equine or non-equine hormone replacement therapy)
|-
|-
|Use of [[antiplatelets]]
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Use of [[antiplatelet]]s
|-
|-
|Cardiovascular disease([[stroke]], [[transient ischaemic attack]], or [[coronary artery disease]])
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Cardiovascular disease([[stroke]], [[transient ischaemic attack]], or [[coronary artery disease]])
|-
|-
|Atrial fibrillation
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Atrial fibrillation
|-
|-
|Asthma
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Asthma
|-
|-
|[[Chronic obstructive pulmonary disease]]
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |[[Chronic obstructive pulmonary disease]]
|-
|-
|Family history of venous thromboembolism
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |Family history of [[venous thromboembolism]]
|}
|}


Revision as of 21:17, 3 June 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.; Rim Halaby, M.D. [3]; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters

Home

Patient Information

Overview

Classification

Pathophysiology

Causes

Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

Assessment of Clinical Probability and Risk Scores

Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Ultrasound

Venography

CT

MRI

Other Imaging Findings

Treatment

Treatment Approach

Medical Therapy

IVC Filter

Invasive Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Special Scenario

Upper extremity DVT

Recurrence

Pregnancy

Trials

Landmark Trials

Case Studies

Case #1

Deep vein thrombosis assessment of clinical probability and risk scores On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Deep vein thrombosis assessment of clinical probability and risk scores

CDC on Deep vein thrombosis assessment of clinical probability and risk scores

Deep vein thrombosis assessment of clinical probability and risk scores in the news

Blogs on Deep vein thrombosis assessment of clinical probability and risk scores

Directions to Hospitals Treating Deep vein thrombosis

Risk calculators and risk factors for Deep vein thrombosis assessment of clinical probability and risk scores

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.

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.

Wells score calculator for DVT

Variables Score[3]
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[3]
≥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.[4]
  • 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.[5][6] 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.

Variables Score[7]
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[7]
≥2 DVT is likely

(Prevalence of DVT or PE - 28%)

<2 DVT is unlikely

(Prevalence of DVT or PE - 6%)

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.

Calculation of the AMUSE Score

Variables Score[8]
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[8]
≤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

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

The variables included in the QThrombosis are:[9]

Age
Body mass index
Smoking status (non-smoker; ex-smoker; light, moderate, or heavy smoker)
Townsend deprivation score
Varicose veins
Congestive cardiac failure
Rheumatoid arthritis
Chronic renal disease
Inflammatory bowel disease
Cancer:(lung, gastrointestinal, pancreas, renal, breast, prostate, other)
Recent hospital admission
Recent hip fracture or hip surgery (or both)
Current use of antipsychotic drugs:(none, atypical, typical)
Current use of tamoxifen
Current use of hormone replacement therapy: (none, equine or non-equine hormone replacement therapy)
Use of antiplatelets
Cardiovascular disease(stroke, transient ischaemic attack, or coronary artery disease)
Atrial fibrillation
Asthma
Chronic obstructive pulmonary disease
Family history of venous thromboembolism

To calculate the risk prediction click here

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. ↑ 3.0 3.1 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.
  4. ↑ 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)
  5. ↑ 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)
  6. ↑ 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.
  7. ↑ 7.0 7.1 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
  8. ↑ 8.0 8.1 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.
  9. ↑ 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)
Retrieved from "https://www.wikidoc.org/index.php?title=Deep_vein_thrombosis_assessment_of_clinical_probability_and_risk_scores&oldid=975389"