Regular ArticleComparison of the diagnostic performance of the original and modified Wells score in inpatients and outpatients with suspected deep vein thrombosis
Introduction
Deep vein thrombosis (DVT) is a common problem in ambulatory and hospitalized patients. Untreated DVT may lead to potentially fatal pulmonary embolism (PE). On the other hand, unjustified anticoagulation therapy poses a risk for bleeding [1]. Correct diagnosis and prompt treatment are therefore crucial. Unfortunately, symptoms and signs of DVT are unspecific. Less than 25% of patients with clinically suspected DVT do actually have the disease [2], [3], underscoring the importance of accurate diagnostic strategies. Several clinical prediction rules have been developed and validated in various populations to simplify and improve the diagnostic process of patients with suspected DVT [4], [5], [6], [7], [8], [9]. Diagnostic strategies based on combining pretest probability with D-dimers measurements have been shown to be safe and cost-effective [10], leading to a significant reduction of ultrasound examinations [5], [11], [12].
The best validated prediction rule is the Wells score, consisting of nine clinical items (Table 1) [6]. This score has been developed in ambulatory patients addressed to a tertiary care center for a suspected first episode of proximal and distal lower limb DVT [6], [13], [14]. It has been subsequently validated in the emergency department, and the hospital setting [4], [11], [15]. More recently, Wells and colleagues published a modified score, adding an item for previously documented DVT [5]. This modified Wells score has been validated in outpatients [5], and emergency department patients only [8]. The aim of this prospective cohort study was to compare the accuracy of the two scores in predicting proximal and isolated distal DVT in a broad, unselected population of ambulatory and hospitalized patients with suspected DVT.
Section snippets
Patients
Consecutive patients, ≥ 18 years of age, with clinically suspected lower limbs DVT addressed to the thrombosis consultation of the vascular medicine service of a teaching hospital were potentially eligible for the present study. Outpatients presenting to the emergency department or directly referred by their general practitioner and inpatients referred by their physician in charge were eligible.
Exclusion criteria were as follows: clinical suspicion of PE, treatment with therapeutic
Results
Between May 4, 2007 and May 31, 2009, 447 consecutive patients with clinically suspected DVT of the lower limbs were screened. 149 patients were excluded because at least 1 of the predefined exclusion criteria was present (clinical suspicion of PE: 39; treatment with therapeutic anticoagulation for more than 48 hours prior to inclusion: 31; planned long-term anticoagulation for a diagnosis other than VTE: 22; pregnancy: 17; life expectancy less than 3 months: 5; unwillingness or inability to
Discussion
Our results demonstrate that original and modified Wells scores are similarly accurate in determining pre-test probability in patients with clinical suspicion of lower limb DVT. While both scores performed well in patients with proximal DVT, the discriminatory power in patients with isolated distal DVT was much lower. Both scores performed rather poorly in inpatients.
Because the modified Wells score comprises an additional variable (previously documented DVT), it classified significantly more
Conflict of interest statement
No conflict of interest to declare.
Acknowledgements
The authors wish to thank Monique Salvi for her excellent technical assistance as well as all the physicians of the division of angiology for performing the ultrasound examinations. This study was financially supported by a grant from Cardiomet.
References (27)
- et al.
Value of assessment of pretest probability of deep-vein thrombosis in clinical management
Lancet
(1997) - et al.
Comparison of four clinical prediction scores for the diagnosis of lower limb deep venous thrombosis in outpatients
Am J Med
(2003) - et al.
Diagnosis of lower limb deep venous thrombosis in emergency department patients: performance of Hamilton and modified Wells scores
Ann Emerg Med
(2006) - et al.
Comparison of four strategies for diagnosing deep vein thrombosis: a cost-effectiveness analysis
Am J Med
(2001) - et al.
Combined use of clinical assessment and d-dimer to improve the management of patients presenting to the emergency department with suspected deep vein thrombosis (the EDITED Study)
J Thromb Haemost
(2003) - et al.
Accuracy of clinical assessment of deep-vein thrombosis
Lancet
(1995) - et al.
Excellent performances of Wells' score and of the modified Wells' score for the diagnosis of proximal or distal deep venous thrombosis in outpatients or inpatients at Toulouse University Hospital: TVP-PREDICT study
J Mal Vasc
(2009) - et al.
Diagnosis of deep venous thrombosis and alternative diseases in symptomatic outpatients
Eur J Intern Med
(2004) Distal DVT: worth diagnosing? Yes
J Thromb Haemost
(2007)- et al.
Clinical prediction of deep venous thrombosis using two risk assessment methods in combination with rapid quantitative D-dimer testing
Am J Med
(2002)
Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis (in consultation with the Council on Cardiovascular Radiology), American Heart Association
Circulation
Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis
Ann Intern Med
Does this patient have deep vein thrombosis?
JAMA
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