EBQ:Wells PE Rule Out - Revision history

Rossdonaldson1: /* Major Points */

2018-07-15T20:12:25Z

Major Points

← Older revision		Revision as of 20:12, 15 July 2018
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	==Major Points==		==Major Points==
	~~===Wells Criteria===~~
	~~{{Wells Criteria}}~~

	~~===Wells Score===~~
	{{Wells Score}}		{{Wells Score}}

Ostermayer: Text replacement - " DVT " to " DVT"

2017-01-27T16:46:58Z

Text replacement - " DVT " to " DVT"

← Older revision		Revision as of 16:46, 27 January 2017
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	===Exclusion Criteria===		===Exclusion Criteria===
	*Suspected DVT of the upper extremity as a likely source of PE		*Suspected [[DVT]]of the upper extremity as a likely source of PE
	*No symptoms of PE within 3 days of presentation		*No symptoms of PE within 3 days of presentation
	*Anticoagulant therapy for more than 24 hours		*Anticoagulant therapy for more than 24 hours
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	*849 patients had the diagnosis of PE excluded		*849 patients had the diagnosis of PE excluded
	**Of these, 5 patients (0.6%) developed PE or DVT during follow-up. However, 4 of these had not undergone the proper diagnostic protocol.		**Of these, 5 patients (0.6%) developed PE or [[DVT]]during follow-up. However, 4 of these had not undergone the proper diagnostic protocol.
	*437 patients had the diagnosis excluded with a negative D-dimer result and low clinical probability		*437 patients had the diagnosis excluded with a negative D-dimer result and low clinical probability
	**Of these, only 1 developed PE during follow-up		**Of these, only 1 developed PE during follow-up

Ostermayer: Text replacement - "Category: Pulm" to "Category:Pulmonary"

2016-03-22T16:11:52Z

Text replacement - "Category: Pulm" to "Category:Pulmonary"

← Older revision		Revision as of 16:11, 22 March 2016
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	[[Category: ~~Pulm~~]][[Category:EBQ]]		[[Category:Pulmonary]][[Category:EBQ]]

Ostermayer: /* Outcomes */

2015-09-30T14:21:42Z

Outcomes

← Older revision		Revision as of 14:21, 30 September 2015
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	**Of these, only 1 developed PE during follow-up		**Of these, only 1 developed PE during follow-up
	'''Negative predictive value''' for combined strategy with D-dimer testing: '''99.5%''' (CI, 99.1% to 100%)		'''Negative predictive value''' for combined strategy with D-dimer testing: '''99.5%''' (CI, 99.1% to 100%)

	~~===Secondary Outcomes===~~



	~~===Subgroup analysis===~~



	==Criticisms & Further Discussion==		==Criticisms & Further Discussion==

Ostermayer: /* Review Questions */

2015-09-30T14:15:32Z

Review Questions

@@ Line 127: / Line 127: @@
 *[http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ MDCalc: Wells' Criteria]
 *[https://vimeo.com/25790659 Pulmonary Embolism Video]
 ==References==

Neil.m.young at 15:53, 29 September 2015

2015-09-29T15:53:04Z

← Older revision		Revision as of 15:53, 29 September 2015
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	</quiz>		</quiz>

			==References==
	<references/>		<references/>


	[[Category: Pulm]][[Category:EBQ]]		[[Category: Pulm]][[Category:EBQ]]

Catierey: discussion

2015-09-28T20:12:30Z

discussion

← Older revision		Revision as of 20:12, 28 September 2015
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	==Criticisms & Further Discussion==		==Criticisms & Further Discussion==
			*Cristopher Study in 2006: algorithm combining clinical probability, D-dimer testing, and computed tomography showed 1.3% incidence of VTE at 3-month follow-up, and 0.5% fatal PE <ref>van Belle, A et al. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography. JAMA. 2006;295(2):172-179.</ref>
			**This impact analysis demonstrated that using the Wells criteria in an algorithm with D-dimer and CT can be safely applied as a level 1 decision rule.
			*Clinical gestalt is heavily weighted in this decision rule
			**Having PE as most likely diagnosis automatically classifies the patient as moderate pretest probability
			*D-dimer used had higher specificity and lower sensitivity than industry standard
	*This study used V-P lung scan, which was been replaced by CTA as imaging of choice		*This study used V-P lung scan, which was been replaced by CTA as imaging of choice
	**CTA has increased sensitivity (83%) and specificity (96%), compared to 65% and 94%, respectively, for V-P scan <ref>Stein PD, et al. "Multidetector Computed Tomography for Acute Pulmonary Embolism". The New England Journal of Medicine. 2006. 354(22):2317-2327.</ref>		**CTA has increased sensitivity (83%) and specificity (96%), compared to 65% and 94%, respectively, for V-P scan <ref>Stein PD, et al. "Multidetector Computed Tomography for Acute Pulmonary Embolism". The New England Journal of Medicine. 2006. 354(22):2317-2327.</ref>
	*Clinical gestalt is heavily weighted in this decision rule		===Relation to PERC rule===
	**Having PE as most likely diagnosis automatically classifies the patient as moderate pretest probability
	*Wells criteria often used in concert with the PERC rule to increase sensitivity		*Wells criteria often used in concert with the PERC rule to increase sensitivity
			**Many argue that the rules shouldn't be applied in parallel because they are not clinically different (they look at many of the same things)
			*Can Wells be considered a rule out criteria?
			**This decision rule study was not designed or validated to be used that way, and further studies must be completed in order for the data to support that application
			**The low pretest probability group in this study had 1.3% diagnosis of PE, suggesting to some that post hoc analysis supports the use of Wells to rule out diagnosis of PE
			*PERC was created to help rule out diagnosis of PE, with a test threshold of 1.8%<ref>Kline JA1, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism.J Thromb Haemost. 2004 Aug;2(8):1247-55.</ref>
			**Using this threshold, some suggest that because the prevalence of PE in the low probability group of the Wells study was well below the test threshold proposed by Kline et all, that PE may be safely excluded in low probability patients without further testing. However, this has not been validated. (see [https://vimeo.com/25790659 Pulmonary Embolism Video] for further discussion)

	==Funding==		==Funding==

Catierey: formatting

2015-09-21T22:04:56Z

formatting

← Older revision		Revision as of 22:04, 21 September 2015
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	{{Wells Score}}		{{Wells Score}}

	PE exclusion		'''PE exclusion:'''
	*Low pre-test probability and negative d-dimer		*Low pre-test probability and negative d-dimer
	*Definitive negative imaging needed for moderate and high pretest probability		*Definitive negative imaging needed for moderate and high pretest probability

Catierey: further discussion

2015-09-21T22:03:42Z

further discussion

← Older revision		Revision as of 22:03, 21 September 2015
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	==Conclusion==		==Conclusion==
	Patients can be safely managed for suspected pulmonary embolism on the basis of pretest probability and d-dimer		Patients can be safely managed for suspected [[pulmonary embolism]] on the basis of pretest probability and d-dimer

	==Major Points==		==Major Points==
			===Wells Criteria===
	{{Wells Criteria}}		{{Wells Criteria}}

			===Wells Score===
	{{Wells Score}}		{{Wells Score}}

			PE exclusion
			*Low pre-test probability and negative d-dimer
			*Definitive negative imaging needed for moderate and high pretest probability
			'''NPV=99.5%''' of diagnostic algorithm

	==Study Design==		==Study Design==
	Prospective ~~Cohort Study of~~ 4 tertiary care hospitals ~~in Canada~~		*Prospective cohort study in 4 Canadian tertiary care hospitals
	*Patients were evaluated by 1 of 43 EM physicians		*Patients were evaluated by 1 of 43 designated EM physicians
	*Physician assigned points according to the Well's criteria points table above		*Physician assigned points according to the Well's criteria points table above
	*~~Physicians were told to use clinical information, CXR, EKG, and whatever blood tests were considered necessary~~		*Primary outcome was development of venous thromboembolic event in patients with excluded PE diagnosis during 3 months of follow-up
	*~~Patients received diagnosis~~ of PE ~~if they had~~ high-probability V-P scan, abnormal result on ultrasound or pulmonary angiography, VTE during follow-up		**Diagnosis of PE made with high-probability V-P scan, abnormal result on ultrasound or pulmonary angiography, or VTE during follow-up
	*If the diagnosis of PE was excluded, patients were followed up for 3 months for the development of thromboembolic events

	==Population==		==Population==
	===Patient Demographics===		===Patient Demographics===
			*Mean age: 50.5 years old
			*Women: 63%
			*Mean duration of symptoms: 3.2 days
			*Diagnosis of cancer: 7.2%
			*Recent surgery: 8.4%
			*Recent immobilization: 7.6%

	===Inclusion Criteria===		===Inclusion Criteria===
	*~~Consecutive patients presenting~~ to participating ~~EDs~~		*Presenting to participating ED
	*Suspicion of PE		*Suspicion of PE
	*Symptoms for <30 days		*Symptoms for <30 days
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	===Primary Outcome===		===Primary Outcome===
			{\| class="wikitable"
			\|-
			! Pretest Probability !! Patients !! Diagnosis of PE
			\|-
			\| Low \|\| 527 \|\| 7 (1.3%)
			\|-
			\| Moderate \|\| 339 \|\| 55 (16.2%)
			\|-
			\| High \|\| 64 \|\| 24 (40.6%)
			\|}

			*849 patients had the diagnosis of PE excluded
			**Of these, 5 patients (0.6%) developed PE or DVT during follow-up. However, 4 of these had not undergone the proper diagnostic protocol.
			*437 patients had the diagnosis excluded with a negative D-dimer result and low clinical probability
			**Of these, only 1 developed PE during follow-up
			'''Negative predictive value''' for combined strategy with D-dimer testing: '''99.5%''' (CI, 99.1% to 100%)

	===Secondary Outcomes===		===Secondary Outcomes===
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	==Criticisms & Further Discussion==		==Criticisms & Further Discussion==
	*This study used V-P lung scan, which was been replaced ~~with~~ CTA as imaging of choice		*This study used V-P lung scan, which was been replaced by CTA as imaging of choice
			**CTA has increased sensitivity (83%) and specificity (96%), compared to 65% and 94%, respectively, for V-P scan <ref>Stein PD, et al. "Multidetector Computed Tomography for Acute Pulmonary Embolism". The New England Journal of Medicine. 2006. 354(22):2317-2327.</ref>
			*Clinical gestalt is heavily weighted in this decision rule
			**Having PE as most likely diagnosis automatically classifies the patient as moderate pretest probability
			*Wells criteria often used in concert with the PERC rule to increase sensitivity

			==Funding==
			Grant from the Heart and Stroke Foundation of Nova Scotia and Ontario

	==See Also==		==See Also==
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	==External Links==		==External Links==
	*[http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ MDCalc: Wells' Criteria]		*[http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ MDCalc: Wells' Criteria]
			*[https://vimeo.com/25790659 Pulmonary Embolism Video]

	==Review Questions==		==Review Questions==

Catierey: added templates

2015-09-21T19:20:42Z

added templates

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 ==Major Points==
-{| class="wikitable"
+{{Wells Criteria}}
-|-
-! Characteristics !! Points
+{{Wells Score}}
 ==Study Design==
 Prospective Cohort Study of 4 tertiary care hospitals in Canada