Wells, D-Dimer in DVT.

Created by Philip Steven Wells in 1995 and validated by other studies (The Christopher Study),
Wells Criteria is a screening tool using set clinical criteria to give a numerical score predicting a
patient's risk of having a deep vein thrombosis (DVT). Initially a model with 3 levels of risk, low
moderate, or high probability, for ease of use has subsequently been simplified to 2 levels –
unlikely or likely.

Interpretation of Point Total

Three tier model Two tier model

Low Moderate High ≤4 ≥4

probability probability probability
-2 - 0 1-2 3-8 Unlikely - LOW Likely - HIGH

The score is calculated on the included criteria and the total is termed the pretest
probability - The probability that a patient has a disease before the result of a diagnostic
test has become available.
The pretest probability is reflected as a percentage, it is identical to the prevalence of the
disease and varies from place to place. According to Attia the prevalence, or pretest
probability Austrailian in each of Wells classifications are; low probability = 3%, moderate
probability = 17% and high probability = 75%. These are slightly different to the American
College of Chest Physicians figures of 5%, 17% and 53% respectively.

Physicians are guided by the screening tool result to follow an algorithm as to what action is
best taken in terms of diagnostic testing. Below is one such example from Sang Medicine
Ltd. In this example we can see if we follow the HIGH pathway preference is to send the
patient for an ultrasound. Following the LOW pathway preference is to perform a D-Dimer
test

A D-dimer test is a blood test that measures D-dimer, a product of fibrin

degradation when a blood clot dissolves in your body. Usually undetectable or
only detectable at a very low level unless your body is forming and breaking
down significant blood clots. This indicates the presence of a venous
thromboembolus (VTE), but not the location of the VTE, hence the need for
an ultrasound to confirm where the clot has formed.
No test is absolutely 100% correct and false negatives and false positives get
in the way of the accuracy of tests so even if a D-Dimer test came back
positive it may be incorrect, and this necessitates the need for knowing the
posttest probability - The probability that a patient has a disease after the result of a diagnostic test
has become available.

So how does one calculate the posttest probability?

By using the pretest probability and the likelihood ration of the test undertaken and graphing
these on a nomogram.
For example, if we use the low probability pretest probability of 3% and
calculate the likelihood ratio of a D-Dimer test values (as reported by
sanjeev) of sensitivity 97% and specificity 62% (average) to get a positive
likelihood ration LR+ of 2.55 (and a negative likelihood ratio LR- of 0.05).
Drawing a direct line from the pretest probability column through the likelihood ratio column
and onto the posttest column we are given a posttest probability value 0.97% with a
corresponding high negative predictive value (NPV) of 99.03 %. Coupled with a negative D-
Dimer test the clinician can confidently rule out the presence of a DVT

Attia, J. (n.d.). Moving beyond sensitivity and specificity: Using likelihood ratios to help interpret
diagnostic tests. https://doi.org/10.18773/austprescr.2003.082
Comparing D-dimer assays using likelihood ratios and Fagan nomograms. (n.d.). Retrieved March 10,
2022, from https://acutecaretesting.org/en/articles/comparing-d-dimer-assays-using-likelihood-ratios-
and-fagan-nomograms

Hill, J., & M.Ed, M. D. (n.d.). PERCs of the Wells Score. Taming the SRU. Retrieved March 10, 2022, from
https://www.tamingthesru.com/blog/2019/5/4/percs-of-the-wells-score

Modi, S., Deisler, R., Gozel, K., Reicks, P., Irwin, E., Brunsvold, M., Banton, K., & Beilman, G. J. (2016).
Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma
patients. World Journal of Emergency Surgery  : WJES, 11, 24. https://doi.org/10.1186/s13017-016-0078-
1

Screening Tests for Common Diseases. (n.d.). Retrieved March 10, 2022, from
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/screening-tests-for-common-
diseases

WELLS Score for evaluating a suspected DVT. (n.d.). Retrieved March 10, 2022, from https://practical-
haemostasis.com/Clinical%20Prediction%20Scores/Formulae%20code%20and%20formulae/Formulae/
VTE-Diagnosis/Wells_DVT_score.html