Сardiac surgery – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Sat, 12 Feb 2022 22:02:16 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.11 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Сardiac surgery – ClinCaseQuest https://clincasequest.hospital 32 32 Wells’ Deep Vein Thrombosis Criteria – online calculator https://clincasequest.hospital/wells-dvt-criteria/ Sat, 12 Feb 2022 09:34:00 +0000 https://clincasequest.hospital/?p=33466 The Wells’ DVT Criteria can be used in the outpatient and emergency department. By risk stratifying to low risk (Wells’ Score <2) and a negative…

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]]> The Wells’ DVT Criteria can be used in the outpatient and emergency department. By risk stratifying to low risk (Wells’ Score <2) and a negative D-dimer the clinician can exclude the further ultrasound (US) diagnostic test to rule out DVT.

The Wells’ Score is less useful in hospitalized patients.

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Treatment or palliation within 6 months

Measured 10 cm below tibial tuberosity

* Required


The physician may not prescribe an ultrasound (ultrasound) to rule out DVT if the patient has low-risk DVT (<2 points) based on risk stratification on Wells` score and negative D-dimer.

The Wells’ scale should only be used after a detailed patient’s history taking and a physical examination in patients who are at risk of DVT.

The Wells’ Deep Vein Thrombosis (DVT) Risk Criteria stratifies patients by risk of DVT. There is a low prevalence of DVT in patients with a low pretest probability of DVT (<25%). Complications of DVT include pulmonary embolism (PE) and pulmonary hypertension, the mortality rate of which is 1-8%, so the timely diagnosis of DVT is the best prevention of PE and pulmonary hypertension.

Traditional diagnosis of DVT involves ultrasonography of the lower extremities, which is associated with time and financial resources. Using Wells` DVT criteria physicians can identify those patients who are generally unlikely have DVT. Further testing of patients for D-dimer can also safely rule out DVT without the necessity for an ultrasound.

The predictive scale includes nine parameters and the clinician’s clinical judgment regarding the likelihood of an alternative diagnosis.Well’s assessment score based on addition of the selected points:

VariablePoints
Active cancer (treatment or palliation within 6 months)1
Bedridden recently >3 days or major surgery within 12 weeks1
Calf swelling >3 cm compared to the other leg (measured 10 cm below tibial tuberosity)1
Collateral (nonvaricose) superficial veins present1
Entire leg swollen1
Localized tenderness along the deep venous system1
Pitting edema, confined to symptomatic leg1
Paralysis, paresis, or recent plaster immobilization of the lower extremity1
Previously documented DVT1
Alternative diagnosis to DVT as likely or more likely-2

There are a few versions of the criteria with minor differences between them. This is the most widely validated scale, based on Wells 2003.

Interpretation:

Шкала Wells’Risk groupPrevalence of DVTRecommendations
≤0Low/unlikely5%These patients should proceed to D-dimer testing:
• A negative high or moderate sensitivity D-dimer results in a probability <1 % and no further imaging is required
• A positive D-dimer should proceed to US testing
• A negative US is sufficient for DVT rule out
• A positive US is concerning for DVT; strongly consider treatment with anticoagulation
1-2Moderate17%These patients should proceed to high-sensitivity D-dimer testing (moderate sensitivity D-dimer is not sufficient)
• A negative high-sensitivity D-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1%
• A positive high sensitivity D-dimer should proceed to US testing
• A negative US is sufficient for ruling out DVT
• A positive US is concerning for DVT, strongly consider treatment with anticoagulation
• Moderate risk group should only undergo D-dimer testing for rule out without ultrasonography if a high-sensitivity D-dimer is being used
≥3High/likely17-53%All DVT likely patients should receive a diagnostic US
• D-dimer testing should be utilized to help risk-stratify these DVT-likely patients
• In DVT likely patients with negative D-dimer: • A negative US is sufficient for ruling out DVT, consider discharge
• A positive US should be concerning for DVT, strongly consider treatment with anticoagulation
•In DVT likely patients with a positive D-dimer:
• A positive US should be concerning for DVT, strongly consider treatment with anticoagulation
• A negative US is still concerning for DVT. A repeat US should be performed within 1 week for re-evaluation

Sometimes patients with DVT and a negative D-dimer are revealed in clinical practice.

  • A negative ultrasound result is sufficient to rule out DVT and consider discharge.
  • A positive ultrasound result indicates the presence of DVT, with the necessity of anticoagulants treatment.

With DVT and positive D-dimer:

  • A positive ultrasound result is sufficient to make a diagnosis of DVT necessity of anticoagulants treatment.
  • Negative ultrasound may also occur with DVT. A follow-up ultrasound should be performed within 1 week for re-evaluation.

This predictive score was derived from a series of studies by Wells’ et al. (Wells 1995, Wells 1997, Wells 2003) in an attempt to stratify the risk of DVT in symptomatic outpatients in order to reduce clinical resource burden and avoid overuse of imaging.

This scale has been included in the American College of Pulmonology guidelines for DVT.

NB!

  • The clinician’s clinical assessment should take precedence over the score on this predictive scale. High suspicion for DVT should require imaging regardless of Wells’ score.
  • The presence of DVT is critical in assessing the presence of PE, and if PE is being differentiated, alternative decision-making tools such as the Wells’ PE score or the PERC rule should be used.

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Sources:

  1. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-30.https://pubmed.ncbi.nlm.nih.gov/7752753/
  2. Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)08140-3/fulltext
  3. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35. https://pubmed.ncbi.nlm.nih.gov/14507948/
  4. Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006 Oct 24;175(9):1087-92. Review. Erratum in: CMAJ. 2007 Nov 20;177(11):1392. https://pubmed.ncbi.nlm.nih.gov/17060659/
  5. Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. 2006 Jan 11;295(2):199-207. Review. https://pubmed.ncbi.nlm.nih.gov/16403932/
  6. Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson M.D., Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. https://pubmed.ncbi.nlm.nih.gov/22315267/
  7. Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med. 2015 Jul;175(7):1112-7. doi: 10.1001/jamainternmed.2015.1687. https://pubmed.ncbi.nlm.nih.gov/25985219/

See also:

Well’s criteria for Pulmonary Embolism probability assessment
PERC Rule for Pulmonary Embolism- online calculator

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]]> Infective Endocarditis (IE) Mortality Risk Score: online calculator https://clincasequest.hospital/ie-mortality-risk-score/ Mon, 17 Jan 2022 16:54:51 +0000 https://clincasequest.hospital/?p=32833 The Infectious Endocarditis Mortality Risk Score can be used in patients with confirmed IE to assess mortality risk. Addition of assigned points. Host Factors Age…

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]]> The Infectious Endocarditis Mortality Risk Score can be used in patients with confirmed IE to assess mortality risk.

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Host Factors

IE Factors

IE Complications

* Required

Addition of assigned points.

Host Factors
Age 
 ≤45     0
 46-60+2      
 61-70+3         
 >70+4
History of DialysisNo0
 Yes+3
IE Factors
Nosocomial IENo0
 Yes+2
Prosthetic IENo0
 Yes+1
Symptoms >1 month before admissionNo0
 Yes-1
Staphylococcus aureusNo0
 Yes+1
Viridans group streptococciNo0
 Yes-2
Aortic vegetationNo0
 Yes+1
Mitral vegetationNo0
 Yes+1
IE Complications
NYHA class 3 or 4 heart failureNo0
 Yes+3
StrokeNo0
 Yes+2
Paravalvular complicationNo0
 Yes+2
Persistent bacteremiaNo0
 Yes+2
Surgical treatmentNo0
 Yes-2

Probability of 6‐month mortality = 2.416*score+0.109*score2−4.849

A simplified risk score ≥8 had sensitivity 86.7% and specificity 50.8% for predicting overall 6‐month mortality (negative predictive value of 86% and positive predictive value of 39%).

The derivation cohort contained 4049 patients, and the validation cohort included 1197 subjects. This study was performed in referral centres (likely tertiary and quaternary academic centres) with experience with endocarditis and cardiac surgery.

Infective endocarditis (IE) has an overall 6-month mortality of approximately 25% in all-comers. Older age and history of dialysis appear to be the highest risk patient factors; IE complications also suggest a high mortality as well. Surgery is associated with a lower mortality rate but is infrequent in the high-risk cohort of patients. Mortality ranges from 10% in the lowest risk quintile to 53% in the highest-risk quintile. Surgery in this study was associated with lower mortality, but the highest risk patients were less likely to receive surgery (probably because they were high-risk surgical patients as well).

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Literature

  1. Lawrence P. Park, Vivian H. Chu, Gail Peterson, Athanasios Skoutelis, Tatjana Lejko‐Zupa, Emilio Bouza, Pierre Tattevin, Gilbert Habib, Ren Tan, Javier Gonzalez, Javier Altclas, Jameela Edathodu, Claudio Querido Fortes, Rinaldo Focaccia Siciliano, Orathai Pachirat, Souha Kanj, Andrew Wang, and the International Collaboration on Endocarditis (ICE) Investigators. Validated Risk Score for Predicting 6‐Month Mortality in Infective Endocarditis. Journal of the American Heart Association.2016.Vol. 5, No. 4. 2016;5:e003016 https://doi.org/10.1161/JAHA.115.003016

See also:

Infective endocarditis. Diagnostic criteria for infective endocarditis

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