Wells score
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Wells score pulmonary embolism DVT criteria official clinical guideline
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https://www.nice.org.uk/guidance/ng158/chapter/recommendatio…
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Wells score estimates the pre-test probability of deep-vein thrombosis (DVT) or pulmonary embolism (PE). Use the correct score for the suspected condition.
1. Two-level Wells score for DVT
| Clinical feature | Points |
|---|---|
| Active cancer, on treatment, treated within 6 months, or palliative | +1 |
| Paralysis, paresis, or recent plaster immobilisation of lower limbs | +1 |
| Bedridden for 3 days or more, or major surgery within 12 weeks requiring general/regional anaesthesia | +1 |
| Localised tenderness along deep venous system | +1 |
| Entire leg swollen | +1 |
| Calf swelling at least 3 cm greater than the asymptomatic side | +1 |
| Pitting oedema confined to symptomatic leg | +1 |
| Collateral superficial veins, non-varicose | +1 |
| Previously documented DVT | +1 |
| Alternative diagnosis at least as likely as DVT | -2 |
Interpretation
- DVT likely: ≥2
- DVT unlikely: ≤1
2. Two-level Wells score for PE
| Clinical feature | Points |
|---|---|
| Clinical signs of DVT, at least leg swelling and deep-vein tenderness | +3 |
| PE is more likely than an alternative diagnosis | +3 |
| Heart rate >100/min | +1.5 |
| Immobilisation for >3 days or surgery within previous 4 weeks | +1.5 |
| Previous objectively diagnosed DVT or PE | +1.5 |
| Haemoptysis | +1 |
| Malignancy, on treatment, treated within last 6 months, or palliative | +1 |
Interpretation
- PE likely: >4
- PE unlikely: ≤4
The alternative-diagnosis item in the PE score is subjective, so it should be applied using overall clinical judgement. The score guides next testing, such as D-dimer or imaging, and does not by itself diagnose or exclude DVT/PE. NICE VTE guidance recommends the two-level versions above.
D dimer significance in Pulmonary embolism
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pulmonary embolism D-dimer diagnostic guidance age-adjusted threshold NICE
D-dimer is a fibrin-degradation product. It rises when fibrin clot formation and breakdown are occurring, as in venous thromboembolism including pulmonary embolism (PE).
Significance in suspected PE
1. Main role: rule out PE, not confirm it
D-dimer is highly sensitive but poorly specific.
- Negative high-sensitivity D-dimer in a patient with low or intermediate clinical probability of PE makes acute PE very unlikely and can avoid CT pulmonary angiography.
- Positive D-dimer does not diagnose PE. It means further evaluation, usually imaging, may be needed depending on pre-test probability.
A normal D-dimer with low or moderate pre-test probability has a high negative predictive value for PE. Fishman's Pulmonary Diseases and Disorders, 2-Volume Set, lines 2627-2643.
2. Use it with clinical probability first
Assess clinical probability with the Wells score, Geneva score, or clinical judgement.
| Clinical probability of PE | D-dimer significance |
|---|---|
| Low / PE unlikely | Negative D-dimer can rule out PE. |
| Intermediate | Negative high-sensitivity D-dimer can generally rule out PE. |
| High / PE likely | Do not rely on D-dimer to exclude PE. Proceed directly to imaging, usually CTPA if suitable. |
This is because the negative predictive value falls when pre-test probability is high, while specificity is low. Fishman's Pulmonary Diseases and Disorders, 2-Volume Set, lines 2636-2643.
3. Why a positive D-dimer is nonspecific
D-dimer may be elevated without PE in:
- Increasing age
- Recent surgery or trauma
- Pregnancy and the postpartum period
- Cancer
- Infection or sepsis
- Inflammation
- Hospitalisation
- Liver disease
- Disseminated intravascular coagulation
- Recent myocardial infarction or stroke
Therefore, a positive result is common and must be interpreted in its clinical setting.
4. Age-adjusted cut-off
For a high-sensitivity assay:
- Age <50 years: negative if below 500 micrograms/L FEU
- Age ≥50 years: negative threshold may be age × 10 micrograms/L FEU
Example: in a 72-year-old, an age-adjusted threshold is 720 micrograms/L FEU. This approach reduces unnecessary imaging in older adults while retaining safety in appropriately selected low/intermediate-risk patients. Thrombosis Canada guidance supports age-adjusted testing.
Practical takeaway
Low/intermediate Wells probability + negative D-dimer = PE can usually be excluded.
Positive D-dimer or high Wells probability = PE is not confirmed, but imaging assessment is generally required.
If PE is suspected with severe breathlessness, chest pain, fainting, coughing blood, or low oxygen levels, urgent medical assessment is needed rather than waiting on a D-dimer result.
Treatment of pulmonary emb olism
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2026 pulmonary embolism treatment guideline anticoagulation thrombolysis catheter directed therapy
Treatment of acute pulmonary embolism (PE)
PE is managed according to haemodynamic risk, bleeding risk, and patient factors such as pregnancy, cancer, renal function, and drug interactions. A suspected or confirmed PE with shock, fainting, severe breathlessness, or low oxygen needs emergency hospital treatment.
1. Immediate supportive care
- Oxygen if hypoxaemic
- Analgesia and monitoring
- Careful IV fluids if needed. Large fluid loads can worsen right-ventricular failure.
- Vasopressors, commonly norepinephrine, if shock persists
- Assess severity: blood pressure, right-ventricular strain on CT/echo, cardiac troponin, and clinical risk score
2. Anticoagulation: main treatment for most patients
Anticoagulation prevents enlargement and recurrence of clots while the body gradually breaks down the embolus.
For haemodynamically stable PE, treatment is usually anticoagulation alone.
Common options include:
- DOACs: apixaban or rivaroxaban are commonly used first-line in suitable patients.
- Low-molecular-weight heparin (LMWH): often preferred in pregnancy and may be selected in cancer or when oral therapy is unsuitable.
- Unfractionated heparin (UFH): preferred when rapid reversal may be required, there is severe renal impairment, or the patient may need thrombolysis/procedure.
- Warfarin: an alternative when DOACs are unsuitable, but requires bridging with heparin initially and INR monitoring.
3. Duration of anticoagulation
- Minimum: 3 months for most PEs.
- Stop after 3 months may be reasonable if PE was provoked by a temporary major risk factor, such as surgery, trauma, or immobilisation, and recurrence risk is low.
- Extended or indefinite therapy may be considered for unprovoked PE, recurrent VTE, ongoing cancer, or persistent risk factors, after balancing recurrence risk against bleeding risk.
4. Reperfusion treatment for high-risk PE
High-risk (massive) PE means PE with persistent hypotension, shock, or cardiac arrest. In addition to anticoagulation, urgent removal or dissolution of clot may be needed.
Systemic thrombolysis
- A clot-dissolving drug, such as alteplase, is used if there is haemodynamic instability and no major contraindication.
- Main hazard: major bleeding, especially intracranial haemorrhage.
Catheter-directed treatment or surgical embolectomy
Considered when:
- Thrombolysis is contraindicated
- Thrombolysis fails
- The patient deteriorates despite anticoagulation
- A selected high-risk patient is managed by an experienced PE response/interventional team
These procedures include catheter-directed thrombolysis, mechanical thrombectomy, or surgical pulmonary embolectomy. Current evidence does not support routine invasive therapy for every stable, intermediate-risk PE. The 2026 ACC/AHA guidance reserves it for selected higher-risk patients or deterioration. ACC discussion of the guideline
5. Intermediate-risk PE
These patients are normotensive but may have right-ventricular dysfunction and elevated troponin.
- Anticoagulation and close monitoring are standard.
- Routine immediate systemic thrombolysis is generally avoided because bleeding risk outweighs benefit in stable patients.
- Escalate to thrombolysis, catheter therapy, or surgery if clinical deterioration occurs.
Textbook support: intermediate-risk, normotensive PE is generally managed with UFH and close monitoring, reserving systemic thrombolysis for PE-related hypotension. Murray & Nadel's Textbook of Respiratory Medicine, 2-Volume Set, lines 2121-2126.
6. Inferior vena cava (IVC) filter
An IVC filter is not routine. It may be considered if:
- Anticoagulation is absolutely contraindicated, such as active major bleeding
- Recurrent PE occurs despite appropriately administered anticoagulation
Remove a retrievable filter when anticoagulation can be safely started.
Important special situations
- Pregnancy: LMWH is generally used. DOACs and warfarin are generally avoided during pregnancy.
- Cancer-associated PE: DOAC or LMWH may be used, but bleeding risk, tumour location, platelet count, and drug interactions guide selection.
- Severe renal impairment: UFH is often preferred initially.
- Antiphospholipid syndrome: warfarin may be favoured over a DOAC in higher-risk disease.
Summary:
- Stable PE: anticoagulation.
- Shock/hypotension: urgent reperfusion therapy, usually systemic thrombolysis if safe.
- Intermediate-risk: anticoagulation plus monitoring, with rescue reperfusion only if deterioration.
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