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cardio.dvt.core.v1

Deep vein thrombosis

cardiologyacutesubacuteadultacuteoutpatienttransition
Start encounter →Print handoutPRODUCTION

4-step DOAC-first regimen (acute → CDT → maintenance → extended; LMWH for cancer/pregnancy; CDT for phlegmasia / massive iliofemoral) authored with RxCUIs from cardio.dvt.core.v1.atoms.treatment.ts. shard-06-cardio-acute deepening pass 2026-05-14: 5 setting playbooks (outpatient, ED, inpatient, ICU for phlegmasia/CDT, transition for 3-mo decision incl. API-CAT 2024 cancer-extended); 6 severity triggers (phlegmasia, concurrent PE, major bleed, unprovoked age-50 cancer screen, pregnancy LMWH, cancer-VTE GI/GU LMWH); 5 band-mapped calculators (wells_dvt 3-tier, has_bled 0/1/2/3+, caprini 4-band, padua dichotomous, ckd_epi_2021 with renal-DOAC bands). Replaced 2 SUSPECTED_FABRICATION PMIDs (29766750 POINT, 23900119 REDUCE — both non-VTE antiplatelet trials) with 27+ verified VTE-domain anchors covering Wells (1997, 2003), Anand 1998, ADJUST 2014, Stein 2004, Goodacre 2005, Bernardi 2008, Righini 2009, AMPLIFY/AMPLIFY-EXT, EINSTEIN/EINSTEIN-CHOICE, Hokusai, RE-COVER, ATTRACT, CaVenT, CLOT, Hokusai-Cancer, CARAVAGGIO, SELECT-D, API-CAT 2024, TRAPS, HERDOO2, DASH, SOX, ASPIRE, SOME, PREPIC2, ESC 2019 PE. Co-located _design-brief.md + _research-bundle.md authored at src/lib/dossiers/cardio.dvt.core.v1._{design-brief,research-bundle}.md — supersedes the missing tier3-problem-package brief; design_brief pointer updated. ROS/DDx/LR seed files authored with engine_id `cardio.dvt.core.v1` to match dossier (legacy `cardio.deep-vein-thrombosis.v1` seed retained separately for backward compat); 14 ROS + 8 ddx + 24 LR rows with Anand 1998 + Wells 1997/2003 + Stein 2004 + Goodacre 2005 + Bernardi 2008 + Righini 2009 anchors. Engine-specific panel src/components/panels/cardio/dvt-panel.tsx wired into cardio-acute-panel-router; vitest panel tests at both src/components/panels/cardio/__tests__/ and tests/components/panels/cardio/ (per agent discovery that vitest only globs the latter).

Entry points (4)

  • symptom
    Unilateral leg swelling / pain / warmth (Wells Lancet 1997)
    unilateral_le_swelling
  • symptom
    Phlegmasia cerulea dolens (limb-threatening); ASH 2020
    phlegmasia
  • lab_abnormality
    D-dimer elevated in symptomatic patient (age-adjusted cutoff; ADJUST-DVT/PE, Righini JAMA 2014)
    d_dimer_elevated
  • imaging
    Compression US showing proximal DVT (ASH 2018)
    us_proximal_thrombus

Required inputs (9)

  • agerequired
    demographic • used at INITIAL_WORKUP
    Age-adjusted D-dimer (ADJUST-DVT/PE; Righini JAMA 2014)
  • creatininerequired
    lab • used at TREATMENT
    DOAC + LMWH renal dose adjustment per FDA labeling and ACCP 2016
  • provoking_factorrequired
    history • used at RISK_STRATIFICATION
    Provoked vs unprovoked drives AC duration (Kearon Chest 2016; ASH 2020)
  • cancer_active
    history • used at CONTEXT
    Cancer-VTE → oral Xa preferred (CARAVAGGIO Agnelli NEJM 2020; Hokusai-VTE-cancer Raskob Lancet Haematol 2018); GI/GU mucosal favors LMWH
  • pregnancy
    history • used at CONTEXT
    LMWH first-line in pregnancy; DOAC contraindicated (ASH 2018; ACOG 2018)
  • prior_vte
    history • used at RISK_STRATIFICATION
    Recurrence drives extended AC consideration (ACCP 2016 Kearon; ASH 2020)
  • bleed_history
    history • used at RISK_STRATIFICATION
    HAS-BLED for AC bleed risk (Pisters Chest 2010)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline platelets / bleeding before AC (ASH 2020)
  • compression_usrequired
    imaging • used at INITIAL_WORKUP
    Proximal vs distal DVT — drives treatment vs surveillance (ASH 2018; ACCP 2016)

12-phase flow (11)

  1. 1FRAME
    Outpatient candidacy for uncomplicated DVT (ASH 2020; PMID 33007077)
    advance: patient is hemodynamically stable, no concurrent PE features
  2. 2ENTRY
    Recognize unilateral LE swelling + Wells DVT score (Wells Lancet 1997)
    inputs: age
    advance: pretest probability assigned
  3. 3CONTEXT
    Risk factors (immobility, surgery, cancer, hormones, prior VTE, family hx) per ASH 2020
    inputs: provoking_factor, cancer_active, pregnancy, prior_vte
    advance: context complete
  4. 4RED_FLAGS
    Phlegmasia cerulea dolens (limb-threatening); concurrent PE; iliofemoral extent (ASH 2020; ESC 2019)
    advance: limb-threatening flags screened
  5. 5INITIAL_WORKUP
    Wells DVT → age-adjusted D-dimer if low PTP (Righini JAMA 2014) → compression US (whole-leg vs proximal); CBC/BMP baseline
    inputs: compression_us, cbc
    actions: panel.coag, panel.cbc, panel.renal, le_edema
    advance: DVT confirmed or alternate diagnosis from le_edema branching
  6. 6BRANCHING_WORKUP
    Cancer screening if unprovoked + age >50 (SOME trial Carrier NEJM 2015); thrombophilia testing only per ASH 2023 indications (PMID 37195076)
    inputs: provoking_factor
    advance: targeted further workup decided
  7. 7RISK_STRATIFICATION
    Provoked vs unprovoked → AC duration (ACCP 2016 Kearon); HAS-BLED bleed risk; iliofemoral / phlegmasia → CDT consideration (ATTRACT Vedantham NEJM 2017)
    inputs: provoking_factor, bleed_history
    actions: calc.has_bled
    advance: duration + intensity decision documented
  8. 8TREATMENT
    DOAC first-line (apixaban / rivaroxaban) — LMWH bridge not needed (AMPLIFY Agnelli NEJM 2013; EINSTEIN Bauersachs NEJM 2010); LMWH preferred in pregnancy + GI/GU cancer (CLOT Lee NEJM 2003); warfarin if APS triple-pos (TRAPS Pengo Blood 2018); CDT for iliofemoral with severe symptoms; AGAINST routine compression for PTS (SOX Kahn Lancet 2014)
    inputs: creatinine, cancer_active, pregnancy
    advance: AC initiated and patient educated
  9. 9DISPOSITION
    Outpatient for uncomplicated (ASH 2020); admit if phlegmasia / massive iliofemoral / concurrent PE / poor reliability
    advance: disposition assigned
  10. 10MONITORING
    No routine PT/INR for DOAC (ASH 2020); periodic creatinine; bleeding surveillance; PTS screen
    inputs: creatinine
    advance: monitoring plan documented
  11. 11FOLLOWUP
    3-month vs extended AC review at 3 mo for unprovoked (ACCP 2016); DASH (Tosetto JTH 2012)/HERDOO2 (Rodger BMJ 2017) risk-of-recurrence; aspirin after stopping AC (ASPIRE Brighton NEJM 2012); PTS rehabilitation
    advance: follow-up + duration plan finalized