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cardio.dvt.long-term-immobilization.v1

DVT from prolonged immobilization (post-stroke / SCI / post-arthroplasty / prolonged ICU)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.dvt.core.v1 — narrowed to long-term immobilization (post-stroke hemiparesis, SCI paralysis, post-knee/hip arthroplasty within 35 d, prolonged ICU >7 d, bed-bound nursing-home, post-cast immobilization). Inherits diagnostic arc + DOAC chronic regimen from parent via routing; specializes for substrate-conditional AC duration + mechanical-first prophylaxis pathway. Manifest pointer reuses cardio.dvt.core.v1 manifest. Design-brief pointer reuses parent (immobilization-specific differences documented inline). Distinguishing features vs travel-related DVT: substrate is persistent (or only partially reversible), so 3-mo provoked rule does NOT always apply; extended AC (full or low-dose 2.5 mg apixaban BID per AMPLIFY-EXT, or 10 mg rivaroxaban daily per EINSTEIN-CHOICE) justified when substrate persists. Mechanical IPC first-line per CLOTS-3 PMID 23484795 if bleed risk precludes pharmacologic AC. SCI: 8-wk LMWH bridge per CSCM 2016 then transition to DOAC. Post-arthroplasty: rivaroxaban 10 mg × 35 d per RECORD-1/2/3. D-dimer often baseline-elevated → unhelpful; compression US is anchor. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as long-term-immobilization DVT variant.

Entry points (4)

  • symptom
    Unilateral lower-extremity swelling, calf pain, or whole-leg swelling in patient with chronic immobility (post-stroke, SCI, post-arthroplasty, prolonged ICU >7 d, bed-bound nursing home)
    unilateral_le_swelling_in_immobilized_patient
  • history
    Patient with established prolonged-immobility substrate (lower-extremity paralysis from stroke or SCI, post-knee/hip arthroplasty within 35 d, ICU stay >7 d, post-cast/orthotic immobilization) — surveillance or symptomatic screen indicated
    prolonged_immobility_substrate_known
  • imaging
    Incidental DVT identified on CT abdomen/pelvis or imaging in ICU patient — confirm diagnostic + initiate AC if no contraindication
    incidental_dvt_on_ct_in_icu_patient
  • symptom
    New pleuritic chest pain, dyspnea, syncope, or hemoptysis in chronically immobilized patient — concurrent PE screen mandated (PERC fail; CTPA or VQ if Wells PE > 4)
    pleuritic_chest_pain_dyspnea_in_immobilized_patient

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Risk increases with age >60; elderly immobilized + frailty drives bleed-risk weighting in AC choice + duration
  • sexrequired
    demographic • used at CONTEXT
    Pregnancy / postpartum is a separate pathway (cardio.dvt.pregnancy.v1); female + chronic immobility + OCP/HRT compounds risk
  • immobilization_substrate_and_durationrequired
    history • used at ENTRY
    Document substrate (post-stroke, SCI, post-arthroplasty, ICU, nursing-home, cast) and duration (days/weeks/indefinite) — determines whether immobility is reversible (stops AC at 3 mo) or persistent (extended AC justified)
  • additive_risk_factorsrequired
    history • used at CONTEXT
    Active malignancy, prior VTE, OCP/HRT, obesity BMI ≥30, recent surgery, known thrombophilia — drives Caprini/Padua tier and AC duration decision
  • leg_swellingrequired
    symptom • used at ENTRY
    Unilateral leg swelling cardinal symptom; bilateral suggests systemic etiology (HF, cirrhosis, nephrotic) or bilateral DVT (rare); document calf circumference difference
  • compression_usrequired
    imaging • used at INITIAL_WORKUP
    Diagnostic anchor — femoral + popliteal compression test; whole-leg US preferred in immobilized patient given proximal-extension risk; pelvic vein involvement may need MR venography given US poor sensitivity above inguinal ligament
  • d_dimerrequired
    lab • used at INITIAL_WORKUP
    OFTEN baseline-elevated in hospitalized/immobilized patients (less useful as rule-out); positive predictive value low in this population — go straight to compression US if symptomatic; age-adjusted cutoff (age × 10 ng/mL FEU if >50) may help in lower-acuity outpatient
  • creatininerequired
    lab • used at TREATMENT
    eGFR for DOAC dosing — apixaban dose-reduction criteria (≥2 of: age ≥80, weight ≤60 kg, Cr ≥1.5); rivaroxaban CrCl <30 caution; dabigatran avoid <30
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline Hgb + platelet for AC bleed risk; monitor for HIT if heparin-exposed
  • bleed_riskrequired
    history • used at RED_FLAGS
    HAS-BLED + recent surgery + falls history determines AC eligibility; mechanical prophylaxis (IPC) first-line if bleed risk precludes pharmacologic AC
  • mr_venography_if_pelvic_concern
    imaging • used at BRANCHING_WORKUP
    Pelvic vein DVT (more common in pelvic immobilization, paralysis, post-pelvic-surgery) requires MR venography — US has poor sensitivity above inguinal ligament

12-phase flow (11)

  1. 1FRAME
    Long-term immobilization DVT = persistent (or only partially reversible) substrate-driven VTE. Prevention is the dominant pre-event question (mechanical first-line if bleed risk; pharmacologic per substrate). Treatment duration is substrate-conditional: 3 mo if immobility resolved (post-cast removed; stroke recovered ambulation); extended/indefinite if substrate persists (chronic SCI, indefinite bed-bound). Route to cardio.dvt.core.v1 for diagnostic arc + DOAC chronic regimen
    inputs: leg_swelling, immobilization_substrate_and_duration
    advance: Long-term-immobilization DVT framed
  2. 2ENTRY
    Wells DVT score; D-dimer often baseline-elevated so go straight to compression US if symptomatic; document substrate type and duration; CV/respiratory exam for concurrent PE screen
    inputs: immobilization_substrate_and_duration, age
    advance: Pretest probability + substrate documented
  3. 3CONTEXT
    Substrate persistence vs reversibility (post-arthroplasty patient walking at 6 wk → reversible; chronic SCI quadriplegic → indefinite); additive risk factors; bleed risk profile (recent surgery, falls, prior bleed); prior prophylaxis history (was patient on prophylaxis when DVT developed → escalation indicated)
    inputs: sex, additive_risk_factors
    advance: Substrate-persistence + bleed-risk profile complete
  4. 4RED_FLAGS
    Concurrent PE (pleuritic pain, dyspnea, hypoxia, tachycardia) — CTPA/VQ if Wells PE > 4; phlegmasia cerulea dolens (cyanosis, severe pain, arterial compromise) requires emergent CDT; absolute AC contraindication (active bleed, recent ICH, severe thrombocytopenia) → MECHANICAL prophylaxis (IPC) only
    inputs: bleed_risk
    actions: pe_full, le_edema
    advance: PE + limb-threatening + AC-contraindication features screened
  5. 5INITIAL_WORKUP
    Compression US (femoral + popliteal; whole-leg preferred); CBC + BMP + INR/PTT; CXR if respiratory symptoms; troponin + BNP if PE confirmed for risk-stratification; if pelvic concern → MR venography
    inputs: compression_us, d_dimer, cbc, creatinine
    actions: panel.cardiac, panel.renal, le_edema
    advance: Imaging confirms DVT + bleed-risk + renal status documented
  6. 6BRANCHING_WORKUP
    CTPA or VQ if PE suspicion; MR venography if pelvic vein concern; thrombophilia workup ONLY if young (<45), strong family history, recurrent unprovoked, or unusual site — chronic immobilization alone is NOT an indication per ASH 2018 (PMID 30482764). Surveillance US in higher-risk SCI patients per CSCM 2016
    advance: Branching workup decisions documented
  7. 7RISK_STRATIFICATION
    Wells DVT (treatment confirmation); HAS-BLED for AC bleed-risk; eGFR for DOAC; Caprini/Padua for prevention-tier (re-confirm prior prophylaxis adequacy); recurrence risk on AC stopping is HIGH if substrate persists (extended-AC justified), LOW if substrate reversible (3-mo provoked rule applies)
    inputs: bleed_risk
    actions: calc.wells_dvt, calc.has_bled, calc.ckd_epi_2021
    advance: AC duration plan documented (substrate-conditional)
  8. 8TREATMENT
    Acute AC: DOAC first-line — apixaban 10 mg BID × 7 d → 5 mg BID OR rivaroxaban 15 mg BID × 21 d → 20 mg daily; alternatives: enoxaparin 1 mg/kg SC BID × 5–10 d bridge to warfarin; SCI: LMWH × 8 weeks minimum then transition to DOAC per CSCM 2016. AC duration: 3 mo if substrate reversed (post-cast removed, stroke ambulating); EXTENDED (indefinite or low-dose apixaban 2.5 mg BID per AMPLIFY-EXT / EINSTEIN-CHOICE PMID 28316279) if substrate persists (chronic SCI, indefinite bed-bound)
    inputs: creatinine, bleed_risk
    advance: AC initiated + substrate-conditional duration plan documented
  9. 9DISPOSITION
    Inpatient management standard given underlying acute illness or post-op course; outpatient may be feasible if patient already at home (chronic SCI ambulatory wheelchair-bound stable, nursing-home patient stable) and adequate caregiver support
    advance: Disposition documented
  10. 10MONITORING
    Symptom resolution at 2 weeks; PTS Villalta at 3/6/12 mo; bleed surveillance during AC; compression stocking 30–40 mmHg if symptomatic for PTS prevention; SCI: surveillance US per CSCM 2016 in higher-risk; substrate-reassessment (is patient now ambulatory? has cast been removed?) at 3 mo for AC stop decision
    actions: panel.cardiac
    advance: Monitoring + substrate-reassessment schedule documented
  11. 11FOLLOWUP
    Substrate reassessment at 3 mo: if reversed → STOP AC per ACCP 2021 provoked rule; if persists → continue at full or low-dose extended AC (apixaban 2.5 mg BID per AMPLIFY-EXT); enforce mechanical + pharmacologic prophylaxis going forward; PT/OT for mobility restoration; if recurrent VTE on prophylaxis → escalate to therapeutic-dose extended AC + reassess substrate
    advance: Substrate-reassessment + AC continuation/stop decision + mobility-restoration plan documented