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cardio.dvt.with-pe.v1

DVT with coexistent pulmonary embolism (combined VTE)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.dvt.core.v1 — combined DVT+PE phenotype (~40-50% of proximal DVTs have asymptomatic PE on systematic CT-PA per Stein PIOPED II PMID 16738268). AC strategy identical to either alone, but decision points differ: systemic tPA for massive PE addresses both clot burdens; CDT of DVT alone less beneficial in coexistence; IVC filter consideration shifts upward only if AC absolutely contraindicated AND saddle PE present (PREPIC2 PMID 25919526 — no PE mortality benefit otherwise). Manifest pointer reuses cardio.dvt.core.v1 manifest. Design-brief pointer reuses parent. 5 setting playbooks (ED, ICU for massive/sub-massive, inpatient floor, transition with CTEPH screen + 3-mo AC decision, outpatient long-term). 6 severity triggers (massive PE conversion, paradoxical embolism via PFO, hemodynamic decompensation in sub-massive, phlegmasia with concurrent PE, major bleed on AC, CTEPH suspicion at 3-6 mo). Routes to pulm.pe.core.v1 for PE-specific hemodynamic management when RV strain present (sub-massive → consider CDT per PEITHO subgroup PMID 24716681; massive → systemic tPA per ESC 2019 PMID 31504429 Class I). 4 band-mapped calculators (wells_dvt 3-tier, has_bled 0-1 / 2 / ≥3, ckd_epi_2021 <15 / 15-30 / 30-60 / >60, caprini 0-1 / 2 / 3-4 / ≥5). Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 9 cross-system variant.

Entry points (4)

  • symptom
    Confirmed/suspected proximal DVT plus dyspnea, pleuritic chest pain, hemoptysis, syncope, or unexplained tachycardia → image for concurrent PE per ESC 2019
    dvt_with_dyspnea_or_pleuritic_pain
  • imaging
    Compression US confirms proximal DVT AND CT-PA confirms PE — combined VTE; stratify by hemodynamics + RV strain
    us_proximal_dvt_with_pe_on_ctpa
  • vital_abnormality
    Resting HR >100, SpO2 <94% on room air, or RR >20 in known DVT — escalate to CT-PA before AC dose adjustment
    unexplained_tachycardia_hypoxemia_in_dvt
  • imaging
    Bedside echo shows RV dilation, septal flattening, McConnell sign, or TAPSE <17 in DVT patient — high probability sub-massive PE; CT-PA confirm
    echo_rv_strain_in_known_dvt

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Age modifies PESI/sPESI score for early mortality risk; informs outpatient candidacy (HESTIA)
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 for ≥15 min OR vasopressors needed = massive (high-risk) PE per ESC 2019 — fundamentally changes management to systemic thrombolysis
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia magnitude correlates with PE clot burden + RV strain; informs O2 + escalation
  • compression_usrequired
    imaging • used at INITIAL_WORKUP
    Confirms DVT and laterality / proximal extent for IVC-filter and CDT consideration
  • ctparequired
    imaging • used at INITIAL_WORKUP
    CT-PA is gold-standard for PE confirmation, clot location (saddle vs lobar vs segmental), and RV/LV ratio measurement (RV/LV >0.9 = RV strain per ESC 2019)
  • echo_rv_functionrequired
    imaging • used at RISK_STRATIFICATION
    Bedside echo for RV dilation, septal flattening, TAPSE, McConnell — drives sub-massive vs low-risk classification when CT-PA shows PE without hypotension
  • troponinrequired
    lab • used at RISK_STRATIFICATION
    Elevated troponin in PE = RV myocardial injury; combined with RV strain → sub-massive (intermediate-high risk per ESC 2019)
  • creatininerequired
    lab • used at TREATMENT
    eGFR for DOAC + LMWH dosing + contrast load for CT-PA
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline Hgb + platelets before AC + thrombolytic-bleed risk stratification
  • bleed_riskrequired
    history • used at RED_FLAGS
    Bleed history drives AC + thrombolytic eligibility; absolute contraindications shift to IVC-filter consideration
  • provoking_factorrequired
    history • used at RISK_STRATIFICATION
    Provoked vs unprovoked drives AC duration decision at 3 mo (same as isolated DVT/PE)

12-phase flow (11)

  1. 1FRAME
    DVT with coexistent PE = combined VTE; manage as PE-driven (typically more dangerous given hemodynamic + gas-exchange dimensions); inherit DVT diagnostic + AC arc; route to pulm.pe.core.v1 for PE-specific hemodynamic management when RV strain present
    inputs: compression_us, ctpa
    advance: both DVT and PE confirmed on imaging
  2. 2ENTRY
    Recognize PE features in known DVT (dyspnea, pleuritic pain, syncope, hypoxia, tachycardia); Wells PE pretest probability if PE not yet confirmed
    inputs: age
    advance: PE imaging triggered or alternate dx documented
  3. 3CONTEXT
    Provoking factors, cancer, pregnancy, prior VTE, bleed history, medication list (anti-platelet, NSAID, cytotoxics), HF/COPD baseline (modifies dyspnea interpretation)
    inputs: provoking_factor
    advance: context complete
  4. 4RED_FLAGS
    Massive PE (SBP <90, vasopressors, cardiac arrest) → systemic tPA per ESC 2019; phlegmasia from limb-occlusive DVT; saddle PE with absolute AC contraindication → IVC filter consideration; suspected paradoxical embolism via PFO with concurrent neurologic event
    inputs: sbp, spo2, bleed_risk
    actions: pe_full
    advance: high-risk features screened
  5. 5INITIAL_WORKUP
    Compression US (proximal DVT extent) + CT-PA (PE clot burden + RV/LV ratio) + bedside echo (RV strain) + troponin + BNP + CBC + BMP + INR/PTT + ABG if hypoxic
    inputs: compression_us, ctpa, cbc, creatinine
    actions: panel.cardiac, panel.renal, pe_full, le_edema
    advance: both sites imaged + RV function known
  6. 6BRANCHING_WORKUP
    Cancer screening if unprovoked + age >50 (SOME); thrombophilia per ASH 2023 indications; consider PFO bubble-study echo if cryptogenic stroke or arterial embolism present
    inputs: provoking_factor
    advance: targeted further workup decided
  7. 7RISK_STRATIFICATION
    PE severity: massive (SBP <90 OR shock) vs sub-massive (RV strain + troponin+ but normotensive) vs low-risk (no RV strain, normal troponin, sPESI 0); HAS-BLED for AC/thrombolytic bleed; provoked vs unprovoked for duration
    inputs: echo_rv_function, troponin, bleed_risk
    actions: calc.has_bled
    advance: severity tier + duration + reperfusion decision documented
  8. 8TREATMENT
    Anticoagulation: DOAC first-line — apixaban 10/7/5 BID, rivaroxaban 15/21/20, edoxaban 60 after 5 d LMWH (AMPLIFY/EINSTEIN-PE/Hokusai); LMWH preferred if pregnancy, severe CKD, or active GI/GU mucosal cancer. Reperfusion: systemic tPA 100 mg/2 h for massive PE; CDT case-by-case for sub-massive with RV strain (PEITHO subgroup); IVC filter ONLY if AC absolutely contraindicated AND saddle/large PE (PREPIC2 — no PE mortality benefit otherwise). CDT of DVT alone less likely beneficial in coexistence (PE drives prognosis; systemic tPA addresses both)
    inputs: creatinine, sbp
    advance: AC + reperfusion + filter decisions documented
  9. 9DISPOSITION
    ICU for massive PE / sub-massive with RV strain on vasopressor / post-thrombolysis; floor for sub-massive without hemodynamic compromise; outpatient for low-risk per HESTIA + sPESI 0 + reliable patient (rare in confirmed combined VTE)
    advance: unit assigned + monitoring plan documented
  10. 10MONITORING
    Continuous SpO2 + telemetry first 24 h; serial troponin + BNP; daily echo if RV strain at baseline; CBC q12h on therapeutic AC; bleeding screen; PTS surveillance later
    inputs: creatinine
    actions: panel.cardiac
    advance: monitoring plan documented + clinical trajectory established
  11. 11FOLLOWUP
    3-mo AC duration decision (same as isolated proximal DVT — provoked vs unprovoked); CTEPH screen at 3-6 mo if persistent dyspnea (echo + V/Q if abnormal per ESC 2019); PTS Villalta scale; reproductive counseling if female of reproductive age
    advance: AC duration + CTEPH-screen + PTS plan finalized