This handout is for dvt with coexistent pulmonary embolism (combined vte). Your care team identified this based on: confirmed/suspected proximal dvt plus dyspnea, pleuritic chest pain, hemoptysis, syncope, or unexplained tachycardia → image for concurrent pe per esc 2019.
Other reasons your team may use this plan: compression us confirms proximal dvt and ct-pa confirms pe — combined vte; stratify by hemodynamics + rv strain; resting hr >100, spo2 <94% on room air, or rr >20 in known dvt — escalate to ct-pa before ac dose adjustment; bedside echo shows rv dilation, septal flattening, mcconnell sign, or tapse <17 in dvt patient — high probability sub-massive pe; ct-pa confirm.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| apixaban | 10 mg BID × 7 days → 5 mg BID | PO | BID × ≥3 mo (extended if unprovoked) | AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — no LMWH bridge; ASH 2020 first-line; same dosing as isolated DVT or isolated PE |
| rivaroxaban | 15 mg BID × 21 days → 20 mg daily with food | PO | BID then daily × ≥3 mo | EINSTEIN-PE (Investigators NEJM 2012 PMID 22449293) — non-inferior to enoxaparin/VKA in PE; same regimen for combined VTE |
| edoxaban | 60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor) | PO | once daily | Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — requires 5-day LMWH lead-in |
| enoxaparin | 1 mg/kg SC q12h (CrCl <30: 1 mg/kg daily) | SC | q12h | CLOT (Lee NEJM 2003 PMID 12853587) — preferred in active GI/GU mucosal cancer; ASH 2018 pregnancy first-line; ease of hold/resume peri-procedurally |
| heparin | 80 U/kg bolus + 18 U/kg/h infusion targeting aPTT 1.5–2.5× | IV | continuous | Rapid reversibility; preferred when intervention possible (ACCP 2021); standard pre-tPA bridge |
| alteplase | 100 mg IV over 2 h (or 0.6 mg/kg over 15 min if cardiac arrest) | IV | one-time infusion | ESC 2019 (PMID 31504429) Class I for massive PE with hemodynamic instability; addresses both PE and DVT clot burden simultaneously, often obviating CDT |
| warfarin | 5 mg daily; INR target 2-3 with overlapping LMWH × ≥5 d AND until INR ≥2 for ≥24 h | PO | daily; INR-driven | TRAPS (Pengo Blood 2018 PMID 30002145) — warfarin preferred in triple-positive APS; alternative when DOAC contraindicated |
Plan: Combined DVT+PE — DOAC-first AC + severity-stratified reperfusion (ACCP 2021 + ESC 2019)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: ACCP/CHEST 2021 + ESC 2019 Acute PE + ASH 2020 VTE Treatment