cardio.dvt.cancer-associated.v1PRODUCTION

cardio.dvt.cancer-associated.v1

Cancer-associated DVT (CAT)

cardiologyacuteadult

Hard-required inputs

0 / 7

Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Cancer-associated thrombosis (CAT) — distinct phenotype with higher recurrence + bleed risk; indefinite AC while cancer active is default; cancer type drives DOAC vs LMWH choice

Inputs

Actions

Advance rule

Set

Advance when

cancer status confirmed

Patient inputs (7)

age*demographic • CONTEXT

Older patients higher cancer risk and AC tolerability concerns

compression_us*imaging • INITIAL_WORKUP

not present

Confirm DVT location and burden

cbc*lab • INITIAL_WORKUP

Baseline platelet count; thrombocytopenia from chemotherapy modifies AC dosing or contraindicates AC entirely if severe

mucosal_bleed_history*history • RED_FLAGS

not present

Mucosal bleed history (especially in GI/GU cancers) shifts choice from DOAC to LMWH

cancer_type_and_stage*history • TREATMENT

not present

Cancer type drives DOAC vs LMWH choice — luminal GI and intracranial malignancy favor LMWH; non-mucosal cancers DOAC equivalent

current_chemotherapy*history • TREATMENT

not present

Drug interaction screen: many chemotherapies and supportive care drugs interact with DOACs (e.g., azoles, rifampin equivalents, P-gp inducers)

creatinine*lab • TREATMENT

eGFR for DOAC dosing; cancer patients often have AKI from chemotherapy or contrast

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement

informationallife_threateningintracranial_hemorrhage_with_brain_mets
New intracranial hemorrhage in CAT patient with brain metastases on AC
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveregi_bleed_on_doac_in_luminal_gi_cancer
Major or clinically relevant non-major GI bleed on DOAC in patient with luminal GI cancer (Hokusai-Cancer / SELECT-D subgroup signal)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresevere_thrombocytopenia_during_chemotherapy
Platelet count <25K during chemotherapy in patient on therapeutic AC for CAT
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevererecurrent_vte_on_appropriate_AC
Recurrent VTE despite therapeutic AC for CAT (apixaban or dalteparin at full dose)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatedvt_in_chemotherapy_drug_interaction_doac
CAT patient on chemotherapy with significant DOAC interaction (azoles, P-gp inducers, certain TKIs, rifampin) — DOAC efficacy unpredictable
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

ENTRYrequiredDrives risk stratification

Loading…

Recommended regimen

Cancer-associated thrombosis (CAT) anticoagulation — DOAC vs LMWH per cancer type (ISTH 2022)

axis: cancer_associated_thrombosis_phenotype

Selected axis "Cancer-associated thrombosis (CAT) anticoagulation — DOAC vs LMWH per cancer type (ISTH 2022)" by default fallback (first axis)

apixaban
first line
doac_factor_xa_direct
10 mg BID × 7 d → 5 mg BID • PO • BID × 6 months minimum (extend to 12 mo per API-CAT 2024)
triggers: cat_non_mucosal_cancer, no_active_bleed, no_brain_mets, egfr_above_25
CARAVAGGIO (Agnelli NEJM 2020 PMID 32223112) — apixaban non-inferior to dalteparin LMWH with similar major bleed in non-mucosal cancer; ISTH 2022 first-line for non-mucosal CAT
rxcui 1364430
edoxaban
first line
doac_factor_xa_direct
60 mg daily after 5 d LMWH lead-in (30 mg if CrCl 15-50 or weight ≤60 kg) • PO • daily × 6 months minimum
triggers: cat_non_mucosal_cancer, lmwh_lead_in_completed, egfr_above_15
Hokusai-Cancer (Raskob NEJM 2018 PMID 29231094) — edoxaban non-inferior to dalteparin; higher GI bleed in luminal GI cancer subgroup
rxcui 1599538
rivaroxaban
comorbidity specific
doac_factor_xa_direct
15 mg BID × 21 d → 20 mg daily • PO • BID then daily × 6 months
triggers: cat_non_mucosal_cancer, no_GI_or_GU_cancer, egfr_above_30
SELECT-D (Young JCO 2018 PMID 29746227) — rivaroxaban reduces recurrent VTE vs dalteparin but increases clinically relevant non-major bleeding; AVOID in GI/GU cancer per subgroup
rxcui 1114195
dalteparin
first line
lmwh
200 IU/kg SC daily × 1 month → 150 IU/kg SC daily • SC • daily × 6 months
triggers: cat_luminal_gi_cancer, cat_intracranial_malignancy, doac_contraindicated, severe_thrombocytopenia_managed
CLOT (Lee NEJM 2003 PMID 12853587) — landmark establishing LMWH > VKA in cancer-VTE; remains first-line in mucosal cancers
rxcui 67109
enoxaparin
first line
lmwh
1 mg/kg SC BID; reduce to 1 mg/kg daily if CrCl <30 • SC • BID
triggers: cat_luminal_gi_cancer, pregnancy_with_cancer, doac_drug_interaction
ASH 2018 in pregnancy; reasonable LMWH alternative to dalteparin
rxcui 67108
warfarin
comorbidity specific
vitamin_k_antagonist
5 mg daily; INR target 2-3 • PO • daily
triggers: cost_constraint, doac_lmwh_unavailable
CLOT showed VKA inferior to LMWH in cancer-VTE; warfarin is last-line option
rxcui 11289

outpatient playbook — drug actions (1)

1. continue apixaban while cancer active
rxcui 1364430
apixaban 5 mg BID (or 2.5 mg BID per API-CAT 2024) • PO • BID
trigger: Active cancer ongoing
ISTH 2022; API-CAT PMID 38780119

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Active cancer (treatment within 6 months OR metastatic) with new DVT → cancer-associated thrombosis (CAT); Cancer diagnosed within preceding 6 months — CAT phenotype regardless of current treatment status; Unprovoked DVT in patient age ≥50 → trigger occult cancer screening per SOME (PMID 26095396); convert to CAT pathway if cancer found.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cancer-associated DVT (CAT)** (cardio.dvt.cancer-associated.v1).
Scope: Cancer-associated thrombosis (CAT) — distinct phenotype with higher recurrence + bleed risk; indefinite AC while cancer active is default; cancer type drives DOAC vs LMWH choice

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cancer-associated thrombosis (CAT) anticoagulation — DOAC vs LMWH per cancer type (ISTH 2022)**.
1. apixaban 10 mg BID × 7 d → 5 mg BID PO BID × 6 months minimum (extend to 12 mo per API-CAT 2024) (doac_factor_xa_direct, first line) — CARAVAGGIO (Agnelli NEJM 2020 PMID 32223112) — apixaban non-inferior to dalteparin LMWH with similar major bleed in non-mucosal cancer; ISTH 2022 first-line for non-mucosal CAT
2. edoxaban 60 mg daily after 5 d LMWH lead-in (30 mg if CrCl 15-50 or weight ≤60 kg) PO daily × 6 months minimum (doac_factor_xa_direct, first line) — Hokusai-Cancer (Raskob NEJM 2018 PMID 29231094) — edoxaban non-inferior to dalteparin; higher GI bleed in luminal GI cancer subgroup
3. rivaroxaban 15 mg BID × 21 d → 20 mg daily PO BID then daily × 6 months (doac_factor_xa_direct, comorbidity specific) — SELECT-D (Young JCO 2018 PMID 29746227) — rivaroxaban reduces recurrent VTE vs dalteparin but increases clinically relevant non-major bleeding; AVOID in GI/GU cancer per subgroup
4. dalteparin 200 IU/kg SC daily × 1 month → 150 IU/kg SC daily SC daily × 6 months (lmwh, first line) — CLOT (Lee NEJM 2003 PMID 12853587) — landmark establishing LMWH > VKA in cancer-VTE; remains first-line in mucosal cancers
5. enoxaparin 1 mg/kg SC BID; reduce to 1 mg/kg daily if CrCl <30 SC BID (lmwh, first line) — ASH 2018 in pregnancy; reasonable LMWH alternative to dalteparin
6. warfarin 5 mg daily; INR target 2-3 PO daily (vitamin_k_antagonist, comorbidity specific) — CLOT showed VKA inferior to LMWH in cancer-VTE; warfarin is last-line option

Setting playbook (outpatient) — Long-term CAT survivors: ongoing AC while cancer active; surveillance for recurrence; transition to no-AC if cancer in durable remission ≥1 year
7. continue apixaban while cancer active apixaban 5 mg BID (or 2.5 mg BID per API-CAT 2024) PO BID — Active cancer ongoing (ISTH 2022; API-CAT PMID 38780119)

Non-pharmacologic actions:
- Lifestyle counseling (nutrition, mobility, weight)
- Vaccination per immunocompromised guidelines

AVOID / contraindication checks:
- Doac_avoid_active_mucosal_bleed (CARAVAGGIO subgroup)
- Doac_avoid_brain_mets_or_intracranial_malignancy (intracranial bleed risk)
- Edoxaban_caution_in_luminal_gi_cancer_higher_bleed (Hokusai Cancer subgroup)
- Rivaroxaban_avoid_gi_or_gu_cancer (SELECT D subgroup)
- Apixaban_egfr_below_15 (FDA label)
- Hold_AC_if_platelet_below_25_or_per_protocol (ASH 2021 cancer VTE)
- Decision:lmwh_preferred_for_luminal_gi_intracranial_or_chemotherapy_drug_interaction
- Decision:duration_indefinite_while_cancer_active (ISTH 2022)

Monitoring

Regimen monitoring:
- cbc weekly during active chemotherapy for thrombocytopenia (ASH 2021)
- creatinine q1mo for doac dose adjustment (FDA labels)
- lfts monthly (chemotherapy + AC interaction)
- cancer imaging q3mo for status reassessment (impacts AC duration)
- bleeding screen at each visit with focus on mucosal sites
- drug interaction review at each chemotherapy change

Setting (outpatient) monitoring:
- Quarterly visits, CBC + BMP, recurrent VTE symptom review

Follow-up plan: 6-month landmark: continue AC if cancer active OR API-CAT 2024 extended apixaban (months 7-18) for active cancer (PMID 38780119); reassess at 12 mo and beyond per cancer status; stop only when cancer in durable remission
- Close-out criterion: extended-AC plan documented

Monitoring phase: Bleeding screen (especially mucosal sites); CBC weekly during chemotherapy; LFTs monthly; reassess cancer status every 3 mo (impacts AC continuation decision)

Disposition

Current setting: outpatient — Long-term CAT survivors: ongoing AC while cancer active; surveillance for recurrence; transition to no-AC if cancer in durable remission ≥1 year

Disposition criteria:
- Indefinite AC while cancer active; stop only with durable remission

Escalation triggers (move to higher acuity):
- Cancer recurrence after remission → resume full AC
- New cancer in survivor → re-evaluate AC strategy

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] New intracranial hemorrhage in CAT patient with brain metastases on AC
- [SEVERE] Major or clinically relevant non-major GI bleed on DOAC in patient with luminal GI cancer (Hokusai-Cancer / SELECT-D subgroup signal)
- [SEVERE] Platelet count <25K during chemotherapy in patient on therapeutic AC for CAT

Citations

- ISTH 2022 Cancer-VTE + ASH 2021 Cancer-VTE + ACCP/CHEST 2021 [PMID:34352295](https://pubmed.ncbi.nlm.nih.gov/34352295/)
- Cited evidence (PMID 33007077) [PMID:33007077](https://pubmed.ncbi.nlm.nih.gov/33007077/)
- Cited evidence (PMID 35727697) [PMID:35727697](https://pubmed.ncbi.nlm.nih.gov/35727697/)
- Cited evidence (PMID 12853587) [PMID:12853587](https://pubmed.ncbi.nlm.nih.gov/12853587/)
- Cited evidence (PMID 32223112) [PMID:32223112](https://pubmed.ncbi.nlm.nih.gov/32223112/)

Last reconciled with current guidelines: 2026-05-14.

References

ISTH 2022 Cancer-VTE + ASH 2021 Cancer-VTE + ACCP/CHEST 2021 — PMID:34352295
Cited evidence (PMID 33007077) — PMID:33007077
Cited evidence (PMID 35727697) — PMID:35727697
Cited evidence (PMID 12853587) — PMID:12853587
Cited evidence (PMID 32223112) — PMID:32223112