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cardio.dvt.core.v1PRODUCTION
cardio.dvt.core.v1

Deep vein thrombosis

cardiologyacutesubacuteadult
Hard-required inputs
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Care setting:

Encounter flow

11/12 authored

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

Current phase

Frame

Detailed

Outpatient candidacy for uncomplicated DVT (ASH 2020; PMID 33007077)

Inputs
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Actions
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Advance rule
Set
Advance when

patient is hemodynamically stable, no concurrent PE features

Patient inputs (9)

Age-adjusted D-dimer (ADJUST-DVT/PE; Righini JAMA 2014)

Baseline platelets / bleeding before AC (ASH 2020)

Proximal vs distal DVT — drives treatment vs surveillance (ASH 2018; ACCP 2016)

Provoked vs unprovoked drives AC duration (Kearon Chest 2016; ASH 2020)

DOAC + LMWH renal dose adjustment per FDA labeling and ACCP 2016

Cancer-VTE → oral Xa preferred (CARAVAGGIO Agnelli NEJM 2020; Hokusai-VTE-cancer Raskob Lancet Haematol 2018); GI/GU mucosal favors LMWH

LMWH first-line in pregnancy; DOAC contraindicated (ASH 2018; ACOG 2018)

Recurrence drives extended AC consideration (ACCP 2016 Kearon; ASH 2020)

HAS-BLED for AC bleed risk (Pisters Chest 2010)

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningphlegmasia_cerulea_dolens
    Limb-threatening DVT — pale or blue, cold, severely painful limb with severe iliofemoral DVT (ASH 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmajor_bleed_on_ac
    Major bleeding on DOAC or warfarin (Hgb drop >2, transfusion, ICH, GI requiring hospitalization) per ISTH criteria 2005
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconcurrent_pe
    DVT + PE features (dyspnea, hypoxemia, RV strain on echo, syncope) per ESC 2019
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_dvt
    Pregnant patient with new or known DVT (ASH 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateunprovoked_dvt_age_over_50
    Unprovoked DVT in patient >50 years (ASH 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecancer_associated_VTE_GI_GU
    Active GI or GU cancer with mucosal lesions causing recurrent bleed risk (ISTH 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

ENTRYrequiredDrives risk stratification
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Recommended regimen

DVT anticoagulation — DOAC-first per ASH 2020 / ACCP 2021
axis: dvt_anticoagulationstep 1 - Step 1 — Acute phase (days 0–21) — DOAC monotherapy or LMWH bridge
Selected step "Step 1 — Acute phase (days 0–21) — DOAC monotherapy or LMWH bridge" — Confirmed proximal DVT or symptomatic distal DVT; hemodynamically stable; no pregnancy or active GI/GU malignancy with mucosal bleeding
  • apixaban
    first line
    DOAC_FXa
    10 mg BID × 7 days → 5 mg BID • PO • BID
    triggers: acute_VTE, no_pregnancy, no_active_GI_GU_malignancy
    AMPLIFY (Agnelli NEJM 2013; PMID 23808982) — no LMWH bridge needed; preferred over warfarin per ASH 2020
    rxcui 1364430
  • rivaroxaban
    first line
    DOAC_FXa
    15 mg BID × 21 days → 20 mg daily with food • PO • BID then daily
    triggers: acute_VTE, no_pregnancy
    EINSTEIN-DVT (Bauersachs NEJM 2010) — no LMWH bridge; CrCl ≥30
    rxcui 1114195
  • edoxaban
    first line
    DOAC_FXa
    60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor) • PO • once daily
    triggers: acute_VTE_after_5d_LMWH
    Hokusai-VTE (Büller NEJM 2013; PMID 23991658) — requires 5-day LMWH lead-in
    rxcui 1599538
  • dabigatran
    first line
    DOAC_DTI
    150 mg BID after 5–10 d LMWH lead-in • PO • BID
    triggers: acute_VTE_after_LMWH
    RE-COVER (Schulman NEJM 2009) — needs LMWH lead-in; idarucizumab reversal available
    rxcui 1546356
  • enoxaparin
    first line
    LMWH
    1 mg/kg SC q12h OR 1.5 mg/kg SC daily (CrCl <30: 1 mg/kg daily) • SC • q12h or daily
    triggers: cancer_VTE_GI_GU_mucosal, pregnancy, severe_renal_impairment_<30_with_specialist
    CLOT (Lee NEJM 2003) — preferred in active GI/GU mucosal cancer; pregnancy first-line per ASH 2018
    rxcui 67108
  • dalteparin
    first line
    LMWH
    200 IU/kg SC daily × 1 mo → 150 IU/kg • SC • daily
    triggers: cancer_VTE_alternative_LMWH
    CLOT (Lee NEJM 2003) — alternate LMWH for cancer-associated VTE
    rxcui 67109
  • heparin
    second line
    unfractionated_heparin
    80 U/kg bolus + 18 U/kg/h infusion targeting aPTT 1.5–2.5× • IV • continuous
    triggers: CrCl_<15, imminent_thrombolysis_or_surgery
    Rapid reversibility; preferred when intervention possible (ACCP 2016 Kearon)
    rxcui 5224
  • warfarin
    second line
    VKA
    Start 5 mg PO with overlapping LMWH × ≥5 d AND until INR ≥2 for ≥24 h • PO • daily; INR-driven
    triggers: APS_triple_pos, DOAC_unavailable, cost_constraint
    TRAPS (Pengo Blood 2018) — warfarin preferred in triple-positive APS over rivaroxaban
    rxcui 11289
  • fondaparinux
    second line
    indirect_FXa
    5 mg <50 kg / 7.5 mg 50–100 kg / 10 mg >100 kg SC daily • SC • daily
    triggers: HIT_history
    Alternative when LMWH/UFH not appropriate; ACCP 2016 recommendation for HIT
    rxcui 321208

outpatient playbook — drug actions (4)

  1. 1. DOAC initiation
    rxcui 1364430
    Apixaban 10 mg BID × 7 d → 5 mg BID OR rivaroxaban 15 mg BID × 21 d → 20 mg daily • PO • BID then maintenance
    trigger: Confirmed DVT, no contraindication
    AMPLIFY (Agnelli NEJM 2013) / EINSTEIN (Bauersachs NEJM 2010) — no LMWH bridge required
  2. 2. LMWH if pregnancy or GI/GU mucosal cancer
    rxcui 67108
    Enoxaparin 1 mg/kg SC q12h or 1.5 mg/kg SC daily • SC • BID/daily
    trigger: Pregnancy or active mucosal cancer
    CLOT (Lee NEJM 2003); ASH 2018 pregnancy guidance
  3. 3. maintenance phase (3 months)
    rxcui 1364430
    Apixaban 5 mg BID OR rivaroxaban 20 mg daily • PO • BID/daily
    trigger: Continuation
    Standard duration for provoked/distal DVT per ACCP 2016 Kearon
  4. 4. extended phase (reduced dose)
    rxcui 1364430
    Apixaban 2.5 mg BID OR rivaroxaban 10 mg daily • PO • BID/daily
    trigger: Unprovoked DVT or persistent risk after 3 mo
    AMPLIFY-EXT (Agnelli NEJM 2013) / EINSTEIN-CHOICE (Weitz NEJM 2017)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unilateral leg swelling / pain / warmth (Wells Lancet 1997); Phlegmasia cerulea dolens (limb-threatening); ASH 2020; D-dimer elevated in symptomatic patient (age-adjusted cutoff; ADJUST-DVT/PE, Righini JAMA 2014).

Objective

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

Assessment

**Deep vein thrombosis** (cardio.dvt.core.v1).
Scope: Outpatient candidacy for uncomplicated DVT (ASH 2020; PMID 33007077)

No severity triggers fired against current inputs.

Plan

Regimen axis: **DVT anticoagulation — DOAC-first per ASH 2020 / ACCP 2021** — step "Step 1 — Acute phase (days 0–21) — DOAC monotherapy or LMWH bridge".
1. apixaban 10 mg BID × 7 days → 5 mg BID PO BID (DOAC_FXa, first line) — AMPLIFY (Agnelli NEJM 2013; PMID 23808982) — no LMWH bridge needed; preferred over warfarin per ASH 2020
2. rivaroxaban 15 mg BID × 21 days → 20 mg daily with food PO BID then daily (DOAC_FXa, first line) — EINSTEIN-DVT (Bauersachs NEJM 2010) — no LMWH bridge; CrCl ≥30
3. edoxaban 60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor) PO once daily (DOAC_FXa, first line) — Hokusai-VTE (Büller NEJM 2013; PMID 23991658) — requires 5-day LMWH lead-in
4. dabigatran 150 mg BID after 5–10 d LMWH lead-in PO BID (DOAC_DTI, first line) — RE-COVER (Schulman NEJM 2009) — needs LMWH lead-in; idarucizumab reversal available
5. enoxaparin 1 mg/kg SC q12h OR 1.5 mg/kg SC daily (CrCl <30: 1 mg/kg daily) SC q12h or daily (LMWH, first line) — CLOT (Lee NEJM 2003) — preferred in active GI/GU mucosal cancer; pregnancy first-line per ASH 2018
6. dalteparin 200 IU/kg SC daily × 1 mo → 150 IU/kg SC daily (LMWH, first line) — CLOT (Lee NEJM 2003) — alternate LMWH for cancer-associated VTE
7. heparin 80 U/kg bolus + 18 U/kg/h infusion targeting aPTT 1.5–2.5× IV continuous (unfractionated_heparin, second line) — Rapid reversibility; preferred when intervention possible (ACCP 2016 Kearon)
8. warfarin Start 5 mg PO with overlapping LMWH × ≥5 d AND until INR ≥2 for ≥24 h PO daily; INR-driven (VKA, second line) — TRAPS (Pengo Blood 2018) — warfarin preferred in triple-positive APS over rivaroxaban
9. fondaparinux 5 mg <50 kg / 7.5 mg 50–100 kg / 10 mg >100 kg SC daily SC daily (indirect_FXa, second line) — Alternative when LMWH/UFH not appropriate; ACCP 2016 recommendation for HIT

Setting playbook (outpatient) — Confirm DVT, initiate appropriate AC per ASH 2020, address provoking factors, manage outpatient anticoagulation safely with patient education
10. DOAC initiation Apixaban 10 mg BID × 7 d → 5 mg BID OR rivaroxaban 15 mg BID × 21 d → 20 mg daily PO BID then maintenance — Confirmed DVT, no contraindication (AMPLIFY (Agnelli NEJM 2013) / EINSTEIN (Bauersachs NEJM 2010) — no LMWH bridge required)
11. LMWH if pregnancy or GI/GU mucosal cancer Enoxaparin 1 mg/kg SC q12h or 1.5 mg/kg SC daily SC BID/daily — Pregnancy or active mucosal cancer (CLOT (Lee NEJM 2003); ASH 2018 pregnancy guidance)
12. maintenance phase (3 months) Apixaban 5 mg BID OR rivaroxaban 20 mg daily PO BID/daily — Continuation (Standard duration for provoked/distal DVT per ACCP 2016 Kearon)
13. extended phase (reduced dose) Apixaban 2.5 mg BID OR rivaroxaban 10 mg daily PO BID/daily — Unprovoked DVT or persistent risk after 3 mo (AMPLIFY-EXT (Agnelli NEJM 2013) / EINSTEIN-CHOICE (Weitz NEJM 2017))

Non-pharmacologic actions:
- Patient education on bleeding signs + missed dose handling (ASH 2020)
- Compression stockings — NOT routinely for PTS prevention (SOX trial Kahn Lancet 2014); only if symptomatic
- Address provoking factors: hormonal therapy, immobility, surgery, smoking (ACCP 2016)
- Cancer screening per age-appropriate guidelines (no extensive search per SOME Carrier NEJM 2015)
- Discuss fall prevention if elderly (ASH 2020)

AVOID / contraindication checks:
- DOAC_avoid_pregnancy_use_LMWH (ASH 2018)
- DOAC_avoid_active_GI_GU_mucosal_cancer_use_LMWH (CARAVAGGIO subgroup; Agnelli NEJM 2020)
- Warfarin_for_APS_triple_pos_TRAPS (Pengo Blood 2018)
- DOAC_renal_dosing_per_label (FDA 2023)
- Thrombolysis_bleed_risk_assessment (ATTRACT Vedantham NEJM 2017)
- Warfarin_drug_interaction_screen (ACCP 2016)

Monitoring

Regimen monitoring:
- creatinine q6-12 months DOAC (ASH 2020)
- INR q4 weeks warfarin at steady state (ACCP 2016)
- CBC at baseline and periodically (ASH 2020)
- PT/PTT baseline (ASH 2020)
- platelets q1-3 d first 2 weeks LMWH for HIT screen (ASH 2018)
- reassess AC at 3 months provoked vs unprovoked (ACCP 2016 Kearon)

Setting (outpatient) monitoring:
- Bleeding screen at each visit (ASH 2020)
- Creatinine q6–12 months on DOAC (ASH 2020)
- INR q4 weeks if warfarin (ACCP 2016)
- Annual reassessment of provoked vs unprovoked status + extended therapy decision (ACCP 2016 Kearon)

Follow-up plan: 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
- Close-out criterion: follow-up + duration plan finalized

Monitoring phase: No routine PT/INR for DOAC (ASH 2020); periodic creatinine; bleeding surveillance; PTS screen

Disposition

Current setting: outpatient — Confirm DVT, initiate appropriate AC per ASH 2020, address provoking factors, manage outpatient anticoagulation safely with patient education

Disposition criteria:
- Outpatient AC if proximal/distal DVT, hemodynamically stable, no PE, reliable patient (ASH 2020)
- Inpatient if phlegmasia, massive iliofemoral, concurrent PE, social factors (ASH 2020)

Escalation triggers (move to higher acuity):
- New PE symptoms (dyspnea, hypoxemia, RV strain) → ED + CT-PA (ESC 2019 Konstantinides)
- Phlegmasia cerulea dolens → ED for thrombolysis evaluation (ASH 2020)
- Major bleed → hold AC, ED, reversal (ACCP 2016)
- Recurrence on AC → switch agent, evaluate APS / cancer (ASH 2020)

Patient Action Plan

**DVT anticoagulation + bleed action plan (ASH 2020)**
Personalised values: AC_drug, AC_duration_plan, next_lab_date, reversal_pathway.

**Doing well — leg improving, no bleed, AC adherent (ASH 2020)** (green):
Triggers:
- Leg swelling and pain improving
- No bleeding (no melena, hematuria, severe bruising)
- Taking AC as prescribed (ACCP 2016)
Actions:
- Continue AC every day (ASH 2020)
- Keep follow-up appointments
- Stay active (walking) but avoid contact sports (ASH 2020)
- Do not skip a dose; if missed, take when remembered (apixaban: skip if >6 h late per FDA label 2023)

**Caution — minor bleed, missed dose, leg worse (ASH 2020)** (yellow):
Triggers:
- Easy bruising or minor nosebleed lasting >10 min (ISTH bleeding definition 2005)
- Missed AC dose >1
- New leg pain or swelling without limb-threatening features
- Black stools without dizziness (ACCP 2016)
Actions:
- Resume AC at next dose (ASH 2020)
- Apply pressure to bleeding
- Schedule provider visit within 24–48 h
- Ultrasound may be repeated by provider (ASH 2018)
Contact provider when:
- Bleeding does not stop in 15 min with pressure
- Multiple missed doses (ACCP 2016)
- Worsening leg symptoms

**Medical alert — major bleed, PE, or limb-threatening DVT (ASH 2020)** (red):
Triggers:
- Vomiting blood, melena, severe nosebleed, intracranial symptoms (severe headache, vision change, weakness, confusion) per ISTH major bleeding criteria 2005
- Sudden chest pain, dyspnea, syncope, hemoptysis (PE concern; ESC 2019)
- Severe leg pain + cold/pale/blue limb (phlegmasia; ASH 2020)
- Major trauma or fall with head injury on AC (ACCP 2016)
Actions:
- Call 911 / go to ED immediately
- Bring AC name + last dose time
- Apply pressure to external bleeding
- Do NOT take additional AC doses (ASH 2020)
Contact provider when:
- Any red zone symptom — ED is destination (ASH 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Limb-threatening DVT — pale or blue, cold, severely painful limb with severe iliofemoral DVT (ASH 2020)
- [LIFE_THREATENING] Major bleeding on DOAC or warfarin (Hgb drop >2, transfusion, ICH, GI requiring hospitalization) per ISTH criteria 2005
- [SEVERE] DVT + PE features (dyspnea, hypoxemia, RV strain on echo, syncope) per ESC 2019

Citations

- ASH 2018/2020/2023 VTE Guidelines + ACCP/CHEST 2021/2024 Antithrombotic + NICE NG158 + ISTH 2022 cancer-VTE [PMID:33007077](https://pubmed.ncbi.nlm.nih.gov/33007077/)
- Cited evidence (PMID 30482767) [PMID:30482767](https://pubmed.ncbi.nlm.nih.gov/30482767/)
- Cited evidence (PMID 37195076) [PMID:37195076](https://pubmed.ncbi.nlm.nih.gov/37195076/)
- Cited evidence (PMID 34352278) [PMID:34352278](https://pubmed.ncbi.nlm.nih.gov/34352278/)
- Cited evidence (PMID 38458430) [PMID:38458430](https://pubmed.ncbi.nlm.nih.gov/38458430/)

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