cardio.dvt.long-term-immobilization.v1PRODUCTION

cardio.dvt.long-term-immobilization.v1

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

cardiologyacuteadult

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11/12 authored

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

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Detailed

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

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Long-term-immobilization DVT framed

Patient inputs (11)

age*demographic • CONTEXT

Risk increases with age >60; elderly immobilized + frailty drives bleed-risk weighting in AC choice + duration

sex*demographic • CONTEXT

Pregnancy / postpartum is a separate pathway (cardio.dvt.pregnancy.v1); female + chronic immobility + OCP/HRT compounds risk

additive_risk_factors*history • CONTEXT

not present

Active malignancy, prior VTE, OCP/HRT, obesity BMI ≥30, recent surgery, known thrombophilia — drives Caprini/Padua tier and AC duration decision

immobilization_substrate_and_duration*history • ENTRY

not present

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)

leg_swelling*symptom • ENTRY

Unilateral leg swelling cardinal symptom; bilateral suggests systemic etiology (HF, cirrhosis, nephrotic) or bilateral DVT (rare); document calf circumference difference

compression_us*imaging • INITIAL_WORKUP

not present

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_dimer*lab • 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

cbc*lab • INITIAL_WORKUP

Baseline Hgb + platelet for AC bleed risk; monitor for HIT if heparin-exposed

bleed_risk*history • RED_FLAGS

not present

HAS-BLED + recent surgery + falls history determines AC eligibility; mechanical prophylaxis (IPC) first-line if bleed risk precludes pharmacologic AC

creatinine*lab • 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

mr_venography_if_pelvic_concernimaging • BRANCHING_WORKUP

not present

Pelvic vein DVT (more common in pelvic immobilization, paralysis, post-pelvic-surgery) requires MR venography — US has poor sensitivity above inguinal ligament

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

Severity triggers (6)

6 need judgement

informationallife_threateningpost_arthroplasty_pe_conversion_during_record_window
Post-major-orthopedic-surgery patient (THA/TKA) within 35-d RECORD prophylaxis window develops PE despite rivaroxaban 10 mg daily — prophylaxis-failure
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningphlegmasia_from_massive_iliofemoral_in_immobilized_patient
Massive acute occlusive iliofemoral DVT in chronically immobilized patient producing phlegmasia cerulea dolens (cyanosis, severe pain, arterial compromise)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningmajor_bleed_during_AC_in_immobilized_high_falls_risk_patient
Major bleed on DOAC/LMWH in chronically immobilized patient with high falls risk (Hgb drop ≥2 g/dL, transfusion, ICH, retroperitoneal); chronic substrate complicates AC continuation decision
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresci_long_term_vte_recurrence_on_prophylaxis
Patient with chronic SCI develops recurrent DVT or PE despite ongoing CSCM-2016-compliant prophylaxis (LMWH bridge → DOAC) — prophylaxis-failure scenario
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereipc_mechanical_prophylaxis_issue_with_bedside_team
IPC mechanical prophylaxis cannot be sustained (skin breakdown, agitated patient pulling off, ICU restraints conflict, supply shortage) in patient with active AC contraindication — protection gap
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereprolonged_icu_pre_existing_ac_with_new_dvt
ICU patient already on therapeutic AC for prior indication (afib, mechanical valve, prior VTE) develops new DVT during prolonged ICU stay (>7 d) — true prophylaxis failure or AC sub-therapeutic level
Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Long-term-immobilization DVT — substrate-conditional AC duration (3 mo if reversed; extended/indefinite if persists) + mechanical-first prevention if bleed risk + SCI-specific 8-wk LMWH bridge per CSCM 2016 (ACCP 2021; ASH 2018)

axis: long_term_immobilization_dvt_substrate_conditional_phenotype

Selected axis "Long-term-immobilization DVT — substrate-conditional AC duration (3 mo if reversed; extended/indefinite if persists) + mechanical-first prevention if bleed risk + SCI-specific 8-wk LMWH bridge per CSCM 2016 (ACCP 2021; ASH 2018)" by default fallback (first axis)

apixaban
first line
doac_factor_xa_direct
10 mg BID × 7 d → 5 mg BID; consider 2.5 mg BID extended-low-dose at 6 mo if substrate persists • PO • BID; substrate-conditional duration
triggers: immobilization_dvt_no_active_bleed, egfr_above_25
AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — apixaban first-line acute; AMPLIFY-EXT (PMID 23216615) — 2.5 mg BID extended-low-dose maintains protection with reduced bleed risk if substrate persists
rxcui 1364430
rivaroxaban
first line
doac_factor_xa_direct
15 mg BID × 21 d → 20 mg daily with food; OR 10 mg daily × 35 d post-major orthopedic surgery (RECORD-1/2/3) for prophylaxis; OR 10 mg daily extended-low-dose maintenance per EINSTEIN-CHOICE • PO • BID then daily; substrate-conditional duration
triggers: immobilization_dvt_no_active_bleed, egfr_above_30, post_arthroplasty_extended_prophylaxis
EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814); EINSTEIN-CHOICE (Weitz NEJM 2017 PMID 28316279) — 10 mg daily extended; RECORD-1/2/3 (PMIDs 18579812, 18582928, 18579811) — 10 mg daily × 35 d post-arthroplasty
rxcui 1114195
enoxaparin
first line
lmwh
Treatment: 1 mg/kg SC BID (1 mg/kg daily if CrCl <30); Prophylaxis: 40 mg SC daily (30 mg BID for high-risk hospitalized, post-arthroplasty); SCI 8-wk bridge: 30 mg SC q12h then transition to DOAC per CSCM 2016 • SC • BID treatment; daily prophylaxis; 8-wk SCI bridge
triggers: initial_treatment_phase, sci_8wk_bridge_per_cscm_2016, high_risk_hospitalized_prophylaxis, doac_contraindicated_or_pregnancy
ASH 2020 (PMID 33007077); ENOXACAN-II (Bergqvist NEJM 2002 PMID 12239342) extended LMWH cancer surgery; PREVAIL (Sherman Lancet 2007 PMID 17499598) enoxaparin in stroke; CSCM 2016 SCI consortium
rxcui 67108
edoxaban
first line
doac_factor_xa_direct
60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or with strong P-gp inhibitor) after 5-10 d LMWH bridge • PO • daily; substrate-conditional duration
triggers: post_lmwh_bridge, doac_alternative_preference
Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — edoxaban after LMWH lead-in non-inferior to warfarin
rxcui 1599538
warfarin
comorbidity specific
vitamin_k_antagonist
5 mg daily; INR target 2-3 • PO • daily; substrate-conditional duration
triggers: severe_renal_impairment_doac_unsafe, cost_constraint, antiphospholipid_syndrome_triple_positive
TRAPS (Pengo Blood 2018) — warfarin > rivaroxaban in triple-positive APS; reasonable alternative if DOAC contraindicated; CrCl <15 → warfarin only
rxcui 11289
aspirin
contraindication substitute
antiplatelet_cox1
81 mg PO daily — limited prophylaxis role post-arthroplasty per AAOS 2011 (only if low-risk + DOAC contraindicated) • PO • daily
triggers: post_arthroplasty_low_risk_doac_contraindicated_per_aaos
AAOS 2011 — ASA acceptable post-arthroplasty in low-risk patients; NOT first-line per ACCP 2021 which favors DOAC/LMWH; do NOT substitute for treatment-dose AC in active DVT
rxcui 243670

outpatient playbook — drug actions (3)

1. STOP AC at 3 mo IF substrate reversed
rxcui 1364430
AC stopped at 3 mo for provoked-by-reversed-factor • PO • n/a
trigger: Standard provoked VTE pathway with substrate reversal
ACCP 2021 strong recommendation
2. CONTINUE AC indefinitely IF substrate persists
rxcui 1364430
apixaban 5 mg BID OR 2.5 mg BID extended-low-dose; OR rivaroxaban 10 mg daily extended • PO • BID or daily
trigger: Chronic SCI, indefinite bed-bound, or other persistent substrate
AMPLIFY-EXT (PMID 23216615); EINSTEIN-CHOICE (PMID 28316279)
3. enoxaparin pre-op or temporary high-risk re-immobilization (e.g., new fracture)
rxcui 67108
40 mg SC daily prophylaxis OR 1 mg/kg SC BID treatment • SC • daily/BID
trigger: Temporary new immobilization event (fracture, surgery)
ACCP 2021 prophylaxis Class I

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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; Incidental DVT identified on CT abdomen/pelvis or imaging in ICU patient — confirm diagnostic + initiate AC if no contraindication.

Objective

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

Assessment

**DVT from prolonged immobilization (post-stroke / SCI / post-arthroplasty / prolonged ICU)** (cardio.dvt.long-term-immobilization.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Long-term-immobilization DVT — substrate-conditional AC duration (3 mo if reversed; extended/indefinite if persists) + mechanical-first prevention if bleed risk + SCI-specific 8-wk LMWH bridge per CSCM 2016 (ACCP 2021; ASH 2018)**.
1. apixaban 10 mg BID × 7 d → 5 mg BID; consider 2.5 mg BID extended-low-dose at 6 mo if substrate persists PO BID; substrate-conditional duration (doac_factor_xa_direct, first line) — AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — apixaban first-line acute; AMPLIFY-EXT (PMID 23216615) — 2.5 mg BID extended-low-dose maintains protection with reduced bleed risk if substrate persists
2. rivaroxaban 15 mg BID × 21 d → 20 mg daily with food; OR 10 mg daily × 35 d post-major orthopedic surgery (RECORD-1/2/3) for prophylaxis; OR 10 mg daily extended-low-dose maintenance per EINSTEIN-CHOICE PO BID then daily; substrate-conditional duration (doac_factor_xa_direct, first line) — EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814); EINSTEIN-CHOICE (Weitz NEJM 2017 PMID 28316279) — 10 mg daily extended; RECORD-1/2/3 (PMIDs 18579812, 18582928, 18579811) — 10 mg daily × 35 d post-arthroplasty
3. enoxaparin Treatment: 1 mg/kg SC BID (1 mg/kg daily if CrCl <30); Prophylaxis: 40 mg SC daily (30 mg BID for high-risk hospitalized, post-arthroplasty); SCI 8-wk bridge: 30 mg SC q12h then transition to DOAC per CSCM 2016 SC BID treatment; daily prophylaxis; 8-wk SCI bridge (lmwh, first line) — ASH 2020 (PMID 33007077); ENOXACAN-II (Bergqvist NEJM 2002 PMID 12239342) extended LMWH cancer surgery; PREVAIL (Sherman Lancet 2007 PMID 17499598) enoxaparin in stroke; CSCM 2016 SCI consortium
4. edoxaban 60 mg PO daily (30 mg if CrCl 15-50, weight ≤60 kg, or with strong P-gp inhibitor) after 5-10 d LMWH bridge PO daily; substrate-conditional duration (doac_factor_xa_direct, first line) — Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — edoxaban after LMWH lead-in non-inferior to warfarin
5. warfarin 5 mg daily; INR target 2-3 PO daily; substrate-conditional duration (vitamin_k_antagonist, comorbidity specific) — TRAPS (Pengo Blood 2018) — warfarin > rivaroxaban in triple-positive APS; reasonable alternative if DOAC contraindicated; CrCl <15 → warfarin only
6. aspirin 81 mg PO daily — limited prophylaxis role post-arthroplasty per AAOS 2011 (only if low-risk + DOAC contraindicated) PO daily (antiplatelet_cox1, contraindication substitute) — AAOS 2011 — ASA acceptable post-arthroplasty in low-risk patients; NOT first-line per ACCP 2021 which favors DOAC/LMWH; do NOT substitute for treatment-dose AC in active DVT

Setting playbook (outpatient) — Long-term substrate-conditional surveillance: continued AC if substrate persists (chronic SCI, indefinite bed-bound); routine prophylaxis going forward (mechanical + pharmacologic per substrate); PTS surveillance; address any persistent additive risk factors
7. STOP AC at 3 mo IF substrate reversed AC stopped at 3 mo for provoked-by-reversed-factor PO n/a — Standard provoked VTE pathway with substrate reversal (ACCP 2021 strong recommendation)
8. CONTINUE AC indefinitely IF substrate persists apixaban 5 mg BID OR 2.5 mg BID extended-low-dose; OR rivaroxaban 10 mg daily extended PO BID or daily — Chronic SCI, indefinite bed-bound, or other persistent substrate (AMPLIFY-EXT (PMID 23216615); EINSTEIN-CHOICE (PMID 28316279))
9. enoxaparin pre-op or temporary high-risk re-immobilization (e.g., new fracture) 40 mg SC daily prophylaxis OR 1 mg/kg SC BID treatment SC daily/BID — Temporary new immobilization event (fracture, surgery) (ACCP 2021 prophylaxis Class I)

Non-pharmacologic actions:
- Lifelong mechanical prophylaxis if substrate persists (compression stockings 15-30 mmHg below knee for daily use)
- PT/OT for ongoing mobility maintenance
- OCP discussion: switch to non-oestrogen contraception if recurrent VTE history
- Address modifiable risk factors (obesity, smoking, inactivity)

AVOID / contraindication checks:
- Doac_avoid_active_bleeding (FDA labels)
- Apixaban_avoid_egfr_below_15 (FDA label)
- Rivaroxaban_avoid_egfr_below_30 (FDA label)
- Warfarin_avoid_pregnancy_use_lmwh (ASH 2018)
- Decision:mechanical_prophylaxis_IPC_first_line_if_active_bleed_or_severe_thrombocytopenia (CLOTS 3 PMID 23484795; ACCP 2021)
- Decision:stop_AC_at_3_months_only_if_immobilization_substrate_reversed (ACCP 2021)
- Decision:extended_AC_indefinite_or_apixaban_2.5mg_BID_if_substrate_persists (AMPLIFY EXT; EINSTEIN CHOICE PMID 28316279)
- Decision:sci_8wk_minimum_lmwh_then_transition_to_doac (CSCM 2016)
- Decision:rivaroxaban_10mg_daily_extended_35d_post_arthroplasty (RECORD trials; AAOS 2011)
- Decision:thrombophilia_testing_only_if_young_recurrent_strong_family_history (ASH 2018 PMID 30482764)

Monitoring

Regimen monitoring:
- cbc creatinine at 4 weeks then 3 months (DOAC label monitoring)
- pts villalta at 3 6 12mo (Kahn Lancet 2014)
- symptom recheck at 2 weeks then 3 months for AC continuation decision (ACCP 2021 + substrate reassessment)
- compression stocking 30 40mmhg if symptomatic pts (ATTRACT subgroup)
- sci surveillance US per cscm 2016 in higher risk
- substrate reassessment at 3 mo (is patient ambulating? has cast been removed? is bed-bound persisting?)
- mobility restoration PT OT engagement documented

Setting (outpatient) monitoring:
- Annual PCP visit
- Substrate-status reassessment at every visit
- CBC + creatinine annually if on extended AC
- PT/OT engagement for mobility maintenance

Follow-up plan: 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
- Close-out criterion: Substrate-reassessment + AC continuation/stop decision + mobility-restoration plan documented

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term substrate-conditional surveillance: continued AC if substrate persists (chronic SCI, indefinite bed-bound); routine prophylaxis going forward (mechanical + pharmacologic per substrate); PTS surveillance; address any persistent additive risk factors

Disposition criteria:
- Indefinite annual follow-up with structured substrate reassessment

Escalation triggers (move to higher acuity):
- New VTE despite prevention plan → restart AC + evaluate for thrombophilia + consider extended-phase AC
- Pregnancy → switch to LMWH per ASH 2018
- New fracture or surgery → temporary high-intensity prophylaxis

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Post-major-orthopedic-surgery patient (THA/TKA) within 35-d RECORD prophylaxis window develops PE despite rivaroxaban 10 mg daily — prophylaxis-failure
- [LIFE_THREATENING] Massive acute occlusive iliofemoral DVT in chronically immobilized patient producing phlegmasia cerulea dolens (cyanosis, severe pain, arterial compromise)
- [LIFE_THREATENING] Major bleed on DOAC/LMWH in chronically immobilized patient with high falls risk (Hgb drop ≥2 g/dL, transfusion, ICH, retroperitoneal); chronic substrate complicates AC continuation decision

Citations

- ACCP/CHEST 2021 (Stevens) + ASH 2018 VTE Prevention (Schünemann) + CSCM 2016 SCI consortium + AAOS 2011 prophylaxis post-arthroplasty + RECORD 1/2/3 + CLOTS-3 [PMID:34352295](https://pubmed.ncbi.nlm.nih.gov/34352295/)
- Cited evidence (PMID 30482764) [PMID:30482764](https://pubmed.ncbi.nlm.nih.gov/30482764/)
- Cited evidence (PMID 33007077) [PMID:33007077](https://pubmed.ncbi.nlm.nih.gov/33007077/)
- Cited evidence (PMID 18579812) [PMID:18579812](https://pubmed.ncbi.nlm.nih.gov/18579812/)
- Cited evidence (PMID 18582928) [PMID:18582928](https://pubmed.ncbi.nlm.nih.gov/18582928/)

Last reconciled with current guidelines: 2026-05-15.

References

ACCP/CHEST 2021 (Stevens) + ASH 2018 VTE Prevention (Schünemann) + CSCM 2016 SCI consortium + AAOS 2011 prophylaxis post-arthroplasty + RECORD 1/2/3 + CLOTS-3 — PMID:34352295
Cited evidence (PMID 30482764) — PMID:30482764
Cited evidence (PMID 33007077) — PMID:33007077
Cited evidence (PMID 18579812) — PMID:18579812
Cited evidence (PMID 18582928) — PMID:18582928