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cardio.dvt.proximal.v1PRODUCTION
cardio.dvt.proximal.v1

Proximal DVT (iliofemoral / popliteal)

cardiologyacuteadult
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Care setting:

Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

Proximal DVT = thrombus at or above popliteal vein; full-dose AC ≥3 months minimum; high CDT-eligibility for iliofemoral; route to cardio.dvt.core.v1 for diagnostic arc

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Actions
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Advance rule
Set
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proximal location confirmed on imaging

Patient inputs (7)

Older patients higher recurrence and bleed risk; informs extended-AC decision

Provoked vs unprovoked status drives 3-month vs extended AC duration decision

Whole-leg vs calf-only distribution differentiates proximal vs distal DVT

Non-compressible femoral/popliteal vein confirms proximal DVT; Bernardi JAMA 2008 single-time whole-leg US strategy (PMID 18272884)

Baseline Hgb + platelet for AC + bleed risk assessment

HAS-BLED + recent surgery + falls history determines AC eligibility and CDT candidacy

eGFR for DOAC dosing; CKD-EPI 2021 race-free preferred

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningphlegmasia_cerulea_dolens
    Massive iliofemoral DVT with cyanosis, severe edema, compromised arterial inflow → limb-threatening
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcdt_associated_major_bleed
    Major bleed on catheter-directed thrombolysis (Hgb drop ≥2 g/dL, transfusion required, ICH, retroperitoneal)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningconcurrent_massive_pe_with_dvt
    Proximal DVT + concurrent PE with hypotension or shock (massive PE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereivc_extension_or_iliac_progression
    DVT extension into IVC or progression of iliac thrombus despite therapeutic AC
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprogressive_pts_at_6mo
    Progressive post-thrombotic syndrome (Villalta ≥10) at 6 mo despite optimal AC
    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

Proximal DVT full-dose anticoagulation — DOAC-first per ACCP 2021 / ASH 2020
axis: proximal_dvt_anticoagulation_phenotype
Selected axis "Proximal DVT full-dose anticoagulation — DOAC-first per ACCP 2021 / ASH 2020" by default fallback (first axis)
  • apixaban
    first line
    doac_factor_xa_direct
    10 mg BID × 7 d → 5 mg BID • PO • BID × ≥3 months
    triggers: proximal_dvt_confirmed, no_active_bleed, egfr_above_25
    AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — non-inferior to LMWH/warfarin with less major bleed; ACCP 2021 first-line
    rxcui 1364430
  • rivaroxaban
    first line
    doac_factor_xa_direct
    15 mg BID × 21 d → 20 mg daily with food • PO • BID then daily × ≥3 months
    triggers: proximal_dvt_confirmed, no_active_bleed, egfr_above_30
    EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814) — non-inferior to enoxaparin/VKA; single-drug regimen
    rxcui 1114195
  • 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 × ≥3 months
    triggers: proximal_dvt_confirmed, lmwh_lead_in_completed
    Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — non-inferior to warfarin with less bleed
    rxcui 1599538
  • enoxaparin
    comorbidity specific
    lmwh
    1 mg/kg SC BID (or 1.5 mg/kg daily); dose-reduce if CrCl <30 to 1 mg/kg daily • SC • BID
    triggers: pregnancy, severe_renal_impairment_doac_unsafe, doac_intolerance
    ASH 2018 VTE in Pregnancy (Bates PMID 30482767); ACCP 2021 LMWH preferred in pregnancy and select renal/comorbid scenarios
    rxcui 67108
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg daily; INR target 2-3 • PO • daily
    triggers: triple_positive_aps, severe_renal_impairment_doac_unsafe, mechanical_valve
    TRAPS (Pengo Blood 2018 PMID 30002145) — warfarin preferred over rivaroxaban in triple-positive APS
    rxcui 11289

outpatient playbook — drug actions (1)

  1. 1. maintenance apixaban
    rxcui 1364430
    apixaban 5 mg BID (full) or 2.5 mg BID (extended-reduced) • PO • BID
    trigger: Post 3-mo decision
    AMPLIFY/AMPLIFY-EXT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Whole-leg swelling, thigh pain, warmth → suggests proximal (iliofemoral) DVT (Wells Lancet 1997); Compression US shows non-compressible femoral or popliteal vein → proximal DVT confirmed; Massive iliofemoral DVT with cyanosis, severe edema, compromised arterial inflow → limb-threatening; CDT/thrombectomy emergency.

Objective

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

Assessment

**Proximal DVT (iliofemoral / popliteal)** (cardio.dvt.proximal.v1).
Scope: Proximal DVT = thrombus at or above popliteal vein; full-dose AC ≥3 months minimum; high CDT-eligibility for iliofemoral; route to cardio.dvt.core.v1 for diagnostic arc

No severity triggers fired against current inputs.

Plan

Regimen axis: **Proximal DVT full-dose anticoagulation — DOAC-first per ACCP 2021 / ASH 2020**.
1. apixaban 10 mg BID × 7 d → 5 mg BID PO BID × ≥3 months (doac_factor_xa_direct, first line) — AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — non-inferior to LMWH/warfarin with less major bleed; ACCP 2021 first-line
2. rivaroxaban 15 mg BID × 21 d → 20 mg daily with food PO BID then daily × ≥3 months (doac_factor_xa_direct, first line) — EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814) — non-inferior to enoxaparin/VKA; single-drug regimen
3. edoxaban 60 mg daily after 5 d LMWH lead-in (30 mg if CrCl 15-50 or weight ≤60 kg) PO daily × ≥3 months (doac_factor_xa_direct, first line) — Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — non-inferior to warfarin with less bleed
4. enoxaparin 1 mg/kg SC BID (or 1.5 mg/kg daily); dose-reduce if CrCl <30 to 1 mg/kg daily SC BID (lmwh, comorbidity specific) — ASH 2018 VTE in Pregnancy (Bates PMID 30482767); ACCP 2021 LMWH preferred in pregnancy and select renal/comorbid scenarios
5. warfarin 5 mg daily; INR target 2-3 PO daily (vitamin_k_antagonist, comorbidity specific) — TRAPS (Pengo Blood 2018 PMID 30002145) — warfarin preferred over rivaroxaban in triple-positive APS

Setting playbook (outpatient) — Maintenance phase AC + PTS surveillance + recurrence prevention; long-term shared decision-making for unprovoked and persistent-risk patients
6. maintenance apixaban apixaban 5 mg BID (full) or 2.5 mg BID (extended-reduced) PO BID — Post 3-mo decision (AMPLIFY/AMPLIFY-EXT)

Non-pharmacologic actions:
- Compression stocking only if symptomatic
- Address modifiable VTE risk factors
- Patient education ongoing

AVOID / contraindication checks:
- Doac_avoid_active_bleeding (FDA labels)
- Apixaban_avoid_egfr_below_15 (FDA label)
- Rivaroxaban_avoid_egfr_below_30 (FDA label)
- Edoxaban_avoid_egfr_above_95_reduced_efficacy (FDA label)
- Doac_avoid_triple_positive_aps_use_warfarin (TRAPS PMID 30002145)
- Warfarin_avoid_pregnancy_use_lmwh (ASH 2018)

Monitoring

Regimen monitoring:
- cbc q week x first month then monthly (ASH 2020)
- creatinine q3mo during doac for dose adjustment (FDA labels)
- inr q1-2 weeks during warfarin initiation target 2-3 (ACCP 2021)
- pts surveillance villalta at 3-6mo (Kahn Lancet 2014)

Setting (outpatient) monitoring:
- Annual reassessment of provoked vs persistent risk
- CBC + BMP
- Recurrent VTE symptoms reviewed

Follow-up plan: 3-month decision: stop AC if provoked + transient major risk resolved; continue extended (reduced dose) if unprovoked or persistent risk; HERDOO2/DASH for risk stratification
- Close-out criterion: extended-AC vs stop decision documented

Monitoring phase: Bleeding screen at each visit; CBC + BMP at week 1 then monthly; PTS surveillance at 3-6 mo (Villalta scale); recurrent VTE symptoms

Disposition

Current setting: outpatient — Maintenance phase AC + PTS surveillance + recurrence prevention; long-term shared decision-making for unprovoked and persistent-risk patients

Disposition criteria:
- Long-term continuation; cross-link to chronic engine if persistent risk

Escalation triggers (move to higher acuity):
- New cancer dx → re-evaluate per cancer-VTE protocol
- New pregnancy plan → switch to LMWH

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Massive iliofemoral DVT with cyanosis, severe edema, compromised arterial inflow → limb-threatening
- [LIFE_THREATENING] Major bleed on catheter-directed thrombolysis (Hgb drop ≥2 g/dL, transfusion required, ICH, retroperitoneal)
- [LIFE_THREATENING] Proximal DVT + concurrent PE with hypotension or shock (massive PE)

Citations

- ACCP/CHEST 2021 Antithrombotic + ASH 2020 VTE Treatment + ESC 2019 PE [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 23808982) [PMID:23808982](https://pubmed.ncbi.nlm.nih.gov/23808982/)
- Cited evidence (PMID 23216615) [PMID:23216615](https://pubmed.ncbi.nlm.nih.gov/23216615/)
- Cited evidence (PMID 21128814) [PMID:21128814](https://pubmed.ncbi.nlm.nih.gov/21128814/)

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