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cardio.dvt.with-pe.v1PRODUCTION
cardio.dvt.with-pe.v1

DVT with coexistent pulmonary embolism (combined VTE)

cardiologyacuteadult
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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

DVT with coexistent PE = combined VTE; manage as PE-driven (typically more dangerous given hemodynamic + gas-exchange dimensions); inherit DVT diagnostic + AC arc; route to pulm.pe.core.v1 for PE-specific hemodynamic management when RV strain present

Inputs
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Advance rule
Set
Advance when

both DVT and PE confirmed on imaging

Patient inputs (11)

Age modifies PESI/sPESI score for early mortality risk; informs outpatient candidacy (HESTIA)

Confirms DVT and laterality / proximal extent for IVC-filter and CDT consideration

CT-PA is gold-standard for PE confirmation, clot location (saddle vs lobar vs segmental), and RV/LV ratio measurement (RV/LV >0.9 = RV strain per ESC 2019)

Baseline Hgb + platelets before AC + thrombolytic-bleed risk stratification

SBP <90 for ≥15 min OR vasopressors needed = massive (high-risk) PE per ESC 2019 — fundamentally changes management to systemic thrombolysis

Hypoxemia magnitude correlates with PE clot burden + RV strain; informs O2 + escalation

Bleed history drives AC + thrombolytic eligibility; absolute contraindications shift to IVC-filter consideration

Bedside echo for RV dilation, septal flattening, TAPSE, McConnell — drives sub-massive vs low-risk classification when CT-PA shows PE without hypotension

Elevated troponin in PE = RV myocardial injury; combined with RV strain → sub-massive (intermediate-high risk per ESC 2019)

Provoked vs unprovoked drives AC duration decision at 3 mo (same as isolated DVT/PE)

eGFR for DOAC + LMWH dosing + contrast load for CT-PA

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningmassive_pe_conversion_with_concurrent_dvt
    Combined VTE patient develops SBP <90 for ≥15 min OR vasopressor need OR cardiac arrest — conversion to massive (high-risk) PE per ESC 2019
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningparadoxical_embolism_via_pfo_in_combined_vte
    New cryptogenic stroke or arterial embolism (gut, limb) in patient with confirmed DVT+PE — paradoxical embolism via patent foramen ovale; bubble-study echo confirms
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemodynamic_decompensation_in_submassive_pe
    Sub-massive PE patient (RV strain + troponin+ but normotensive at baseline) develops hypotension, worsening SpO2, lactate rise, or syncope — converting to massive
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningphlegmasia_cerulea_dolens_with_concurrent_pe
    Limb-threatening DVT (cyanosis, severe pain, arterial compromise) with concurrent PE — combined emergency requiring decisions about CDT of DVT vs systemic tPA addressing both
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmajor_bleed_on_ac_in_combined_vte
    Major bleeding on therapeutic AC for combined VTE (Hgb drop ≥2 g/dL, transfusion, ICH, GI hospitalization) per ISTH criteria 2005
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecteph_suspicion_at_3_6mo_post_combined_vte
    Persistent dyspnea or echo-detected pulmonary hypertension at 3-6 mo post combined VTE — chronic thromboembolic pulmonary hypertension (CTEPH) screen
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Combined DVT+PE — DOAC-first AC + severity-stratified reperfusion (ACCP 2021 + ESC 2019)
axis: combined_dvt_pe_anticoagulation_with_severity_stratified_reperfusion
Selected axis "Combined DVT+PE — DOAC-first AC + severity-stratified reperfusion (ACCP 2021 + ESC 2019)" by default fallback (first axis)
  • apixaban
    first line
    doac_factor_xa_direct
    10 mg BID × 7 days → 5 mg BID • PO • BID × ≥3 mo (extended if unprovoked)
    triggers: confirmed_dvt_with_pe, no_pregnancy, no_active_gi_gu_mucosal_malignancy, egfr_above_25
    AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — no LMWH bridge; ASH 2020 first-line; same dosing as isolated DVT or isolated PE
    rxcui 1364430
  • rivaroxaban
    first line
    doac_factor_xa_direct
    15 mg BID × 21 days → 20 mg daily with food • PO • BID then daily × ≥3 mo
    triggers: confirmed_dvt_with_pe, no_pregnancy, egfr_above_30
    EINSTEIN-PE (Investigators NEJM 2012 PMID 22449293) — non-inferior to enoxaparin/VKA in PE; same regimen for combined VTE
    rxcui 1114195
  • edoxaban
    first line
    doac_factor_xa_direct
    60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor) • PO • once daily
    triggers: confirmed_dvt_with_pe_after_5d_lmwh
    Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — requires 5-day LMWH lead-in
    rxcui 1599538
  • enoxaparin
    first line
    lmwh
    1 mg/kg SC q12h (CrCl <30: 1 mg/kg daily) • SC • q12h
    triggers: cancer_vte_gi_gu_mucosal, pregnancy, severe_renal_impairment_doac_unsafe, planned_invasive_procedure
    CLOT (Lee NEJM 2003 PMID 12853587) — preferred in active GI/GU mucosal cancer; ASH 2018 pregnancy first-line; ease of hold/resume peri-procedurally
    rxcui 67108
  • heparin
    second line
    unfractionated_heparin
    80 U/kg bolus + 18 U/kg/h infusion targeting aPTT 1.5–2.5× • IV • continuous
    triggers: crcl_below_15, imminent_thrombolysis_or_surgery, massive_pe_pre_tpa
    Rapid reversibility; preferred when intervention possible (ACCP 2021); standard pre-tPA bridge
    rxcui 235473
  • alteplase
    rescue
    fibrinolytic_tpa
    100 mg IV over 2 h (or 0.6 mg/kg over 15 min if cardiac arrest) • IV • one-time infusion
    triggers: massive_pe_with_shock, cardiac_arrest_with_high_pe_suspicion, low_bleed_risk
    ESC 2019 (PMID 31504429) Class I for massive PE with hemodynamic instability; addresses both PE and DVT clot burden simultaneously, often obviating CDT
    rxcui 8410
  • warfarin
    second line
    vitamin_k_antagonist
    5 mg daily; INR target 2-3 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 PMID 30002145) — warfarin preferred in triple-positive APS; alternative when DOAC contraindicated
    rxcui 11289

outpatient playbook — drug actions (2)

  1. 1. maintenance apixaban
    rxcui 1364430
    apixaban 5 mg BID full dose OR 2.5 mg BID extended-reduced based on 3-mo decision • PO • BID
    trigger: Post 3-mo decision
    AMPLIFY / AMPLIFY-EXT
  2. 2. aspirin if AC stopped for unprovoked + not extended-AC candidate
    rxcui 1191
    aspirin 100 mg daily • PO • once daily
    trigger: Unprovoked combined VTE who stopped AC at 3-6 mo
    ASPIRE (Brighton NEJM 2012 PMID 23121403) — 32% reduction in major vascular events vs placebo

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Confirmed/suspected proximal DVT plus dyspnea, pleuritic chest pain, hemoptysis, syncope, or unexplained tachycardia → image for concurrent PE per ESC 2019; 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.

Objective

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

Assessment

**DVT with coexistent pulmonary embolism (combined VTE)** (cardio.dvt.with-pe.v1).
Scope: DVT with coexistent PE = combined VTE; manage as PE-driven (typically more dangerous given hemodynamic + gas-exchange dimensions); inherit DVT diagnostic + AC arc; route to pulm.pe.core.v1 for PE-specific hemodynamic management when RV strain present

No severity triggers fired against current inputs.

Plan

Regimen axis: **Combined DVT+PE — DOAC-first AC + severity-stratified reperfusion (ACCP 2021 + ESC 2019)**.
1. apixaban 10 mg BID × 7 days → 5 mg BID PO BID × ≥3 mo (extended if unprovoked) (doac_factor_xa_direct, first line) — AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — no LMWH bridge; ASH 2020 first-line; same dosing as isolated DVT or isolated PE
2. rivaroxaban 15 mg BID × 21 days → 20 mg daily with food PO BID then daily × ≥3 mo (doac_factor_xa_direct, first line) — EINSTEIN-PE (Investigators NEJM 2012 PMID 22449293) — non-inferior to enoxaparin/VKA in PE; same regimen for combined VTE
3. edoxaban 60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor) PO once daily (doac_factor_xa_direct, first line) — Hokusai-VTE (Büller NEJM 2013 PMID 23991958) — requires 5-day LMWH lead-in
4. enoxaparin 1 mg/kg SC q12h (CrCl <30: 1 mg/kg daily) SC q12h (lmwh, first line) — CLOT (Lee NEJM 2003 PMID 12853587) — preferred in active GI/GU mucosal cancer; ASH 2018 pregnancy first-line; ease of hold/resume peri-procedurally
5. 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 2021); standard pre-tPA bridge
6. alteplase 100 mg IV over 2 h (or 0.6 mg/kg over 15 min if cardiac arrest) IV one-time infusion (fibrinolytic_tpa, rescue) — ESC 2019 (PMID 31504429) Class I for massive PE with hemodynamic instability; addresses both PE and DVT clot burden simultaneously, often obviating CDT
7. warfarin 5 mg daily; INR target 2-3 with overlapping LMWH × ≥5 d AND until INR ≥2 for ≥24 h PO daily; INR-driven (vitamin_k_antagonist, second line) — TRAPS (Pengo Blood 2018 PMID 30002145) — warfarin preferred in triple-positive APS; alternative when DOAC contraindicated

Setting playbook (outpatient) — Long-term AC management, PTS surveillance, CTEPH monitoring if at risk, annual reassessment of duration vs bleed risk
8. maintenance apixaban apixaban 5 mg BID full dose OR 2.5 mg BID extended-reduced based on 3-mo decision PO BID — Post 3-mo decision (AMPLIFY / AMPLIFY-EXT)
9. aspirin if AC stopped for unprovoked + not extended-AC candidate aspirin 100 mg daily PO once daily — Unprovoked combined VTE who stopped AC at 3-6 mo (ASPIRE (Brighton NEJM 2012 PMID 23121403) — 32% reduction in major vascular events vs placebo)

Non-pharmacologic actions:
- Compression stocking only if symptomatic PTS (against routine per SOX 2014)
- Continue activity / exercise
- Lifestyle: smoking cessation, weight, hydration
- Hormone management discussion (avoid OCP if reproductive age and unprovoked)

AVOID / contraindication checks:
- Doac_avoid_pregnancy_use_lmwh (ASH 2018)
- Doac_avoid_active_gi_gu_mucosal_cancer_use_lmwh (CARAVAGGIO subgroup)
- Tpa_avoid_recent_neurosurgery_intracranial_bleed_active_internal_bleed (ESC 2019)
- Tpa_avoid_severe_uncontrolled_htn_sbp_above_185 (ESC 2019)
- Warfarin_for_aps_triple_pos (TRAPS Pengo Blood 2018)
- Decision:cdt_of_dvt_alone_less_beneficial_in_coexistence_with_pe_systemic_tpa_addresses_both
- Decision:ivc_filter_only_if_ac_absolutely_contraindicated_and_saddle_or_large_pe (PREPIC2 PMID 25919526)

Monitoring

Regimen monitoring:
- continuous spo2 and telemetry first 24h for pe component
- serial troponin and bnp q6 8h first 24h (ESC 2019 RV strain trajectory)
- daily echo if rv strain at baseline (ESC 2019)
- creatinine q3 6mo during doac (FDA labels)
- cbc baseline and q12h first 2 d then periodically (ASH 2020)
- inr q4 weeks warfarin steady state (ACCP 2021)
- platelets q1 3d first 2wk lmwh for hit screen (ASH 2018)
- reassess ac at 3mo provoked vs unprovoked (ACCP 2021)
- cteph screen at 3 6mo if persistent dyspnea echo then vq (ESC 2019)

Setting (outpatient) monitoring:
- Annual PTS + bleed assessment
- Annual labs
- Echo annually if CTEPH on radar

Follow-up plan: 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
- Close-out criterion: AC duration + CTEPH-screen + PTS plan finalized

Monitoring phase: Continuous SpO2 + telemetry first 24 h; serial troponin + BNP; daily echo if RV strain at baseline; CBC q12h on therapeutic AC; bleeding screen; PTS surveillance later

Disposition

Current setting: outpatient — Long-term AC management, PTS surveillance, CTEPH monitoring if at risk, annual reassessment of duration vs bleed risk

Disposition criteria:
- Annual outpatient follow-up; lifelong if extended AC or CTEPH; cross-link to pulm.pe.core.v1 for any PE-specific concerns

Escalation triggers (move to higher acuity):
- New PE/DVT → resume indefinite AC; evaluate APS / cancer
- Persistent dyspnea → V/Q + RH cath for CTEPH (refer to PH clinic per ESC 2019)
- Major bleed on extended AC → reassess risk-benefit, may stop for transient-risk provoked or switch class
- Pregnancy → switch DOAC to LMWH per ASH 2018

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Combined VTE patient develops SBP <90 for ≥15 min OR vasopressor need OR cardiac arrest — conversion to massive (high-risk) PE per ESC 2019
- [LIFE_THREATENING] New cryptogenic stroke or arterial embolism (gut, limb) in patient with confirmed DVT+PE — paradoxical embolism via patent foramen ovale; bubble-study echo confirms
- [LIFE_THREATENING] Sub-massive PE patient (RV strain + troponin+ but normotensive at baseline) develops hypotension, worsening SpO2, lactate rise, or syncope — converting to massive

Citations

- ACCP/CHEST 2021 + ESC 2019 Acute PE + ASH 2020 VTE Treatment [PMID:34352295](https://pubmed.ncbi.nlm.nih.gov/34352295/)
- Cited evidence (PMID 31504429) [PMID:31504429](https://pubmed.ncbi.nlm.nih.gov/31504429/)
- Cited evidence (PMID 33007077) [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 23808982) [PMID:23808982](https://pubmed.ncbi.nlm.nih.gov/23808982/)

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