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Instructions

For use in the treatment of hemodynamically stable patients with VTE who do not exhibit symptoms of limb ischemia.

Transfer immediately to a Vascular Specialist if the patient:

is hemodynamically unstable,
has signs or symptoms of limb ischemia, *OR*
has a highly symptomatic DVT and/or ischemic symptoms on ambulation.

Patients are NOT required to have radiological confirmation of VTE to be assessed under this app.

Should multiple scenarios be present (i.e., DVT and PE), the app should be run individually for each scenario, with the highest level of care assigned to the patient (e.g., transfer > inpatient > outpatient.)

What is the clinical status of the patient's (potential) VTE?

Radiologically confirmed PERadiologically confirmed DVTSuspected PE (not radiologically confirmed)Suspected DVT (not radiologically confirmed)

Why Clinicians Ought to Consider a Screening Tool for Venous Thromboembolic Disease (VTE)?

Screening for VTE is crucial for early diagnosis, reducing complications, preventing recurrence, and improving overall patient outcomes.

Early Detection and Prevention of Severe Complications
- VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), can be life-threatening if not detected early.
- Early diagnosis allows for timely interventions to prevent severe outcomes such as PE, which can be fatal.
Cost-Effective Prevention Strategy
- Detecting VTE early reduces the economic burden associated with advanced disease treatment, including hospitalizations and long-term anticoagulation therapy.

App Components

The VTE Screening app incorporates several assessment modalities to assist the clinician in detecting the presence and pre-test probability of VTE and determining if the patient is a candidate for inpatient vs. outpatient care.

Wells Score Calculator for DVT and PE
PERC Rule and Hestia Criteria for Pulmonary Embolism
Clinical Decision Tree for Suspected VTE when Radiological Confirmation is not immediately available
Antithrombotic Medication Management Strategies for Inpatient and Outpatient Management
Select Non-pharmacological VTE management

Studies indicate that appropriate anticoagulation therapy can decrease the rates of recurrent VTE and associated complications. Additional factors, such as bleeding risk, also play a role in the judicial use of anticoagulants. Medication treatment plans in the presence of bleeding risk factors will require additional scrutiny as the clinician and patient weigh the risks versus benefits.

The content of this app provided is for informational purposes for medical professionals only and is not intended to be used or relied upon by them as specific medical advice, diagnosis, or treatment, the determination of which remains the responsibility of the medical professionals for their patients.

App Logic

To learn how the app logic works, you can inspect the app builder or refer to the VTE Evaluation & Management in the Emergency Department App Logic Map.

All questions & possible results

Evalution of VTE in the EDTitle not visible

What is the clinical status of the patient's (potential) VTE?

Select one option:

Radiologically confirmed PE
Radiologically confirmed DVT
Suspected PE (not radiologically confirmed)
Suspected DVT (not radiologically confirmed)

Radiologically Confirmed DVT

Is the DVT distal or proximal?

*if pelvic vein involvement is present (external iliac vein) then strongly consider abd/pelvis CT with contrast to assess for central clot. If patient can not have contrast, then no-contrast CT is preferred to no CT.

Select one option:

Distal
Proximal (or having a proximal component)

Distal DVT: Anticoagulation vs. Clinical Surveillance

Guidance suggests select patients with isolated distal DVT may not require anticoagulation therapy.

Anticoagulation therapy should be initiated when:

The patient has cancer: active or diagnosed within the previous 6 months. (ESC 2019)
Patient is at high risk for VTE recurrence.* (ESC 2022)

Anticoagulation should be strongly considered in patients is without increased bleeding risk who have a favorable benefit vs. risk ratio until further follow-up and evaluation can be completed.

If anticoagulation therapy is not implemented strict clinical surveillance should be implemented. Clinical surveillance includes serial monitoring for clot extension into or near the proximal system. Anticoagulation should be promptly initiated If the thrombus is within 3-5cm of the proximal junction and/or is 5cm or greater in length. (ESC 2022, CHEST 2021)

*Risk factors for recurrent or progressive VTE include hospitalization or reduced mobility, active cancer (especially if metastatic or on chemotherapy), pregnancy, lack of reversible VTE risk factor(s), and/or low cardiopulmonary reserve. (ESC 2022, CHEST 2021)

Select one option:

Distal DVT: Initiate Anticoagulation.
Distal DVT: Initiate Clinical Surveillance.

Suspected DVT (not radiologically confirmed)

Suspected DVT: Is the D-dimer positive?

Use a moderate- or high-sensitivity assay.

Select one option:

No: DVT unlikely.
Yes

Is venous ultrasound available?

Select one option:

No: Anticoagulate until radiological study is complete.
Yes

Is the US Positive for DVT?

Select one option:

No: Seek alternate diagnosis.
Yes

What is the anatomy of the DVT?

Guidance suggests select patients with isolated distal DVT may not require anticoagulation therapy.

Anticoagulation therapy should be initiated when:

The patient has cancer: active or diagnosed within the previous 6 months. (ESC 2019)
Patient is at high risk for VTE recurrence.* (ESC 2022)

Anticoagulation should be strongly considered in patients is without increased bleeding risk who have a favorable benefit vs. risk ratio until further follow-up and evaluation can be completed.

Select one option:

Proximal DVT or Proximal component: Anticoagulation recommended by guidelines.
Distal DVT: Anticoagulation desired.
Distal DVT: Anticoagulation is not desired. Implement clinical surveillance.

Suspected PE (not radiologically confirmed)

Is CTA available?

Select one option:

Suspected PE: Is the D-dimer positive?

Use a moderate- or high-sensitivity assay.

Select one option:

No: PE Unlikely.
Yes: Anticoagulate until radiological study is complete.

Does the patient have a PE?

*If clinical suspicion is high for PE, yet CT is negative, consider consulting the Vascular Specialist.

Select one option:

No: Seek alternate diagnosis.
Yes

Radiologically Confirmed PE

Does the patient have a Massive, Sub-Massive, or Low Risk PE?

High-Risk PE (Massive) Criteria:

Sustained hypotension (SBP < 90 mmHg for ≥ 15 minutes or requiring inotropic support) *OR*
Pulselessness *OR*
Sustained HR < 40 BPM with signs/symptoms of shock

Intermediate-Risk PE (Sub-massive) Criteria:

SBP > 90 mmHg and RV dysfunction or myocardial necrosis, defined as having ANY of the following:
- RV/LV ratio > 0.9 *OR* RV systolic dysfunction on ECHO or CT
- BNP elevation (> 90 pg/mL) *OR* N-terminal pro-BNP elevation (> 500 pg/mL)
- EKG changes *OR* positive troponin (troponin I > 0.4 ng/mL or troponin T > 0.1 ng/mL)

Low-Risk PE Criteria:

Patient does not meet the above criteria (normotensive, no evidence of right heart strain, normal biomarkers.)

BNP indicates brain natriuretic peptide; BP, blood pressure; BPM, beats per minute; CT, computed tomography; ECHO, echocardiogram; EKG, electrocardiography; LV, left ventricular;and RV, right ventricular. (AHA 2013, Am J Respir Crit Care Med 2018)

Select one option:

Low Risk PE
Intermediate-Risk PE (Submassive)
High-Risk PE (Massive): Stabilize and Transfer to Critical Care Clinician and/or Vascular Specialist. Anticoagulate per receiving clinician.

Does the patient have an SUBSEGMENTAL PE (and no other VTE)?

Select one option:

Subsegmental and Low-Risk PE

Guidance suggests select patients with isolated subsegmental PE (without proximal DVT) may not require anticoagulation therapy.

Anticoagulation therapy should be initiated when:

The patient has cancer: active or diagnosed within the previous 6 months. (ESC 2019)
Patient is at high risk for VTE recurrence.* (CHEST 2021)

Anticoagulation should be strongly considered in patients is without increased bleeding risk who have a favorable benefit vs. risk ratio until further follow-up and evaluation can be completed.

If anticoagulation therapy is not implemented (following consultation with a Vascular or Hematology specialist) strict clinical surveillance should be implemented. Clinical surveillance includes serial venous ultrasound weekly x 2 weeks and (US or CT) if worsening symptoms.

*Risk factors for recurrent or progressive VTE include: hospitalization or reduced mobility, active cancer (especially if metastatic or on chemotherapy), pregnancy, lack of reversible VTE risk factor(s), and/or low cardiopulmonary reserve. (CHEST 2021)

Select one option:

Initiate Anticoagulation Therapy.
Implement Clinical Surveillance.

Anticoagulation Decision Tree

Does the patient have a high bleeding risk?

Bleeding Risk Factors to Consider:

Concurrent NSAID or other antiplatelet agents
History of hemorrhagic stroke, intracranial hemorrhage, or significant bleeding
Recent GI ulceration
Active malignant neoplasms at risk of bleeding
History of vascular aneurysms
History of coagulopathies/bleeding disorders
Uncontrolled hypertension (SBP > 160 mmHg)
Heavy alcohol use or esophageal varices
Acute liver or renal failure
Recent trauma or surgery

These factors represent a sampling of bleeding risk factors from validated tools and the primary literature.

Select one option:

No
Yes - Requires Inpatient Anticoagulation Initiation

Outpatient Treatment: Is anticoagulation CONTRAINDICATED?

Do NOT give anticoagulants if patient has any of the following ABSOLUTE contraindications:

Current active bleeding
Major surgery in the past 7 days
Intracranial hemorrhage in the past 30 days
Platelet count < 25,000

Anticoagulation is strongly discouraged in the presence of the following RELATIVE contraindications:*

Intracranial or intraspinal tumor
Aortic dissection
GI bleeding in the past 7 days
Platelet count < 50,000

*In this setting, the clinician must weigh the risks and benefits in each case.

Select one option:

No
Yes: Consult Vascular Specialist. Patient may be a candidate for IVC filter.

Outpatient Treatment: Is the CrCl < 30 ml/min?

Select one option:

Outpatient Treatment: Is the CrCl < 15 mL/min *or* is the patient on dialysis (HD or PD)?

HD = hemodialysis. PD = peritoneal dialysis.

Select one option:

Outpatient Treatment: Does the patient have a CONTRAINDICATION to direct-acting oral anticoagulant (DOAC) therapy?

DOAC Contraindications include concurrent:

Mechanical Valve
Antiphospholipid Syndrome
Pregnancy or Lactation
Severe Liver Impairment (Child-Turcotte-Pugh class C)
Neuraxial anesthesia or spinal puncture
History of Bariatric Surgery (ISTH 2021)
Drug-Drug Interaction with strong CYP Inducers, CYP Inhibitors, strong PGP Inhibitors (e.g., rifampin, carbamazepine, phenytoin, St. Jon's wort, ketoconazole, itraconazole, ritonavir, etc.), or BTK Inhibitors for cancer (ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib.) ** Consult pharmacy for identification additional potential drug interactions. FDA Labeling may suggest dose alteration for some drug-drug interactions. Dose adjustments for drug interactions in VTE is not generally recommended. Consider alternate agent.**

Select one option:

Inpatient Treatment: Is anticoagulation CONTRAINDICATED?

Do NOT give anticoagulants if patient has any of the following ABSOLUTE contraindications:

Current active bleeding
Major surgery in the past 7 days
Intracranial hemorrhage in the past 30 days
Platelet count < 25,000

Anticoagulation is strongly discouraged in the presence of the following RELATIVE contraindications:*

Intracranial or intraspinal tumor
Aortic dissection
GI bleeding in the past 7 days
Platelet count < 50,000

*In this setting, the clinician must weigh the risks and benefits in each case.

Select one option:

No
Yes: Consult Vascular Specialist. Patient may be a candidate for an IVC filter.

Inpatient Treatment: Is the CrCl < 30 ml/min?

Select one option:

Inpatient Treatment: Is the CrCl < 15 ml/min or is the patient on dialysis (HD or PD)?

HD = hemodialysis. PD = peritoneal dialysis.

Select one option:

Inpatient Treatment: Does the patient have a CONTRAINDICATION to direct-acting oral anticoagulant (DOAC) therapy?

DOAC Contraindications include concurrent:

Mechanical Valve
Antiphospholipid Syndrome
Pregnancy or Lactation
Severe Liver Impairment (Child-Turcotte-Pugh class C)
Neuraxial anesthesia or spinal puncture
History of Bariatric Surgery (ISTH 2021)
Drug-Drug Interaction with strong CYP Inducers, CYP Inhibitors, strong PGP Inhibitors (e.g., rifampin, carbamazepine, phenytoin, St. Jon's wort, ketoconazole, itraconazole, ritonavir, etc.), or BTK Inhibitors for cancer (ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib.) ** Consult pharmacy for identification additional potential drug interactions. FDA Labeling may suggest dose alteration for some drug-drug interactions. Dose adjustments for drug interactions in VTE is not generally recommended. Consider alternate agent.**

Select one option:

Management

Select Anticoagulation Therapy: Outpatient with CrCl > 30 mL/min

DOAC therapy (apixaban & rivaroxaban) are preferred over warfarin + enoxaparin in most patients.

Exclusions: Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, and select Drug-Drug interactions.

Enoxaparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

DOAC or LMWH are preferred over LMWH + warfarin therapy for patients with cancer per NCCN guidelines (except in patients on BTK Inhibitors like ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib.) Consider using apixaban for gastrointestinal luminal cancers due to lower rates of GI bleeding.

Dabigatran therapy requires 5-10 days of parenteral therapy prior to initiation and is suboptimal for initial outpatient treatment.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Apixaban 10mg po twice daily (initiation dose x 7 days), then decrease to 5mg po twice daily
Rivaroxaban 15mg po twice daily (initiation dose x 21 days), then decrease to 20mg daily with food
Warfarin 2.5mg po daily (add enoxaparin)
Warfarin 5mg po daily (add enoxaparin)
Enoxaparin 1mg/kg subq every 12 hours (max. weight = 150kg)
Enoxaparin 1.5mg/kg every 24 hours (max. weight = 100kg)

Select Anticoagulation Therapy: Outpatient with CrCl 15-30 mL/min

DOAC therapy (apixaban & rivaroxaban) are preferred over warfarin + enoxaparin in most patients.

Exclusions: Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, and select Drug-Drug interactions.

Enoxaparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

Dabigatran therapy requires 5-10 days of parenteral therapy prior to initiation and is suboptimal for initial outpatient treatment.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

DOAC therapy is not dose-reduced for this indication. Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Apixaban 10mg po twice daily (initiation dose x 7 days), then decrease to 5mg po twice daily
Rivaroxaban 15mg po twice daily (initiation dose x 21 days), then decrease to 20mg daily with food
Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)
Warfarin 2.5mg po daily *AND* Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)
Warfarin 5mg po daily *AND* Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)

Select Anticoagulation Therapy: Outpatient with CrCl < 15 mL/min *or* on dialysis

Data on the use of DOAC therapy may be a consideration for anticoagulation therapy based upon available data and prescribing patterns.

Apixaban, at present, is the most widely studied and may have lower rates of recurrent VTE and major & clinically relevant non-major bleeding vs. warfarin. (Cohen 2022, Ellenbogen 2022, Wetmore 2022)

Apixaban Dosing:

It is uncertain at this time if apixaban induction dosing (i.e., 10mg po BID x 7 days) should be utilized or deferred in favor of the apixaban 5mg po BID dosing.

Evaluate individual patient risk vs. benefit and utilize shared decision making.

Warfarin Alternative:

Initiation of warfarin therapy requires inpatient admission for concurrent heparin bridge therapy.

Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Heparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select one option:

Apixaban 10mg po twice daily (initiation dose x 7 days), then decrease to 5mg po twice daily
Apixaban 5mg po twice daily (omit initiation dose)
Admit for Anticoagulation Initiation

Select Anticoagulation Therapy: Inpatient with CrCl > 30 mL/min

DOAC therapy (apixaban & rivaroxaban) are preferred over warfarin + enoxaparin in most patients.

Exclusions: Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, and select Drug-Drug interactions.

Heparin and enoxaparin are contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

Dabigatran therapy requires 5-10 days of parenteral therapy prior to initiation and is suboptimal for initial outpatient treatment.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Apixaban 10mg po twice daily (initiation dose x 7 days), then decrease to 5mg po twice daily
Rivaroxaban 15mg po twice daily (initiation dose x 21 days), then decrease to 20mg daily with food
Enoxaparin 1mg/kg subq every 12 hours (max. weight = 150kg)
Enoxaparin 1.5mg/kg every 24 hours (max. weight = 100kg)
Unfractionated Heparin per protocol
Warfarin 5mg po daily (add enoxaparin or UFH)
Warfarin 2.5mg po daily (add enoxaparin or UFH)

Select Anticoagulation Therapy: Inpatient with CrCl 15-30 mL/min

DOAC therapy (apixaban & rivaroxaban) are preferred over warfarin + enoxaparin in most patients.

Exclusions: Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, and select Drug-Drug interactions.

Heparin and enoxaparin are contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

Dabigatran therapy requires 5-10 days of parenteral therapy prior to initiation and is suboptimal for initial outpatient treatment.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

DOAC therapy is not dose-reduced for this indication. Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Apixaban 10mg po twice daily (initiation dose x 7 days), then decrease to 5mg po twice daily
Rivaroxaban 15mg po twice daily (initiation dose x 21 days), then decrease to 20mg daily with food
Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)
Unfractionated Heparin per protocl
Warfarin 2.5mg po daily (add enoxaparin or UFH)
Warfarin 5mg po daily (add enoxaparin or UFH)

Select Anticoagulation Therapy: Inpatient with CrCl < 15 mL/min *or* on dialysis

Data on the use of DOAC therapy may be a consideration for anticoagulation therapy based upon available data and prescribing patterns.

Apixaban, at present, is the most widely studied and may have lower rates of recurrent VTE and major & clinically relevant non-major bleeding vs. warfarin. (Cohen 2022, Ellenbogen 2022, Wetmore 2022)

Apixaban Dosing:

It is uncertain at this time if apixaban induction dosing (i.e., 10mg po BID x 7 days) should be utilized or deferred in favor of the apixaban 5mg po BID dosing.

Evaluate individual patient risk vs. benefit and utilize shared decision making.

Warfarin Alternative:

Initiation of warfarin therapy requires inpatient admission for concurrent heparin bridge therapy.

Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Heparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Apixaban 10mg po twice daily (initiation dose x 7 days), then decrease to 5mg po twice daily
Apixaban 5mg po twice daily (omit initiation dose)
Warfarin 2.5mg po daily *AND* Unfractionated Heparin per protocol
Warfarin 5mg po daily *AND* Unfractionated Heparin per protocol

Select Anticoagulation Therapy: Outpatient with CrCl > 30 mL/min with DOAC Contraindicated

DOAC therapy (apixaban & rivaroxaban) are contraindicated in Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, History of Bariatric Surgery, and select Drug-Drug Interactions.

Enoxaparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

LMWH is preferred over LMWH + warfarin therapy for patients with cancer per NCCN guidelines.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Warfarin 2.5mg po daily (add enoxaparin)
Warfarin 5mg po daily (add enoxaparin)
Enoxaparin 1mg/kg subq every 12 hours (max. weight = 150kg)
Enoxaparin 1.5mg/kg every 24 hours (max. weight = 100kg)

Select Anticoagulation Therapy: Outpatient with CrCl 15-30 mL/min with DOAC Contraindicated

DOAC therapy (apixaban & rivaroxaban) are contraindicated in Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, History of Bariatric Surgery, and select Drug-Drug Interactions.

Enoxaparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

LMWH is preferred over LMWH + warfarin therapy for patients with cancer per NCCN guidelines.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)
Warfarin 2.5mg po daily *AND* Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)
Warfarin 5mg po daily *AND* Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)

Select Anticoagulation Therapy: Inpatient with CrCl > 30 mL/min with DOAC Contraindicated

DOAC therapy (apixaban & rivaroxaban) are contraindicated in Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, History of Bariatric Surgery, and select Drug-Drug Interactions.

Heparin and enoxaparin are contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

LMWH is preferred over LMWH + warfarin therapy for patients with cancer per NCCN guidelines.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Warfarin 2.5mg po daily (with Enoxaparin or UFH)
Warfarin 5mg po daily (with Enoxaparin or UFH)
Enoxaparin 1mg/kg subq every 12 hours (max. weight = 150kg)
Enoxaparin 1.5mg/kg every 24 hours (max. weight = 100kg)
Unfractionated Heparin per protocol
Pharmacy Consult for Anticoagulant Selection

Select Anticoagulation Therapy: Inpatient with CrCl 15-30 mL/min with DOAC Contraindicated

DOAC therapy (apixaban & rivaroxaban) are contraindicated in Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, History of Bariatric Surgery, and select Drug-Drug Interactions.

Heparin and enoxaparin are contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

LMWH is preferred over LMWH + warfarin therapy for patients with cancer per NCCN guidelines.

Warfarin use requires concurrent parenteral bridge with enoxaparin. Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Enoxaparin 1mg/kg subq every 24 hours (max. weight = 150kg)
Unfractionated Heparin per protocl
Warfarin 2.5mg po daily (with Enoxaparin or UFH)
Warfarin 5mg po daily (with Enoxaparin or UFH)

Select Anticoagulation Therapy: Inpatient with CrCl < 15 mL/min *or* on dialysis with DOAC Contraindicated

DOAC therapy (apixaban) is contraindicated in Pregnancy, Lactation, Artificial Heart Valves, Antiphospholipid Syndrome, History of Bariatric Surgery, and select Drug-Drug Interactions.

Warfarin Therapy:

Initiation of warfarin therapy requires inpatient admission for concurrent heparin bridge therapy.

Target INR goal is 2.0-3.0, unless compelling indication for increased goal is present.

Heparin is contraindicated in alpha-gal syndrome (pork product) and history of heparin-induced thrombocytopenia.

Consult pharmacy for anticoagulant dosing and/or selection questions.

Select all that apply:

Warfarin 2.5mg po daily (add heparin)
Warfarin 5mg po daily (add heparin)
Unfractionated Heparin per protocl
Pharmacy Consult for Anticoagulant Selection

Outpatient: Indicate Non-Pharmacologic Management

Select all that apply:

Pre-Discharge Consult: Social Work or Care Planning
Pre-Discharge Consult: Pharmacy
Post-Discharge Care: Internal Medicine evaluation in 24-48 hours (PE)
Post-Discharge Care: Internal Medicine evaluation in 24-72 hours (DVT)
Outpatient Radiological Confirmation: Schedule/Perform chest CT ASAP
Outpatient Radiological Confirmation: Schedule/Perform venous ultrasound (bilaterally) ASAP
Outpatient Radiological Confirmation: Schedule venous ultrasound for serial evaluation of distal DVT (3-7 days)
Outpatient Radiological Confirmation: Schedule/Perform transthoracic ECHO
Outpatient Consult: Vascular Specialist (Vascular Surgery or Vascular Cardiology)
Outpatient Consult: Hematology
Place compression stockings
Deferred

Inpatient: Indicate Non-Pharmacologic Management

Select all that apply:

Radiological Confirmation: Schedule/Perform chest CT
Radiological Confirmation: Schedule/Perform venous ultrasound (bilaterally)
Radiological Confirmation: Schedule/Perform transthoracic ECHO
Inpatient Care: Oxygen to maintain 02 saturation > 90%
Inpatient Care: Nursing assessment every 1 hour (high PE or bleed risk)
Inpatient Care: Place sequential compression devices (contraindicated with DVT)
Inpatient Care: Place compression stockings
Consult: Vascular Specialist (Vascular Surgery or Vascular Cardiology)
Consult: Hematology
Consult: Internal Medicine
Consult: Social Work or Care Planning
Consult: Pharmacy
Deferred

GuidanceTitle not visible

Age

Select one option:

≤ 80 years
> 80 years

History of Cancer

Select one option:

History of chronic cardiopulmonary disease

Select one option:

Heart Rate

Select one option:

< 110 bpm
≥ 110 bpm

Systolic Blood Pressure

Select one option:

≥ 100 mmHg
< 100 mmHg

Oxygen Saturation

Select one option:

≥ 90%
< 90%

GuidanceTitle not visible

Is the patient hemodynamically unstable?

*SBP < 100 mmHg and HR > 100, needing ICU care, or by clinician judgement

Select one option:

Is thrombolysis or embolectomy indicated/needed?

*for reasons other than hemodynamic instability

Select one option:

Does the patient have active bleeding or is at high-risk for bleeding?

High-bleeding risk characteristics includes:

GI bleeding or surgery <= 2 weeks ago
Stoke <= 1 month ago
Bleeding disorder or platelet count < 75,000
Uncontrolled HTN (SBP > 180 or DBP < 110 mmHg)
High-risk by clinician judgement

Select one option:

Does the patient need supplemental oxygen for > 24 hours?

*required to maintain SaO2 > 90%

Select one option:

Was the PE diagnosed while actively anticoagulated?

*and fully compliant

Select one option:

Does the patient need IV pain medication for severe pain?

*required for > 24 hours

Select one option:

Is there a compelling medical or social reason for admission of > 24 hours?

*e.g., infection, malignancy, no support system

Select one option:

Is the patient's creatinine clearance < 30 mL/min?

*CrCl as calculated by Cockcroft-Gault formula

Select one option:

Does the patient have severe liver impairment?

*per clinician judgement

Select one option:

Is the patient pregnant?

Select one option:

Does the patient have a documented history of heparin-induced thrombocytopenia (HIT)?

Select one option:

GuidanceTitle not visible

Active Cancer (treatment or palliation within 6 months)

Select one option:

Bedridden for > 3 days recently *or* Major surgery within 12 weeks

Select one option:

Calf swelling > 3 cm compared to the contralateral leg (measured 10 cm below the tibial tuberosity)

Select one option:

Collateral (non-varicose) superficial veins present

Select one option:

Entire leg is swollen

Select one option:

Localized tenderness along the deep venous system

Select one option:

Pitting edema, confined to the symptomatic leg

Select one option:

Paralysis, paresis, or recent plaster immobilization of the lower extremity

Select one option:

Previously documented DVT

Select one option:

Alterative diagnosis to DVT as likely or more likely

Select one option:

GuidanceTitle not visible

Age ≥ 50

Select one option:

HR ≥ 100

Select one option:

O₂ sat on room air < 95%

Select one option:

Unilateral leg swelling

Select one option:

Hemoptysis

Select one option:

Recent surgery or trauma

Surgery or trauma ≤ 4 weeks ago requiring treatment with general anesthesia

Select one option:

Prior PE or DVT

Select one option:

Hormone use

Oral contraceptives, hormone replacement, or estrogenic hormones use in males or female patients

Select one option:

GuidanceTitle not visible

Clinical signs and symptoms of DVT

Select one option:

PE is the primary diagnosis or equally likely

Select one option:

Heart rate > 100

Select one option:

Immobilization at least 3 days OR surgery in the previous 4 weeks

Select one option:

History of PE or DVT diagnosis

Select one option:

Hemoptysis

Select one option:

Malignancy with treatment within 6 months or palliative

Select one option:

Possible results

Radiologically Confirmed DVT: Outpatient Treatment

Radiologically Confirmed DVT meeting criteria for OUTPATIENT Treatment.
Patient requires prompt anticoagulation.
Schedule follow-up with Primary Care prior to ED discharge.
Education about symptoms which require return to the ED should be provided (increased limb swelling, limb numbness, limb cold to touch or blue in color, tachycardia, increasing SOB, hemoptysis, etc.)

Radiologically Confirmed DVT: Inpatient Treatment

Radiologically confirmed DVT requiring INPATIENT treatment due to elevated bleed risk.
Patient requires prompt anticoagulation (unless contraindicated) & close monitoring.

Radiologically Confirmed PE: Outpatient Treatment

Radiologically Confirmed PE meeting criteria for OUTPATIENT Treatment.
Patient requires prompt anticoagulation.
Schedule follow-up with Primary Care prior to ED discharge.
Education about symptoms which require return to the ED should be provided (increased limb swelling, limb numbness, limb cold to touch or blue in color, tachycardia, increasing SOB, hemoptysis, etc.)

Stabilize & Refer to Vascular Specialist or Facility Transfer. Promptly anticoagulate per the receiving clinician.

Patient requires referral to Vascular Specialist and/or facility transfer for consideration of higher level of care, thrombectomy, thrombolysis, and/or IVC filter placement.

Anticoagulation therapy should be initiated promptly, with agent selection discussed with next care provider.

Inpatient Treatment for Possible DVT: Pending Radiological Confirmation

Possible DVT meeting criteria for INPATIENT Treatment due to elevated bleeding risk.
Patient requires prompt anticoagulation (unless contraindicated) and close monitoring while awaiting radiological confirmation.

Outpatient Treatment for Possible DVT: Pending Radiological Confirmation

Possible DVT meeting criteria for OUTPATIENT Treatment.
Patient requires prompt anticoagulation.
Schedule radiological evaluation & follow-up with Primary Care prior to ED discharge.
Education about symptoms which require return to the ED should be provided (increased limb swelling, limb numbness, limb cold to touch or blue in color, tachycardia, increasing SOB, hemoptysis, etc.)

Outpatient Treatment for Possible PE: Pending Radiological Confirmation

Possible PE meeting criteria for OUTPATIENT Treatment.
Patient requires prompt anticoagulation.
Schedule radiological evaluation & follow-up with Primary Care prior to ED discharge.
Education about symptoms which require return to the ED should be provided (increased limb swelling, limb numbness, limb cold to touch or blue in color, tachycardia, increasing SOB, hemoptysis, etc.)

Radiologically Confirmed PE: Inpatient Treatment

Radiologically confirmed PE requiring INPATIENT treatment due to elevated bleed risk and/or PE severity.
Patient requires prompt anticoagulation (unless contraindicated) & close monitoring.

Inpatient Treatment for Suspected PE: Pending Radiological Confirmation

Suspected PE requiring INPATIENT treatment due to elevated bleed risk and/or PE severity.
Patient requires prompt anticoagulation (unless contraindicated) & close monitoring while awaiting radiological evaluation.

Anticoagulation not prescribed.

VTE is:

ruled out *OR*
unlikely *OR*
anticoagulation is not preferred at this time.

Patient may require ongoing clinical surveillance and/or prompt outpatient post-discharge care.

Low Mortality Risk (0 points): 1.1% risk of death, with 1.5% of having recurrent thromboembolism or non-fatal bleeding within 30-days.

High Mortality Risk (1+ points): 8.9% risk of death or higher within 30-days.

Low Risk: Patient a candidate for outpatient PE treatment

If no criteria are positive, studies indicate a 0% mortality and a 2% VTE recurrence.

Patient is a candidate for outpatient PE treatment.

*Note: No decision rule should trump clinical gestalt.*

If anticoagulated and treated as an outpatient, the patient must be counseled about the risks of outpatient treatment and should be given close return precautions.

The patient should be counseled regarding anticoagulation-related bleeding risks and standard safety precautions while on anticoagulant therapy.

The patient should have close outpatient follow-up with a primary care provider.

NOT Low Risk: Recommend admission for inpatient PE treatment

If any criteria are positive, the patient is not a candidate for outpatient PE treatment per the Hestia Criteria and requires initial inpatient admission.

DVT Unlikely: 5% incidence of DVT (0-1 points)

Result is based on a two tier model of "DVT Unlikely" or "DVT Likely".

Guidelines appear to favor the two-tier model which implements only the high sensitivity d-dimer and more conservative risk stratification. However, "intermediate" risk patients may be still too high risk to be evaluated without further risk stratification.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
Consider moderate- or high-sensitivity d-dimer testing
- If the dimer is negative, consider stopping the workup, DVT is unlikely.
- If the dimer is positive, consider venous ultrasound testing.

Considerations

Since the high sensitivity d-dimer has a low specificity (approximately 50%), patients who are considered high risk ought to be ruled out with venous ultrasound.
Consider using age adjusted d-dimer cutoffs in low-risk patients over 50 years (Wells' "DVT Unlikely").
- Age (years) x 10 µg/L = cutoff (patients > 50 yrs)

DVT Likely: 17-53% incidence of DVT (2+ points)

Result is based on a two tier model of "DVT Unlikely" or "DVT Likely".

Guidelines appear to favor the two-tier model.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
Due to higher risk in this cohort, consider venous ultrasound testing.

Considerations

A positive ultrasound is diagnostic for DVT; strongly consider anticoagulation therapy.
A negative ultrasound in combination with a "Likely DVT" Well's criterion is still concerning for DVT. Consider repeat ultrasound within 1-week for re-evaluation.

Cannot Rule-out PE

If any criteria are positive, the PERC rule cannot be used to rule out PE in this patient.

In the context of a low-risk patient who is not PERC negative, the clinician ought to consider a d-dimer for further evaluation.
If the d-dimer is negative in the context of a low-risk patient with a pre-test probability of > 15%, then the patient does not require further testing for PE.
If the d-dimer is positive, further testing is indicated, such as a CTA.
Consider using the Wells' Criteria for risk stratification and workup guidance, or obtain a d-dimer or imaging based on risk.

No need for further workup: < 2% chance of PE

If no criteria are positive and clinician's pre-test probability is <15%, PERC Rule criteria are satisfied.

Moderate risk group: 16.2% incidence of PE in an ED population (2-6 points)

Result is based on a three tier model of low, moderate or high risk groups.

Guidelines appear to favor the two tier model of "PE Unlikely" or "PE Likely" (see below result panel) which implements only the high sensitivity d-dimer and more conservative risk stratification. However, "intermediate" risk patients may be still too high risk to be evaluated without further risk stratification.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
Consider high sensitivity d-dimer testing or CTA
- If the dimer is negative consider stopping the workup
- If the dimer is positive consider CTA

Considerations

Since the high sensitivity d-dimer has a low specificity (approximately 50%), patients who are considered high risk ought to be ruled out with CTA.
Consider using age adjusted d-dimer cutoffs in low risk patients over 50 years (rGeneva "not high" or Wells' "low").
- Age (years) x 10 µg/L = cutoff (patients > 50 yrs)

High risk group: 40.6% incidence of PE in an ED population (> 6 points)

Result is based on a three tier model of low, moderate or high risk groups.

Guidelines appear to favor the two tier model of "PE Unlikely" or "PE Likely" (see below result panel) which implements only the high sensitivity d-dimer and more conservative risk stratification. However, "intermediate" risk patients may be still too high risk to be evaluated without further risk stratification.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
Due to higher risk, consider CTA
- D-dimer testing is not recommended.

Considerations

Since the high sensitivity d-dimer has a low specificity (approximately 50%), patients who are considered high risk ought to be ruled out with CTA.

Low risk group: 1.3% incidence of PE in an ED population (< 2 points)

Result is based on a three tier model of low, moderate or high risk groups.

Guidelines appear to favor the two tier model of "PE Unlikely" or "PE Likely" (see below result panel) which implements only the high sensitivity d-dimer and more conservative risk stratification. However, "intermediate" risk patients may be still too high risk to be evaluated without further risk stratification.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
An alternative is to consider applying the PERC rule-out criteria to stop workup for PE
Consider d-dimer testing to rule out pulmonary embolism
- If the dimer is negative consider stopping the workup
- If the dimer is positive consider CTA

Considerations

Multiple d-dimer assays are available. Ensure that a proven high-sensitivity assay is available and that the test has been validated/audited.
Since the high sensitivity d-dimer has a low specificity (approximately 50%), patients who are considered high risk ought to be ruled out with CTA.
Consider using age adjusted d-dimer cutoffs in low risk patients over 50 years (rGeneva "not high" or Wells' "low").
- Age (years) x 10 µg/L = cutoff (patients > 50 yrs)

PE Unlikely: 3% incidence of PE (0-4 points)

Result is based on a two tier model of "PE Unlikely" or "PE Likely".

Guidelines appear to favor the two tier model which implements only the high sensitivity d-dimer and more conservative risk stratification. However, "intermediate" risk patients may be still too high risk to be evaluated without further risk stratification.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
Consider high sensitivity d-dimer testing
- If the dimer is negative consider stopping the workup
- If the dimer is positive consider CTA

Considerations

Since the high sensitivity d-dimer has a low specificity (approximately 50%), patients who are considered high risk ought to be ruled out with CTA.
Consider using age adjusted d-dimer cutoffs in low risk patients over 50 years (rGeneva "not high" or Wells' "low").
- Age (years) x 10 µg/L = cutoff (patients > 50 yrs)

PE Likely: 28% incidence of PE (> 4 points)

Result is based on a two tier model of "PE Unlikely" or "PE Likely".

Guidelines appear to favor the two tier model which implements only the high sensitivity d-dimer and more conservative risk stratification. However, "intermediate" risk patients may be still too high risk to be evaluated without further risk stratification.

Management

The original intent of the Well's score was to determine who was low risk enough to rule out testing with a d-dimer.
Due to higher risk, consider CTA testing.

Considerations

Since the high sensitivity d-dimer has a low specificity (approximately 50%), patients who are considered high risk ought to be ruled out with CTA.
Consider using age adjusted d-dimer cutoffs in low risk patients over 50 years (rGeneva "not high" or Wells' "low").
- Age (years) x 10 µg/L = cutoff (patients > 50 yrs)

Literature

2021 Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report — Stevens S, Woller S, Baumann Kreuziger L, et al.
2022 ESC guidelines on the diagnosis and management of acute deep vein thrombosis — Mazzolai L, Ageno W, Altari A, et al.
2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) — Konstantinides S, Meyer G, Becattini C, et al.
2020 ASH VTE Guidelines: Treatment of Deep Vein Thrombosis and Pulmonary Embolism — Ortel T, Neumann I, Ageno W, et al.
NCCN Guidelines Version 1.2025 Cancer-Associated Venous Thromboembolic Disease — National Comprehensive Cancer Network
Use of direct oral anticoagulants in patients with obesity for treatment and prevention of venous thromboembolism: Updated communication from the ISTH SSC Subcommittee on Control of Anticoagulation — Martin K, Beyer‐Westendorf J, Davidson B, et al.
Submassive Pulmonary Embolism - Circulation Cardiovascular Case Series from the American Heart Association (AHA) — Clark D, McGiffin D, Dell'Italia L, and Ahmed M
Submassive Pulmonary Embolism - American Journal of Respiratory and Critical Care Medicine — Rali P and Criner G

Provided by OSU Center for Health Sciences
Primary Contributor Kelly Rudd, PharmD, BCPS, CACP, FCCP Clinical Associate Professor of Medicine, Oklahoma State University Center for Health Sciences
Contributor Gershon Koshy
Reviewed by Kelly Rudd, PharmD, BCPS, CACP, FCCP Clinical Associate Professor of Medicine, Oklahoma State University Center for Health Sciences Reviewed August 10, 2026

All questions & possible results

Literature

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