The Significance Of Plasma D-dimer For Extended Anticoagulation In Elderly Patients With Hip Fracture After Discharge

Objective: To study the guidance significance of plasma D-dimer extension anticoagulation in elderly patients with hip fracture after discharge.Methods: The data of elderly patients with hip fracture admitted to the Third Hospital of Hebei Medical University from Jan 2016 to Nov 2020 were retrospectively analyzed.355 patients met the inclusion criteria,including 107 males and 248 females,aged 79.0(12.0)years(65-102 years),179 cases(50.4%)with femoral neck fracture,159 cases(44.8%)with intertrochanteric fracture and 17 cases with subtrochanteric fracture(4.8%).All patients were detected plasma D-dimer concentration on admission,before operation and 35 days after operation;Color Doppler ultrasound examination of lower extremity deep vein was performed on admission,before operation,before discharge and 35 days after operation(in addition,color Doppler ultrasound of lower extremity deep vein was reexamined on 15 days after discharge in patients with DVT at discharge),According to the results of plasma D-dimer,color Doppler ultrasound of lower extremity deep vein and symptoms and signs,the anticoagulant strategy was formulated.For patients with positive D-dimer and fresh DVT,rivaroxaban 10 mg/day was given.For proximal DVT,inferior vena cava(IVC)filter was given,If D-dimer was positive and DVT disappeared,rivaroxaban 10 mg/d was given every 2 weeks until D-dimer was negative.All patients were followed up until 3 months after operation.Results: In this study,the plasma D-dimer concentrations at admission,before operation and 35 days after operation were 2.73(3.41),1.31(1.86),0.49(0.55)mg/L,respectively.The level of D-dimer at 35 days after operation was significantly lower than that at admission and before operation(P <0.001);The number of DVT cases detected by color Doppler ultrasound at admission,before operation and before discharge were 105 cases,126 cases and 191 cases respectively,most of which were distal DVT.At 35 days after operation,91 cases(25.6%)were D-dimer positive while 264 cases(74.3%)negative,and 148 cases(41.6%)had DVT while 207 cases(58.3%)had no DVT,including:(1)171 patients(48.2%)with negative D-dimer and no DVT,and there was no DVT recurrence 3 months after operation.(2)36 patients(10.1%)had positive D-dimer and no DVT.2 patients with recurrent proximal DVT were given IVC filter implantation plus rivaroxaban 10 mg oral 2/day.During the reexamination every 2 weeks,the DVT disappeared and D-dimer turned negative at 3 months after operation.(3)92 patients(25.9%)with negative D-dimer and DVT were all distal and asymptomatic old DVT.All patients were given Graduated compression stockings(GCS)and encouraged to go to the ground.Reexamination to 3 months after surgery,only 55 cases of DVT disappeared in this group,while the remaining 37 cases had no significant changes,but no DVT recurrence.(4)35 days after surgery,56patients(15.8%)with positive D-dimer and DVT were given rivaroxaban10 mg 2/day,and 3 of them underwent retractable IVC filter implantation,which were taken out 14 days after IVC filter implantation and reexamined every 2 weeks until D-dimer was negative.All the 56 patients in this group were negative for D-dimer 3 months after surgery.DVT disappeared in 44 patients,and the remaining 12 patients had distal,asymptomatic,old DVT,and no DVT recurrence.In this study,there was a significant difference in D-dimer concentration between patients with DVT and no DVT 35 days after operation(P < 0.001).The area under ROC curve(AUG)was only 0.665 after operation,which was slightly higher than that before operation(Aug = 0.538),but the diagnostic accuracy of DVT was still low,so the value of plasma D-dimer 35 days after operation was still limited for the diagnosis of DVT.Conclusions: Extended anticoagulation and continuous monitoring of plasma D-dimer are very important for elderly patients with hip fracture after discharge.For patients with DVT at discharge,negative plasma D-dimer is a sign of termination of anticoagulation;for patients without DVT at discharge,it is reasonable to extend anticoagulation 35 days after operation.