Case Analysis Of D-Dimer Increased In8Venous Thromboembolism Patients Post Anticoagulation Treatment

Objective: Study the cause of D-dimer increased in the anticoagulation posttreatmentpatients in venous thromboembolism. Explore further therapeutic schedule andexperience.Method: In1778case of venous thromboembolism patients of The First Hospital ofDalian Medical Univercity from April2007to February2014. There are8patientsD-dimer level increased after the anticoagulation therapy or D-dimer level increaserepeatedly during the anticoagulation therapy. Which have no anticoagulantcontraindications with acute pulmonary embolism patients. We gave the continousintravenous heparin pumping or low molecular weight heparin associate with warfarinto those8patients.Results:1、NO3cases with VTE History, and3cases was diagnosed PTE in other hospital3month ago using urokinase thrombolysis then sequential oral warfarin, but no monitorINR during the treatment (repeatedly use antibiotics for infection); case NO.5diagnosedas PTE one and half months ago, did not regular use oral warfarin and monitoring INR;case NO.8,1year history of PTE, regular anticoagulantion treatment of warfarin for7months then stop.2、Anticoagulant therapy:8patients with VTE use ordinary heparin/low molecularheparin and then sequential oral warfarin as the anticoagulant therapy. Case NO.2cannot except the possibility of malignant tumors so no warfarin during the wholetherapy, but pumping in heparin then switch to0.6ml low molecular heparinsubcutaneous injection,2times a day; case NO.6use0.4ml low molecular heparin2times a day then oral sequential warfarin; The remaining6cases starting withintravenous heparin pumping. Adjust the ordinary heparin application based on APTTuntil the APTT achieve normal levels1.5-2.5times which is35.5-75.5seconds, then after1-3days start to add in warfarin with the starting amount of2.5-5mg, heparin andoverlapping warfarin at least3to5days, monitor INR and keep it between2.0to3.0.3、monitoring coagulation indexes and D-dimer during the treatment.3.1Case NO.3after10days anticoagulation treatment, D-dimer decreased and APTTis betweent37.6-59.8seconds at the same time. At the11th day, we stop using ordinaryheparin,then D-dimer abnormally elevated (42160ug/L); The rest of7cases are inanticoagulation therapy, plasma D-dimer rise or no sign of decline, especially in the no.1and no.8cases, APTT standards even extend (>150seconds) and D-dimer continuesto rise.7cases with sequential warfarin therapy, INR reach the normal level whichbetween2.0to3.0.3.2Fibrinogen (Fib): Case no.1in anticoagulation terapy after3days to2weeks, Fibprogressive decline, a minimum of0.306g/L, the APTT was normal, D-dimer tends tobe increased. no.4, no.6, and no.7patients’ Fib is higher than normal.6cases Fib>7.5g/L.4、Subsequent treatment and disease outcomes: Case no.1, anticoagulant treatmentassociate with temporary vena cava filter placement at the first day, increase the dose ofheparin to2times, at the same time plasma transfusion to supplement clotting factors.Case no.3use heparin and warfarin for3days, the stop the heparin. D-dimerabnormally rise, consider possible warfarin is invalid, continue to add with heparin thenD-dimer began to fall. Case no.8got fever during hospitalization, routine bloodneutrophils in higher proportion (86.21%) appeared after platelets (68x109/L), at thesame time D-dimer is high (up to49680ug/L), consider thrombosis secondaryfibrinolytic hyperthyroidism, larger area blood coagulation factor and plateletconsumption, inadequate infection caused by factors such as anticoagulant, increase thedose of heparin for1-2times, at the same time plasma transfusion to supplementaryclotting factors and resistance to infection, symptomatic treatment. Case no.5useheparin associate warfarin4days the INR reach the normal level (2.46), then stop usingheparin and monitoring the D-dimer level increase slowly, so at day9we add in lowmolecular heparin0.6ml,2times a day, D dimer decreased.The rest of the four patienta s after standard anticoagulation dyspnea, chest pain and blood in phlegm and othersymptoms are improved or ease. Case no.2has the anti dsDNA antibody positive, andmay be have connective tissue diseases, which may cause D-dimer level abnormal.Case No.4and no.6got fever, cough, yellow sputum during hospitalization, routineblood leukocyte counts and neutral grain than up, prompt infection, add antibiotics inthe treatment.Conclusion:1、During the anticoagulation process of VTE, simply monitoring APTT or INR doesn’tmean the anticoagulant effective.2、 D-dimer abnormaly increase while APTT level is normal, does not meansanticoagulant drugs adequate or excessive. But it suggest the possibility of unsefficientof anticoagulation.