Anticoagulant-induced hemopericardium with tamponade: A case report and review of the literature

Abstract

Acute cardiac tamponade requires urgent diagnosis and treatment. We report a case of a 43-year-old man who was receiving warfarin treatment for 8 months following mitral valve replacement. The patient had complaint of dyspnea and fatigue for a few days. Cardiac tamponade was diagnosed, and the INR at that time was 10.4. Urgent pericardiocentesis were undertaken and 1400 ml of peri­cardial blood was drained. Following surgery the patient\'s recovery was uneventful. An intravenous vitamin K injec­tion and fresh frozen plasma transfusion were adminis­tered to reverse the patient\'s over-anticoagulated state. The final pathology revealed chronic inflammation and there was no malignancy, and no bacteria or mycobacte­rium were seen. Emergency physicians should remember that over-anticoagulation with warfarin may contribute to certain complications, including hemopericardium, and that strict control of target INR should be the goal for pa­tients who require continuous warfarin treatment. J Clin Exp Invest 2013; 4 (2): 229-233

Keywords

• Hemopericardium, tamponade, oral antico­agulation, warfarin, echocardiography

Antikoagülasyonun indüklediği hemoperikardiyumlu tamponad: Olgu sunumu ve literatür incelemesi

Öz

Akut kardiyak tamponad acil tanı ve tedavi gerektirir. Biz 43 yaşında, erkek ve mitral valv replasmanı sonrası sekiz aydır warfarin tedavisi alan bir olguyu aldık. Hastanın bir­kaç gündir başlayan nefes darlığı ve halsizlik şikayetikleri mevcuttu. Kardiyak tamponad tanısı konuldu ve 1400 ml mai perikardiyosentezle acil olarak drene edildi. Tanı sı­rasında İNR değeri çok yüksek olan hastaya Vitamin K antagonistleri ve taze donmuş plazma verilerek yuksek koagülasyon durumu geriye döndürüldü. Patolojik incele­me sonucunda enfeksiyon ve malingnensi saptanmadı. Hastada kronik inflamasyon düşünüldü. Sonuç olarak warfarin overdoz acil bir durum olup hemoperikardiyumla tamponada yol açabilmektedir. Bunun için warfarin teda­visi başlanılan hastalarda warfarin dozu ve hedef İNR de­ğerleri sıkı kontrol edilmelidir.

Anahtar Kelimeler

• Warfarin, hemoperikardiyum, tampo­nad, İNR

Kaynakça

1. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does this patient with a pericardial effusion have cardiac tamponade? JAMA 2007;297:1810-1818.
2. Imazio M, Mayosi BM, Brucato A, et al. Triage and management of pericardial effusion J Cardiovasc Med 2002;11:928-935.
3. Hillyard RF. Delayed clinical presentation of hemor- rhagic pericardial effusion in a patient receiving warfa- rin sodium. Am J Orthop 2007;36:E144-147.
4. Granot H, Shinar E. Spontaneous anticoagulant-in- duced hemopericardium with tamponade. Acta Hae- matol 1982;68:339-340.
5. Wong PS, Pugsley WB. Raised international nor- malised ratio (INR): Is it a cause or an effect of late cardiac tamponade? Br Heart J 1992;68:212-213.
6. Lee KS, Marwick T. Hemopericardium and cardiac tam- ponade associated with warfarin therapy. Cleve Clin J Med 1993 Jul-Aug;60:336-338.
7. Jadoon E, Vafadouste R, Barrett LO. Cardiac tampon- ade caused by drug interaction: a delayed complica- tion of apical pacemaker placement. Hopsital Physi- cian 2000;12:63-64.
8. Katis PG. Atraumatic hemopericardium in a patient receiving warfarin therapy for a pulmonary embolus. Can J Emerg Med 2005;7:168-170.

9. Hong YC, Chen YG, Hsiao CT, et al. Cardiac tampon- ade secondary to haemopericardium in a patient on warfarin. Emerg Med J 2007;24:679-680.
10. Griffiths AP, Beddall A, Pegler S. Fatal haemopericar- dium and gastrointestinal haemorrhage due to pos- sible interaction of cranberry juice with warfarin J R Soc Promot Health 2008;128:324-326.
11. Fadi Braiteh, Juan Carlos. Plana Spontaneous hae- mopericardium with subacute cardiac tamponade in a patient with lung cancer receiving coumadin. Q J Med 2009;102:575.
12. Joel T. Levis, Mucio C. Delgado. Hemopericardium and cardiac tamponade in a patient with an elevated international normalized ratio. West JEM 2009;10:115
13. HA Gumrukcuoglu, M Tuncer, S Akdag, A Akyol, Y Gunes. PP-110 Hemopericardium and cardiac tam- ponade in a patient with an elevated international nor- malized ratio: Two case report. International Journal of Cardiology, Volume 140, Supplement 1, April 2010, Page S72.
14. His DH, Krishnamurthy M, Ryan GF, et al. Successful management of hemopericardium and cardiac tam- ponade secondary to occult malignancy and antico- agulation. Exp Clin Cardiol 2010;15:33-35.
15. Al-Jundi W, Rubin N. Cardiac tamponade secondary to haemopericardium in a patient on warfarin. BMJ Case Rep 2010;9;201.
16. Reed RM, Ramani GV, Hashmi S. Unraveling the paradox of cardiac tamponade: case presentation and discussion of physiology. BMJ Case Rep 2012:23;304.
17. Yared K, Baggish AL, Picard MH, Hoffmann U, Hung J. Multimodality imaging of pericardial diseases. JACC Cardiovasc Imaging 2010;3:650-60.
18. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clin Proc 2002;77:429-436.