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Bleeding heart: a case of spontaneous hemopericardium and tamponade in a hyperthyroid patient on warfarin
Muhammad Sajawal Ali1, Benjamin I Mba1, Farah Diba Ciftci1
1Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA.
Insights
Warfarin use for atrial fibrillation can lead to rare but fatal hemopericardium, especially in patients with hyperthyroidism. Prompt management is crucial, but patient refusal of treatment can have dire consequences.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- Hyperthyroidism is a risk factor for atrial fibrillation and may increase bleeding risk.
- Warfarin is a common anticoagulant for stroke prevention in atrial fibrillation.
- Hemopericardium is a rare but serious complication of warfarin therapy.
Observation:
- An 81-year-old female with hyperthyroidism-related atrial fibrillation developed hemopericardium while on warfarin.
- The patient, a Jehovah's Witness, initially refused treatment to reverse coagulopathy.
- Delayed intervention due to patient refusal and coagulopathy led to rapid deterioration and death.
Findings:
- Elevated INR, hemoglobin drop, and CT findings confirmed warfarin-induced hemopericardium.
- Hyperthyroidism likely predisposed the patient to warfarin-related bleeding.
- Only 10 previous cases of warfarin-associated hemopericardium have been reported.
Implications:
- This case highlights the critical importance of recognizing and managing warfarin-induced hemopericardium.
- Patient beliefs and refusal of treatment can significantly impact outcomes in anticoagulant-related emergencies.
- Clinicians must consider underlying conditions like hyperthyroidism when assessing bleeding risk in patients on warfarin.
Abstract:
We describe the case of an 81-year-old female, diagnosed with hyperthyroidism-related atrial fibrillation. Given her CHA2DS2VASc score of 3, she was started on warfarin for stroke prevention. One month later, she was admitted with cardiac tamponade. This tamponade was suspected to be secondary to hemopericardium, based on the elevated international normalized ratio (INR), drop in haemoglobin and the radiodensity (55 HU) of the pericardial effusion on CT. The patient was a Jehovah's witness who therefore initially refused measures for reversing coagulopathy. Given her coagulopathy and absence of imminent haemodynamic compromise, pericardiocentesis was deferred. Unfortunately, 1 day later, the patient deteriorated rapidly. By the time pericardiocentesis was performed and factor VIIa administered, the patient had already started developing multiple organ failure. She developed cardiac arrest and died 3 days after her admission. Only 10 cases of hemopericardium attributable to warfarin have previously been reported. In this report, we review the literature and also describe how hyperthyroidism most likely predisposed our patient to bleeding complications from warfarin.
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