Bleeding heart: a case of spontaneous hemopericardium and tamponade in a hyperthyroid patient 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.

Pharmacotherapeutic Management Strategies for Thyroid Disease–Induced Pericarditis

“…Hemopericardium has been reported with warfarin as well as the majority of direct oral anticoagulants used to treat atrial fibrillation. [46][47][48][49] Additionally, hyperthyroidism itself can affect the PD of warfarin, causing an increase in the INR, potentially increasing the risk for bleeding and, subsequently, hemopericardium. 49,50 Less is known regarding thyroid disease and its effect on the direct oral anticoagulants, which prompts some clinicians to use warfarin because of the ability to control for the drug-drug interaction.…”