Hemorrhagic Pericarditis as a Complication of Combined Thrombolytic, Antiplatelet and Anticoagulant Treatment

A 61year old man on chronic aspirin treatment with unstable angina was admitted to our hospital to undergo programmed percutaneous coronary artery angioplasty. A balloon angioplasty (with a 3.5 mm diameter balloon) to a type B lesion in the proximal LAD was performed, and a stent (4.0 x 16mm stent) was implanted because of a dissection producing acute vessel occlusion. During the procedure 5000 IU of heparin was administered as a bolus. However, after the stent placement, haziness and a slow flow distally to the lesion was observed, TIMI scale 1 to 2, suggestive of coronary thrombus, and a bolus of 0.25 mg/kg body weight of the glycoprotein IIb/IIIa antagonist abciximab was given followed by infusion of 10 Ìg/min. Unfortunately, a short time later the chest pain recurred with concomitant ST elevation in all precordial leads. An anteriorlateral myocardial infarction evolved, and at that time thrombolytic treatment with a total of 10 U of reteplase was administered intravenously. Reteplase was administered as 2 boluses, 5+5 IU, with half an hour interval in between. The pain abated and the patient remained stable for 4 hours after which he became hypotensive and developed shortness of breath. The clinical manifestations of jugular veins distension, hypotension and pulsus paradoxus were strongly suggestive of cardiac tamponade (Fig. 1). This was further confirmed by cardiac echocardiography that revealed a large pericardial effusion surrounding the right and left ventricles and the right and left atria. Diastolic compression of the right ventricle and right atrium and severe hypokinesia of the apical part of the interventricular septum and the cardiac apex were present. Careful examination of the heart, especially in the severely hypokinetic segments of the apex, showed no evidence of cardiac rupture. A