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© 2003 European Association of Cardio-Thoracic Surgery
Long-term ibuprofen overdose may exacerbate the risk for acute hemorrhagic pericardial tamponade during myocardial infarction
a Department of Cardiothoracic Surgery, Tampere University Hospital, Tampere, Finland
* Corresponding author. Tel.: +358-3-2474945; fax: +358-3-247-5756 Received February 24, 2003; received in revised form April 17, 2003; accepted April 18, 2003
Pericardial tamponade is a feared, though rare complication during myocardial infarction. We present a case of an unusual hemorrhagic appearance of pericardial fluid accumulation during ibuprofen overdose and myocardial infarction.
Key Words: Hemorrhagic tamponade; Myocardial infarction; Ibuprofen
Pericardial tamponade presents a challenge for emergency intervention. It often requires prompt interventional treatment such as subxifoideal pericardiotomy for the relief of proper heart function. However, pericardial tamponade is usually a consequence of an acute emergency, such as trauma [1], dissection or rupture of the ascending aorta [2], after open heart surgery [3] or occasionally, after myocardial infarction and ventricular free wall rupture [4]. Therefore, pericardial tamponade, together with its etiology, is preferably treated at the operating room, whenever possible. Idiopathic pericardial effusion leads rarely to pericardial tamponade, and effusion [5] or myocarditis [6] may occasionally be caused by treatment itself, such as mesalasine, a 5-ASA drug. Immune response to ongoing cardiac inflammation has also been suspected to cause pericardial effusion [7]. Our case presents a patient, who acutely developed symptoms of pericardial tamponade. As ascending aorta dissection and rupture was suspected, the patient was immediately transferred to the nearest university hospital for cardiopulmonary bypass facilities.
A previously healthy, though slightly demented 73-year-old man collapsed without any physical stress at his home. The patient was admitted to his district hospital for initial care. According to relatives, only ibuprofen medication (1.8 g daily) was recommended to the patient for occasional pain of knee arthrosis.
Transthoracic ultrasound study was carried on and acute ascending aorta dissection with pericardial fluid accumulation was suspected. As the assumed diagnosis required cardiopulmonary bypass and thoracic surgery for final treatment, the patient was immediately transferred to the nearest university hospital, where such facilities were available. Computer tomography (CT) study showed only significant pericardial tamponade, suggesting intact ascending aorta and heart, and later, chronic left renal artery dissection without free vessel rupture. However, ascending aorta dissection was not ruled out by the negative CT study. Meanwhile, the patient developed classical symptoms of acute pericardial tamponade; though the patient remained conscious, grave hypotension, dyspnea and cyanosis progressed. Jugular venous distension was apparent. Auscultation revealed friction rub, but no other additional heart sounds. Metabolic acidosis (pH 7.27), mild thrombocytopenia ( As definite diagnosis was unclear and acute pericardial tamponade developed promptly, it was feared that pericardial fluid relief by subxiphoideal needle puncture and catheter drainage would not suffice. Yet, It was possible to transfer the patient instantly to a vacant operating room, which was situated close to the emergency department. Sternotomy was performed together with transesophageal echography (TEE). Hemorrhagic pericardial fluid (1300 ml) was evacuated, but no pathological reason for fluid accumulation was found despite meticulous inspection; heart and ascending aorta were intact, though only mild hemorrhagic left atrial wall was present. Clinical status improved immediately after relief of cardiac function. The patient experienced mild elevation of troponin (8.9 µg/l), creatinine kinase (413 U/l) and creatinine kinase MB (70 U/l) enzymes, which declined towards normal values during follow-up period of 4 days. ECG-changes normalized, though minimal depression of the ST-segments remained 4 days after the operation. An ultrasound study was subsequently performed, but after ibuprofen withdrawal, pericardial fluid remained minimal. The aging patient suffered from some degree of amnesia, though his acute distress subsided. As for this patient it was clinically interpreted that the sternotomy wound need to heal completely before further procedures could be accomplished, planned angiographic evaluation was rejected for the present. According to patient's wishes, close follow-up was continued in his district hospital.
The patient presumably suffered an episode of myocardial infarction, as detected by elevated troponin and creatinine kinase values, together with ECG changes. These findings were rather mild compared to the comparable clinical manifestation of hemorrhagic pericardial tamponade, which depressed myocardial function. Therefore, rupture of ventricular free wall was suspected, as its clinical representation can be highly variable [4]. However, during surgery such a myocardial defect was not present, and it was assumed that a concealed cardiac rupture might have been present, as described by van Mantgem and Becker in 1976 [8]. As no other reasons for pericardial tamponade remained after thorough ultrasonic, CT, TEE and surgical evaluations, more and more emphasis was laid on ibuprofen overdose. Unintentional overdose is rather common in non-prescribed medication [9]. In our case, specified anamnesis was given by the patient's relatives, who assured that ibuprofen use was, indeed, ‘handful quantities’ daily. Unfortunately, distances in our country for patient transfer from the central hospital to the university hospital are long, and time was wasted; ibuprofen drug measurement would have been too late, as the metabolic half-time of ibuprofen is short. However, hypokalemia, metabolic acidosis and thrombocytopenia have been reported as side effects of aspirin abuse. Metabolic acidosis and mild thrombocytopenia were present in our case, and therefore it is tempting to speculate whether these findings were also related to ibuprofen poisoning. Ibuprofen poisoning may be related to various complications, such as metabolic acidosis, hypotension and central nervous system depression [10]. Side effects of ibuprofen include induction of exocrine liver dysfunction, thrombocytopenia and a higher incidence of occult bleeding [11]. Drugs containing 5-aminosalicylic acid have been implicated as the cause of pericarditis in inflammatory bowel disease [5]. To our current knowledge, neither anti-inflammatory drug nor ibuprofen-related hemorrhagic pericardial tamponade has been mentioned in previous reports. However, after open heart surgery, antithrombotic agents may enhance pericardial effusion [3]. Because of its known antithrombonemic effect, e.g. aspirin would be expected to facilitate intrapericardial hemorrhage and consequently, pericardial tamponade [3]. Nevertheless, though evidence is not available, aspirin is suggested as a treatment against pericardial effusion to prevent pericardial adhesion formation [3]. We emphasize patient education during ibuprofen use, and suspect its overdose as a provocative factor for hemorrhagic pericardial tamponade during myocardial infarction and concealed cardiac rupture. doi:10.1016/S1569-9293(03)00082-3
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Abstract
1. Introduction
) and high lactate (9.2 mmol/l) values were present. Electrocardiography (ECG) revealed profound anterolateral and inferior ST-segment drops, together with its elevation on lead 1.