THE DANGER OF DUAL ANTIPLATELET THERAPY IN A PATIENT WITH ACUTE EFFUSIVE CONSTRICTIVE PERICARDITIS WHO WAS SUBJECTED TO STENTING.

Background: Patients admitted with chest pain and electrocardiographic (ECG) changes have more than one possibility. Wrong diagnosis and management can lead to complications up to death. Case presentation: A 55 year male presented with severe chest pain. ECG revealed raised ST segment in inferior leads. The PR segment depression of pericarditis was overlooked. The patient was admitted, received loading doses of dual antiplatelet (DAP) (ASA 300 mg & Clopidogrel 300 mg) plus heparin. Clinical findings: Exam: B.P.: 110/70, T. 37 ˚C. Normal jugular venous pulse (JVP). Heart: Normal. Echo revealed no regional wall motion abnormalities and no pericardial effusion. CKMB = -ve, Troponin Zero. Diagnostic assessments: Coronary angio revealed 95% lesion in proximal RCA segment (Figure). Therapeutic interventions: Primary stenting was done. He was still complaining of the chest pain; 3 days later pericardial Rub was heard. ECHO revealed Large Pericardial effusion with no signs of tamponade. Ibuprofen (400 mg t.i.d.) + DAP with stomach protection. Follow-up and outcomes: Three weeks later the patient was complaining of dyspnea grade III, no cyanosis. Cardio-thoracic surgery was consulted for open pericardiocentesis; 12 hours later, the patient's dyspnea became Grade IV, his blood pressure was 80/50 mmHg with pulsus paradoxus, RR= 40 cycles/min. The patient became anuric. Lab: INR = 2.5, K = 6.9 mmol/L, BUN = 87 mg/dl, then 110, Cr = 3.5 mg/dl, then 5. SGOT= 1023, SGPT= 501. One session of hemodialysis was done. Patient arrested before open pericardiocentesis was done. Conclusions: Acute pericarditis if subjected to dual antiplatelet therapy can lead to hemorrhagic pericardial effusion, then constrictive pericarditis and congestive heart failure.