Postgrad Med J: first published as 10.1136/pgmj.70.824.455 on 1 June 1994. Downloaded from

Postgrad Med J (1994) 70, 455 - 456 © The Fellowship of Postgraduate Medicine, 1994 Cardiac tamponade after thrombolysis T.D. Heymann and W. Culling Department ofMedicine, Kingston Hospital, Kingston upon Thames, Surrey KT2 7QB, UK

Summary: Thrombolysis has been very effective in reducing the morbidity and mortality from acute myocardial infarction. Serious adverse events are not uncommon, however. We describe a case in which a haemopericardium and tamponadedeveloped in a patient with a history ofrecurrent idiopathicpericarditis and to whom streptokinase had been administered following a suspected myocardial infarction. The case highlights the need for caution in the administration of thrombolytics to patients with a documented history of pericarditis.

Introduction Thrombolysis is the treatment of choice in acute On the following morning the patient's pain myocardial infarction although serious adverse became much more severe. She was dyspnoeic and effects are well recognized and not uncommon.' nauseated. Though examination revealed no objec- Cerebrovascular accidents and gastrointestinal tive deterioration in the patient's clinical state her bleeding are the commoner life-threatening prob- electrocardiogram revealed new T wave inversion lems described. Little attention has been paid to in the anterior leads. Concerned that she was another potentially fatal haemorrhagic complica- suffering a myocardial infarction, streptokinase tion, that of cardiac tamponade. We report a case was administered. Two hours later the patient of tamponade following the administration of became hypotensive. She had a tachycardia, an streptokinase to a patient presenting with severe elevated jugular venous pressure and quiet heart central chest pain. sounds. Urgent echocardiography was arranged. A large pericardial effusion was demonstrated and the diagnosis ofcardiac tamponade made. Pericar- Case report diocentesis with the drainage of several litres of

haemorrhagic fluid followed. http://pmj.bmj.com/ A 42 year old woman with an established diagnosis With the correction ofher streptokinase-induced of recurrent idiopathic pericarditis presented with clotting disorder the patient made a steady com- further central chest pain one week after the plete recovery. Cardiac enzyme assay results that withdrawal of non-steroidal anti-inflammatory were later available demonstrated no sequential drugs. On this occasion the patient's pain was rise suggesting that no ischaemic damage had in reported as significantly more severe than during fact occurred. any previous episode. Radiation of the pain to the The patient's electrocardiogram has since left shoulder was described. returned to normal. The patient herself remains on October 2, 2021 by guest. Protected copyright. Clinical examination was unremarkable. No well on a low dose of prednisolone. pericardial rub was audible. Electrocardiography recorded a sinus tachycardia at a rate of 100 beats per minute with widespread concave ST segment Discussion elevation. Chest X-ray showed a heart of normal size and contour with clear lung fields. A small Of the haemorrhagic complications of throm- pericardial effusion was demonstrated by echocar- bolysis for acute myocardial infarction, cere- diography. brovascular and gastrointestinal problems feature A presumptive diagnosis of recurrence of most strongly in the literature.' Only recently have pericarditis was made and the patient admitted studies focused on the problem of pericardial for observation. Non-steroidal anti-inflammatory effusion. One author reported that pericardial drugs were reintroduced. A cardiac enzyme series effusion as a side effect of thrombolysis per se is was ordered. very rare and possibly no greater than that due to the process of infarction itself.2 In another series Correspondence: T.D. Heymann, M.A., M.R.C.P., 75 approximately 1% of patients treated with throm- Colwith Road, London W6 9EZ, UK. bolytics for acute myocardial infarction suffered Accepted: 1 November 1993 from haemorrhagic effusions significant enough to Postgrad Med J: first published as 10.1136/pgmj.70.824.455 on 1 June 1994. Downloaded from

456 CLINICAL REPORTS require pericardiocentesis. Those patients with bolysis can be exacerbated in the presence of large anterior myocardial infarcts and throm- pre-existing pericardial disease. We suggest that a bolysed early appeared to be at greatest risk.3 Even recent history of pericarditis may be a contra- in the absence of coronary disease patients may be indication to thrombolysis. If the differential diag- at risk of developing life-threatening effusions if nosis includes pericarditis then thrombolysis given thrombolytic drugs.4 should only proceed with caution. A high level of Our case highlights how the dangers of throm- suspicion for tamponade should be exercised.

References 1. ISIS 2, Second International Study of Infarct Survival: Col- 3. Renkin, J., de Bruyne, B., Benit, E., Joris, J.M., Carlier, M. & laborative Group. Randomised trial of intravenous strep- Col, J. Cardiac tamponade early after thrombolysis for acute tokinase, oral aspirin, both or neither among 17,187 cases of myocardial infarction: a rare but not reported haemorrhagic suspected myocardial infarction. Lancet 1988, ii: 349-360. complication. J Am Coil Cardiol 1991, 17: 280-285. 2. Belkin, R.N., Mark, D.B., Aronson, L., Szwed, H., Califf, 4. Blankenship, J.C. & Almquist, A.K. Cardiovascular complica- R.M. & Kisslo, J. Pericardial effusion after intravenous tions of thrombolytic therapy in patients with a mistaken recombinant tissue type plasminogen activator for acute diagnosis of acute myocardial infarction. J Am Coil Cardiol myocardial infarction. Am J Cardiol 1991, 67: 496-500. 1989, 14: 1579-1582. http://pmj.bmj.com/ on October 2, 2021 by guest. Protected copyright.