Cardiac Tamponade Risk Associated With Anticoagulation for Atrial Fibrillation in Dialysis-Associated Pericarditis: A Case Report

Abstract

Heparin is a preferred initial anticoagulant in patients with new-onset atrial fibrillation (AF). Despite continuous debate about the risk, there has been a concern about heparin-induced hemorrhagic pericarditis and cardiac tamponade. We present a case of a new onset atrial fibrillation (AF) in a patient with renal impairment and evidence of pericardial effusion complicated by hemopericardium development after starting anticoagulation. Although the risk of hemorrhagic conversion of uremic pericarditis induced by heparin in ESRD patients with new onset AF was suggested in the literature, this case raises the possibility of a similar complication in dialysis-associated pericarditis. Therefore, we aim to heighten alertness regarding this potential complication of a commonly used medication in clinical practice. We also aim to review the current anticoagulation recommendations in this setting.

Uremic Pericarditis with Cardiac Tamponade in a Patient on Hemodialysis

“…We presented a patient with ESRD on maintenance dialysis complicated with pericarditis and cardiac tamponade requiring pericardiocentesis. The prevalence of pericarditis in patients with ESRD varies from 2% to 21% [ 2 , 4 ]. Dialysis-induced pericarditis has been reported in patients of varied age groups ranging from 50 to 90 years of age [ 4 , 5 ] like our patient.…”

“…The prevalence of pericarditis in patients with ESRD varies from 2% to 21% [ 2 , 4 ]. Dialysis-induced pericarditis has been reported in patients of varied age groups ranging from 50 to 90 years of age [ 4 , 5 ] like our patient.…”

“…Clinical presentation in dialysis-associated pericarditis is nonspecific with dyspnea, abdominal pain, hypoxemia, and occasionally fever or chest pain being reported; laboratory abnormalities are usually related to the renal disease [ 4 , 5 , 8 ]. Findings of leukocytosis, hypocalcemia, transaminitis, and elevated lactic acid, as observed in our patient, are relatively uncommon and not specific [ 4 , 5 , 8 ]. Chest imaging often shows cardiomegaly and pulmonary congestion patterns which suggest cardiac dysfunction [ 2 – 5 , 11 , 12 ].…”

“…Diagnosis requires a high index of suspicion; echocardiogram is an excellent diagnostic tool for pericardial effusion or tamponade in general. Echocardiogram could show dilated inferior vena cava, diastolic dysfunction, right ventricular collapse, and accumulation of fluid [ 4 , 5 ].…”

“…Trials of anti-inflammatory medications have been reported to be beneficial [ 9 ]. However, in our patient, due to hemodynamic instability and large effusion with tamponade, pericardiocentesis is the recommendation of choice [ 4 , 9 ]. Analysis of pericardial fluid is needed to evaluate for other causes of pericardial effusion, especially infectious causes, tuberculosis, and malignancy where management will be modified.…”