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Asystole Due to Spontaneous Hemopericardiac Tamponade in a Patient on Warfarin.

Hemopericardiac tamponade secondary to iatrogenic coagulopathy is extremely rare. We present a case of spontaneous cardiac tamponade secondary to warfarin therapy with supratherapeutic international standardized ratio (INR) which led to asystole. Correction of tamponade with pericardiocentesis led to return of spontaneous circulation. A 55-year-old man with hepatic cirrhosis because of alcohol abuse and untreated hepatitis C presented with acute dyspnea. He was taking warfarin for pulmonary embolism for about 3 months. His blood pressure was 118/67 mm Hg, heart rate 81, respiratory rate 18, and oxygen saturation of 96% on 3 L via nasal canula. He denied any trauma, hemoptysis, hematemesis, hematuria, hematochezia, or melena. Cardiopulmonary examination revealed normal breath sounds, regular but distant heart sounds, and no jugular venous distension. Laboratory test results were significant for elevated INR of 7.4, hemoglobin of 6.8 g/dL (baseline 10 g/dL), hematocrit of 22.2%, and platelet of 334 3109/L. Fecal occult blood and urine analysis for blood were negative. Chest imaging revealed mild cardiomegaly and was otherwise unremarkable. Computed tomography imaging ruled out abdominal or retroperitoneal bleeding but revealed bilateral pleural effusion and a large pericardial effusion (Figure 1). Bedside echocardiogram confirmed the effusion which was . 2 cm with right atrial collapse but no definite right ventricular diastolic collapse suggesting early cardiac tamponade. INR was corrected with vitamin K and fresh frozen plasma to 3.26 with plans to place a pericardial window. Although waiting for further improvement of coagulopathy, he was found unresponsive and in asystole. Advanced cardiac life support with high-quality chest compressions was initiated and he received epinephrine as per protocol. An emergent bedside pericardiocentesis with removal of 650 mL blood from pericardial sac immediately led to return of spontaneous circulation with initial rhythm of bradycardia. Postresuscitation care was performed in intensive care unit. Unfortunately, patient underwent anoxic brain damage and was transitioned to comfort care 3 weeks later. Warfarin is a commonly used oral anticoagulant. It works by blocking vitamin K epoxide reductase in the liver, which affects gamma carboxylation and hence production of vitamin K dependent clotting factors that is, factor II, VII, IX, and X.1 Effective anticoagulation is determined by the therapeutic range of INR. A supratherapeutic INR predisposes the patient to