Between Scylla and Charybdis: thromboembolic risk versus hemorrhagic risk

Introduction: Pathologies implying thromboembolic risk always need the evaluation of haemorrhagic complications’ probability. In patients with atrial fibrillati-on, stroke risk is estimated by CHA2DS2-VASc score, while the haemorrhagic risk is evaluated using the HAS-BLED score.
Case presentation: We are presentig the case of a pa-tient in which the associated pathologies amplified not only the thromboembolic risk, but also the hemorrha-gic one, making the therapeutic decision very difficult and unable to fit the current guidelines.
A 80 years old patient, with permanent atrial fibrilla-tion, under acenocumarol treatment (overdosed), presented to the emergency department with clinical signs and symptoms of acute heart failure, with impor-tant right pleural effusion, in the context of malignant hypertension. She also associates type 2 diabetes melli-tus, hypertension (poorly controlled by her medicati-on) and dyslipidemia. The ECG confirmed the atrial fibrillation with high ventricular rate (140 bpm) witho-ut repolarisation abnormalities. The echocardiography revealed mild systolic dysfunction (EF=40%) and mo-derate degenerative mitral valve regurgitation. She re-cieved conventional heart failure treatment and aceno-cumarol was stopped until INR values decreased under 2, in order to perform thoracocentesis. The evacuatory right thoraconentesis revealed hemorhhagic pleural fluid so we decided to investigate it by chest compu-ted tomography, that confirmed the hematic density of the pleural effusion, but it also showed type A aortic haematoma extended from the ascendent segment to the distal descending aorta and a serohaematic collec-tion in the anterior mediastinum, findings that impo-sed emergency surgical intervention. The surgical risk of the patient (EuroSCORE II=23%) and her refusal to undergo the procedure lead to conservatory treatment and cessation of the anticoagulant therapy. The initi-al evolution of the patient was favorable with optimal control of the heart rate and blood pressure values, but 10 days after the admission, she developed dyspneea. We repeated the chest computed tomography, that re-vealed stationary dimensions of the aortic haematoma, but also showed right pulmonary thromboembolism, that according to biomarkers and echocardioraphy findings was classified as intermediary-high risk pul-monary embolism. At this point, we had two indica-tions for the anticoagulant treatment, but considering the high risk for aortic rupture, we still decided against it, opting for aggresive antihypertensive treatment.12 month after discharge, the patient is clinically stable and free of thromboembolic events.
Conclusions: T he therapeutic decision in cases that associate indications but also contraindications for anticoagulant treatment is difficult to manage, especially when the hermorrhagic risk can’t be out ruled by an adequate intervention. It can be taken into considerati-on the utility of implanting an inferior vena cava filter in these patients or perform other procedures able to reduce the thromboembolic risk associated with atrial fibrillation.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)