Hemorrhagic cardiac tamponade complicating myocardial infarction in a hemodialysis patient with essential thrombocythemia: A case report

Rationale: Hemopericardium, the accumulation of blood within the pericardial sac, can lead to fatal cardiac tamponade if untreated. Its subtle presentation often obscures classic tamponade signs, complicating timely diagnosis. Essential thrombocythemia (ET), a chronic myeloproliferative neoplasm, predisposes patients to both thrombotic and hemorrhagic complications. While aspirin is effective in reducing thrombotic risks associated with ET, it can also precipitate life-threatening bleeding, such as hemorrhagic cardiac tamponade. Patient concerns: A 71-year-old hemodialysis-dependent woman with ET experienced worsening dyspnea and chest tightness 1 month after starting dual antiplatelet therapy. This therapy was initiated immediately following a percutaneous coronary intervention for an acute non-ST elevation myocardial infarction. Diagnoses: Computed tomography revealed a massive pericardial effusion, and echocardiography confirmed cardiac tamponade. Ultrasound-guided pericardiocentesis yielded hemorrhagic fluid, establishing the diagnosis of hemorrhagic cardiac tamponade. Interventions: Pericardiocentesis resolved the effusion, but recurrent non-ST elevation myocardial infarctions and in-stent restenosis necessitated repeated balloon angioplasty. Outcomes: Discontinuation of aspirin and the addition of cilostazol to clopidogrel failed to prevent further complications. The patient later developed pulse ventricular tachycardia in the emergency department, and after her family declined cardioversion, she died. Lessons: This case exemplifies the complex challenges of managing thrombotic and hemorrhagic risks in ET patients with cardiovascular disease and renal impairment, highlighting the necessity for tailored therapeutic strategies and further research.