Korean Circ J.  2013 Jul;43(7):497-499. 10.4070/kcj.2013.43.7.497.

Pulmonary Alveolar Hemorrhage after Clopidogrel Use for ST Elevation Myocardial Infarction

• Kim Y
• Lim J
• Lim J
• Kim S
• Jung T
• Choi W

• KMID: 2145507
• DOI: http://doi.org/10.4070/kcj.2013.43.7.497

Abstract

Combination treatment of antiplatelet drugs containing aspirin and clopidogrel reduces systemic ischemic events after percutaneous coronary intervention (PCI) in high risk patients. However, this combination treatment of antiplatelet drugs is associated with increased risk of nonfatal and fatal bleeding. Diffuse alveolar hemorrhage after PCI is a rare complication that has been mostly reported in association with glycoprotein IIb/IIIa inhibitors. We report the case of a 62-year-old man who presented with ST elevation myocardial infarction and suffered a diffuse alveolar hemorrhage after clopidogrel use following primary PCI.

Keyword

Hemoptysis; Antiplatelet drugs; Myocardial infarction

MeSH Terms

Aspirin
Glycoproteins
Hemoptysis
Hemorrhage
Humans
Myocardial Infarction
Percutaneous Coronary Intervention
Platelet Aggregation Inhibitors
Ticlopidine
Aspirin
Glycoproteins
Platelet Aggregation Inhibitors
Ticlopidine

Figure

• 

  Fig. 1 A: coronary angiograms show 99% stenosis of mid left anterior descending artery with large occlusive thrombus. B: coronary angiogram after stent implantation demonstrates adequate luminal diameter of mid left anterior descending artery.

• 

  Fig. 2 Chest radiographs on the third day after admission (A), after acute respiratory distress thereby showing diffuse alveolar hemorrhage on both lung field (B) and showing decreased infiltration on both lung field on the seventeenth day (C).

• 

  Fig. 3 Chest computed tomography on the sixth day after admission shows diffuse alveolar hemorrhage on both lung fields.

Reference

1. Peters RJ, Mehta SR, Fox KA, et al. Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation. 2003; 108:1682–1687.

2. Mehta SR, Tanguay JF, Eikelboom JW, et al. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet. 2010; 376:1233–1243.

3. Chae SC. Antiplatelet agents in high-risk patients with coronary artery disease. Korean Circ J. 2004; 34:23–27.

4. Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation. 2004; 110:1202–1208.

5. Hansen ML, Sørensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010; 170:1433–1441.

6. Payne DA, Hayes PD, Jones CI, Belham P, Naylor AR, Goodall AH. Combined therapy with clopidogrel and aspirin significantly increases the bleeding time through a synergistic antiplatelet action. J Vasc Surg. 2002; 35:1204–1209.

7. Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009; 54:2205–2241.

8. Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006; 114:774–782.

9. Ener RA, Bruno N, Dadourian D, et al. Alveolar hemorrhage associated with platelet glycoprotein IIb/IIIa receptor inhibitors. J Invasive Cardiol. 2006; 18:254–261.

10. Kilaru PK, Schweiger MJ, Kozman HA, Weil TR. Diffuse alveolar hemorrhage after clopidogrel use. J Invasive Cardiol. 2001; 13:535–537.

11. Ikeda M, Tanaka H, Sadamatsu K. Diffuse alveolar hemorrhage as a complication of dual antiplatelet therapy for acute coronary syndrome. Cardiovasc Revasc Med. 2011; 12:407–411.