Case Report

A 64-year-old Caucasian female, presents to the clinic with exertional dyspnea and peripheral edema. Her past medical history includes essential hypertension, hyperlipidemia, type II diabetes mellitus, and coronary artery disease status post percutaneous coronary intervention with stent placement. The echocardiogram shows a dilated right ventricle. Right heart catheterisation revealed a mean pulmonary artery pressure (mPAP) of 41 mmHg. She used to take statins for her hyperlipidemia, which she discontinued after improvement.

What’s wrong?
Dyspnea, oedema and RV dilation point to right heart failure and mPAP > 20 mmHg at rest suggests pulmonary arterial hypertension. These findings point to chronic cor pulmonale; long-term right heart disease due to pulmonary cause. Simply put, due to various reasons, pulmonary blood flow becomes harder (or the vascular resistance is higher), which forces the right ventricle to pump harder, causing hypertrophy and in the long run, dilation.

How can PAH be treated?

(Some early years reading might ask: hold on…why are we talking about treating PAH when the diagnosis was chronic cor pulmonale? Because PAH is what caused the cor pulmonale, so treating PAH is the same as treating cor pulmonale.)
In our case, the woman was found to have idiopathic (no specific cause identifiable) PAH. Therefore she was started on the following drugs
- Treprostinil, a prostacyclin analogue. Prostacyclin is a vasodilator and inhibits platelet activation.
- clopidogrel 75 mg daily
- warfarin 3 mg daily.

Image from: Kawabe, J., Ushikubi, F., & Hasebe, N. (2010). Prostacyclin in vascular diseases. - Recent insights and future perspectives -. Circulation journal : official journal of the Japanese Circulation Society, 74 5, 836-43.

The last 2 drugs are all anti-clotting drugs, each playing a different role. Clopidogrel inhibits platelet activation and warfarin inhibits vitamin K-dependent activation of clotting factors. Review the previous article for a more basic discussion.

And she lived happily ever after…except, she came back one fine day, with new onset confusion, without any trauma. She was sent for a CT, the findings are below

What drug(s) should be discontinued? And why?
As the CT scan shows an acute subdural hematoma, clopidogrel and warfarin should be discontinued to decrease the risk of further bleeding. As a tip, if anti-clot medication is taken, and the patient presents with confusion, intracranial bleeding should be suspected.

She was continued on treprostinil for treatment of her pulmonary hypertension. She had no residual neurological deficits as a result of her bleed.

References:

Louis L, Bair N, Banjac S, Dweik RA, Tonelli AR. Subdural hematomas in pulmonary arterial hypertension patients treated with prostacyclin analogs [corrected]. Pulm Circ. 2012 Oct;2(4):518-21. doi: 10.4103/2045-8932.105041. Erratum in: Pulm Circ. 2013 Jan;3(1):I. PMID: 23372937; PMCID: PMC3555423.

AMBOSS