Reactions Weekly | 2021
Clopidogrel/heparin
Abstract
Lack of efficacy: case report A 66-year-old man exhibited lack of efficacy following treatment with heparin and clopidogrel for non-bacterial thrombotic endocarditis (NBTE)[not all routes stated; dosages not stated]. The man, who had metastatic small cell lung carcinoma, chronic obstructive lung disease, chronic hepatitis-C and hypertension, presented with vomiting, nausea and hyponatraemia secondary to the paraneoplastic syndrome of inappropriate antidiuretic syndrome. Abdominal and thoracic CT scan showed a right hilar mass with lymphangitic spread to the middle and lower lobes of the right lung, hepatic metastases and obstructive lobar pneumonia. He developed acute hypoxic respiratory failure. ECG showed a new-onset atrial fibrillation with a rapid ventricular response. He was administered metoprolol and diltiazem, which resulted in achievement of sinus rhythm. Additionally, he was administered IV heparin and amiodarone, in the setting of borderline BP. Transthoracic echocardiogram revealed left ventricular diastolic dysfunction with mild mitral regurgitation. On day 6, he started receiving etoposide and carboplatin. On day 9, he developed acute pulmonary oedema requiring intubation. A repeat transthoracic echocardiogram revealed eccentric and severe mitral regurgitation. ECG revealed recurrence of atrial fibrillation without ST-segment elevation. A transoesophageal echocardiogram showed thickening of the tips of the mitral valve leaflets with multiple, small valvular vegetations and severe mitral regurgitation. Cardiac catheterisation showed 100% occlusion of the right coronary artery. He underwent an aspiration thrombectomy. Sterile vegetations associated with an underlying malignancy suggested NBTE with myocardial infarction. The findings were suggestive of thrombotic embolism due to NBTE. Aspiration thrombectomy was performed and coronary blood flow was restored. He received a 72h infusion of heparin, and dual-antiplatelet therapy with clopidogrel. However, his status failed to improve, and he remained dependent on unspecified vasopressors and ventilator respiratory support. On day 14, he was put on comfort measures. He died due to multiorgan failure following extubation.