TICAGRELOR INDUCED DIFFUSE ALVEOLAR HEMORRHAGE AFTER PCI INTERVENTION
H Sajjad, MD, R Chan, MD, R Panicker, MD, S Shahid, MD, WD Brown, MD, M Fashho, MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA
INTRODUCTION Diffuse alveolar hemorrhage (DAH) is a medical emergency that must be immediately recognized and treated. DAH is characterized by bilateral pulmonary infiltrates, hypoxia, hemoptysis, and/or falling blood count. Treatment ranges from supportive measures, to withdrawal of offending agents, steroid administration, plasmapheresis, and/or direct immunosuppression. CASE A 56 -year-old woman with a history of hypertension, hyperlipidemia, diabetes, and tobacco abuse presented with one- week of episodic, sharp, pressure-like, substernal chest pain that worsened with activity. EKG at admission revealed sinus tachycardia with ST elevations in the infero-lateral leads and elevated troponin-I. She was given Aspirin, started on a heparin drip, and underwent emergent percutaneous coronary intervention with a drug eluding stent to the right coronary artery and the circumflex artery. Post-procedure she was bolused with tirofiban, loaded with ticagrelor, and transferred to the intensive care unit. The following day she was started on dual antiplatelet therapy (DAPT) with Aspirin and Brilinta, Lopressor, and Atorvastatin. Overnight she developed dyspnea and hemoptysis. CT Angiography revealed diffuse bilateral infiltrates. Labs revealed hyponatremia, elevated BNP, and hemoglobin decrease from 13.5 to 11.5. She became febrile, tachycardic, and tachypneic with leukocytosis. Broad spectrum antibiotics were started. Chest x-ray revealed worsening bilateral opacities concerning for DAH. Brilinta was immediately discontinued and replaced with Plavix. Exam was significant for bilateral rhonchi and coarse breath sounds. Ultimately, she was intubated for acute hypoxemic respiratory failure, DAPT was discontinued, and methylprednisolone administered. She was extubated after a bronchoalveolar lavage, which revealed blood-tinged aspirate without signs of active bleeding. Aspirin and Plavix were restarted once her hemoptysis resolved. Her dyspnea improved and she was discharged home with oxygen. She is awaiting pulmonology and cardiology follow-up. DISCUSSION This case highlights the need for immediate recognition of Ticagrelor induced DAH and discontinuation of therapy in preventing life threatening progression to acute hypoxic respiratory failure.
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