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Fatal Spontaneous Retroperitoneal Hematoma Secondary to Enoxaparin

Kirk M. Chan-Tack, MD
Volume: 96 Issue: 1 January, 2003

Abstract:

An 83-year-old woman was transferred to our cardiac intensive care unit with an acute non-Q-wave myocardial infarction and pulmonary edema. Enoxaparin was one component of the treatment regimen used. Her hospital course was complicated by episodes of hypotension, as well as by recurrent left hip and left thigh pain. The defining event occurred when the patient became acutely hypotensive and developed abdominal distention, peritoneal signs, intense left flank pain, and a 3.3 g/dl hemoglobin decrease. Abdominal computed tomography showed a 9 × 6 × 20 cm left retroperitoneal hematoma. The hematoma was spontaneous, secondary to enoxaparin use. The patient died despite vigorous supportive care. Enoxaparin is being increasingly used in patients with acute coronary syndromes. Review of the medical literature revealed that this is the first reported case of a patient with an acute coronary syndrome who died as a result of an enoxaparin-induced, spontaneous retroperitoneal hematoma. This article reviews important clinical signs and symptoms, identifies high-risk patient populations, and discusses management strategies.

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References:

1. Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease: Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997; 337: 447–452.
 
2. Gurfinkel EP, Manos EJ, Mejail RI, et al. Low molecular weight heparin versus regular heparin or aspirin in the treatment of unstable angina and silent ischemia. J Am Coll Cardiol 1995; 26: 313–318.
 
3. Thrombolysis in Myocardial Infarction (TIMI) IIA Trial Investigators. Dose-ranging trial of enoxaparin for unstable angina: results of TIMI IIA: The Thrombolysis in Myocardial Infarction (TIMI) IIA Trial Investigators. J Am Coll Cardiol 1997; 29: 1474–1482.
 
4. Antman EM, McCabe CH, Gurfinkel EP, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction: Results of the thrombolysis in myocardial infarction (TIMI) IIB trial. Circulation 1999; 100: 1593–1601.
 
5. Antman EM, Cohen M, Radley D, et al. Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction: TIMI IIB-ESSENCE meta-analysis. Circulation 1999; 100: 1602–1608.
 
6. Noble S, Spencer CM. Enoxaparin: A review of its clinical potential in the management of coronary artery disease. Drugs 1998; 56: 259–272.
 
7. Hirsh J, Levine MN. Low molecular weight heparin. Blood 1992; 79: 1–17.
 
8. Frydman A. Low-molecular-weight heparins: An overview of their pharmacodynamics, pharmacokinetics and metabolism in humans. Haemostasis 1996; 26 (Suppl 2): 24–38.
 
9. Weitz JI. Low-molecular-weight heparins. N Engl J Med 1997; 337: 688–698.
 
10. Montoya JP, Pokala N, Melde SL. Retroperitoneal hematoma and enoxaparin. Ann Intern Med 1999; 131: 796–797 (letter).

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