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Ann Thorac Surg 1998;66:941-942
© 1998 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
Accepted for publication March 25, 1998.
Address reprint requests to Dr Izzat, Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, NT, Hong Kong (e-mail)
e-mail: izzat{at}cuhk.edu.hk
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Abstract |
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Introduction |
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A 62-year-old man with a past history of severe rheumatic mitral regurgitation underwent mitral valve replacement with a mechanical bileaflet prosthesis in our hospital. His postoperative progress was uneventful, and an echocardiogram performed on discharge on day 7 after the operation confirmed normal prosthetic valve hemodynamics, moderately impaired left ventricular function, and absence of pericardial or pleural effusions. His medications on discharge were digoxin, 0.125 mg; captopril, 75 mg; and frusemide, 40 mg daily. He was also prescribed warfarin, 5 mg daily, and had an international normalized ratio (INR) stabilized at around 3.0. He was reviewed as an outpatient 2 and 4 weeks after discharge and was making satisfactory progress, his chest radiographs showed only mild cardiomegaly, and he did not require any adjustment of his warfarin dose.
Six weeks after discharge from the hospital, he attended the emergency department complaining of nonspecific central chest wall pain, increasing dyspnea, and decreased exercise tolerance over the previous 2 weeks. Chest radiography revealed an increased cardiac silhouette and massive right pleural effusion, and echocardiography confirmed the presence of large pericardial and right pleural fluid collections. Blood tests showed that his hemoglobin concentration was only 7.6 g/dL, and his platelet count was 333 x 109/L. He also had a severely deranged clotting profile, with an INR of more than 8.4 and an activated partial thromboplastin time of more than 120 seconds, even though he confirmed that he was taking the correct dose of warfarin as prescribed. Detailed history taking revealed that over the 2 weeks before this second admission, on the recommendation of a Chinese herbalist, he also drank a decoction of danshen daily to help "mending his heart."
Warfarin and danshen administration was stopped, and he required 6 units of fresh frozen plasma over 2 days, together with seven units of packed red blood cells, before his INR was brought down to around 2.0. A right pleural drain was inserted, and more than 4.5 L of nonclotted blood was drained. Later, echocardiography confirmed that both pleural and pericardial collections had disappeared. Over the following 2 weeks, warfarin was gradually reintroduced and, similar to his first admission, a daily dose of 5 mg stabilized his INR at around 3.0.
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Recent reports suggested that danshen, through yet unclear mechanisms, can decrease the elimination of warfarin and result in over-anticoagulation [2, 4]. Our patient illustrates a clinically significant interaction of that kind. The absence of other precipitating factors and the temporal relationship between the consumption of danshen, the onset of symptoms, and the associated increase in INR from 3.0 to more than 8.4 are strongly suggestive of an adverse interaction between danshen and warfarin.
Danshen is easily available from herbal dispensaries for the treatment of nonspecific somatic complaints. Hence, when appropriate, patients taking warfarin should be warned not to take this herb. In addition, the physician should be alert to the possibility of an interaction with herbal medicine when anticoagulation control becomes irregular or deviates from the optimum when no other causes are apparent.
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