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(Circulation. 2006;113:e698-e702.)
© 2006 American Heart Association, Inc.

Clinician Update

Anticoagulants and Transaminase Elevation

Nipun Arora, MD; Samuel Z. Goldhaber, MD

From the Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass.

Correspondence to Samuel Z. Goldhaber, MD, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail sgoldhaber@partners.org

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Case 1: Mr F., a 65-year-old man with hypertension and atrial fibrillation, began long-term anticoagulation with warfarin 1 year ago. He presented with a 1-week history of nausea, anorexia, jaundice, and altered mental status. His laboratory workup showed elevated serum transaminases and direct bilirubin. Could warfarin be potentially responsible?

Case 2: Mr S., a 75-year-old man with diabetes and coronary artery disease, presented with an acute anterior myocardial infarction. Echocardiography showed a left ventricular aneurysm with apical akinesis and thrombus. He was started on enoxaparin, and 3 days later, he developed a rise in alanine aminotransferase (ALT) >5 times the upper limit of normal (ULN). Could this laboratory abnormality be related to enoxaparin?

	Epidemiology

 
Drug-induced hepatotoxicity is the most common cause of acute liver failure in the United States and is the most frequently cited reason for withdrawal of an approved drug from the market.¹ It occurs at rates of 1 in 1000 to 1 in 100 000 patients, making it difficult to detect in the premarketing randomized controlled trials that are required for drug approval.²

Anticoagulant-induced liver injury has been infrequently reported. Case reports have described the association of anticoagulants with asymptomatic elevation of serum transaminases, clinically significant hepatitis, and fatal liver failure.^3–22 As an increasing number of patients receive long-term anticoagulation for prevention of stroke and venous thromboembolism, the rare adverse event of anticoagulant-induced liver injury is gaining attention.

Ximelagatran is an oral direct thrombin inhibitor that prevents the conversion of fibrinogen to fibrin by thrombin. This agent is . . . [Full Text of this Article]