A 78-year-old male with a history of paroxysmal atrial fibrillation, coronary artery disease, hypertension, and chronic kidney disease, on warfarin and aspirin, presented after a syncopal episode. While sitting, he suddenly felt lightheaded and passed out. Exam was notable for a blood pressure of 70/40 mmHg, heart rate of 110 beats/min, and a large ecchymosis across his anterior chest (Fig. 1). There was no history of fall or trauma. Labs revealed a hemoglobin level of 4.2 g/dL and INR 7.8. Computed tomography (CT) of the chest demonstrated bilateral pectoral hematomas (Fig. 2). The patient’s hemodynamic status improved with fluids, blood transfusions and reversal of anticoagulation. Warfarin was discontinued on discharge.

Figure 1.
figure 1

Large ecchymosis across the anterior chest.

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Figure 2.
figure 2

CT chest demonstrating bilateral pectoral hematomas, left greater than right.

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Most cases of muscular hematomas have been described in context of invasive procedures or trauma. This is the first reported case of spontaneous hematoma due to anticoagulation resulting in hemorrhagic shock. The decision to initiate anticoagulation is complicated. The CHADS2 score is frequently used to estimate risk of stroke in atrial fibrillation, while the HAS-BLED score can help estimate bleeding risk after starting warfarin therapy.1,2 With these tools, the risks and benefits of anticoagulation can be better estimated, and the decision to begin anticoagulation can be individualized to each unique situation.