rivaroxaban and Pericardial-Effusion

Spontaneous hemopericardium, associated with direct oral anticoagulant (DOAC) use, is one of the uncommon complications with high morbidity that has not been extensively studied We aimed to determine demographic characteristics, clinical features, lab evaluation, management, and outcomes of the studies focusing on hemopericardium as a DOAC use.. PubMed, Web of Science, Google Scholar, and CINAHL databases were searched for relevant articles using MeSH key-words and imported into referencing/review software. The data regarding demographics, clinical characteristics, cardiac investigations, and management were analyzed in IBM Statistics SPSS 21. t-Test and Chi-square test were used. A P score of <0.05 was considered statistically significant.. After literature search, a total of 41 articles were selected for analysis. The mean age of the patients was 70.09 ± 11.06 years (p < 0.05); the majority of them were males (58.5%). Most of the patients presented with shortness of breath (75.2%) and had more than 3 co-morbid conditions (43.9%). The most frequently used anticoagulant was rivaroxaban (15/41; 36.6%); the common indication being arrhythmia (78.0%). CYP4503A4/P-Gp inhibitors (22.2%) were commonly used by the patients. Majority of the cases had a favorable outcome (95.1%). Pericardial tamponade was noted in 31/41 cases. Pericardiocentesis was performed in 37/41 cases.. Hemopericardium from DOAC use has a favorable outcome but requires urgent pericardiocentesis. However, long term mortality, monitoring of DOAC activity, and drug-drug interactions have not been widely studied.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Female; Humans; Male; Middle Aged; Pericardial Effusion; Pericardiocentesis; Rivaroxaban

We previously reported that dabigatran increased the risk of microthromboembolism and hemopericardium compared with warfarin. The safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in the periprocedural use of atrial fibrillation (AF) ablation is controversial. This study aimed to compare the incidence of asymptomatic cerebral microthromboembolism and hemopericardium in AF ablation among periprocedural use of rivaroxaban, apixaban, and warfarin.. This study was a prospective, randomized registry. Patients taking NOACs upon visiting our hospital were randomly assigned into 2 groups; rivaroxaban and apixaban. Warfarin was continued in patients taking warfarin. Asymptomatic cerebral microthromboembolism was evaluated by magnetic resonance imaging on the day after the ablation procedure. In 176 consecutive patients (101 paroxysmal, and 75 persistent AF), rivaroxaban was used in 55, apixaban in 51, and warfarin in 70. There were no symptomatic cerebral infarctions in this study. Asymptomatic cerebral microthromboembolism was detected in 32 (18.4%) patients; nine (16.4%) with rivaroxaban, 10 (20%, p=0.80; vs. rivaroxaban) with apixaban, and 13 (18.8%, p=0.81; vs. rivaroxaban) with warfarin. Hemopericardium occurred in 5 (2.8%) patients; 2 with rivaroxaban, 1 with apixaban (p=1.0; vs. rivaroxaban), and 2 with warfarin (p=1.0; vs. rivaroxaban). In multivariate analysis, concomitant coronary angiography (p<0.05, odds ratio 5.73) was a predictor of cerebral thromboembolism.. The incidence of asymptomatic cerebral microthromboembolism and hemopericardium in AF ablation is similar among the periprocedural use of rivaroxaban, apixaban, and warfarin.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Combined Modality Therapy; Coronary Angiography; Factor Xa Inhibitors; Female; Humans; Incidence; Intracranial Thrombosis; Magnetic Resonance Angiography; Male; Middle Aged; Pericardial Effusion; Prospective Studies; Pyrazoles; Pyridones; Registries; Rivaroxaban; Warfarin

We present a female patient with a history of systolic heart failure with an ejection fraction of 25-30%, and unprovoked pulmonary embolism on extended anticoagulation therapy with rivaroxaban who underwent a pericardial window for cardiac tamponade due to hemopericardium in the setting of direct oral anticoagulant (DOAC). The rivaroxaban was held following the pericardial window, and she experienced another episode of pulmonary embolism before the rivaroxaban could be restarted. Currently, there are no guidelines on when to restart anticoagulation postpericardial window for DOAC-associated hemopericardium. Studies are needed to help solve this dilemma.. We present a female patient with a history of systolic heart failure which means their left ventricle was unable to pump blood efficiently. They also have a history of an unprovoked disruption in the flow of blood in the pulmonary arteries or its branches, known as a pulmonary embolism. The patient was on direct oral anticoagulation medication to thin their blood, promoting efficient blood flow and minimizing the risk of clots and blockages. While on this medication, the patient developed a significant collection of blood around the heart, so the medication was withheld and the blood collection was drained. She developed another episode of pulmonary embolism before the medication could be restarted. Healthcare providers need guidance on when to restart anticoagulation medications in these types of patients.

Topics: Anticoagulants; Female; Humans; Pericardial Effusion; Pulmonary Embolism; Rivaroxaban; Thromboembolism; Venous Thromboembolism

Although the risk of major bleeding with non-vitamin K antagonist oral anticoagulant (NOAC) is low, life-threatening bleeding can occur.. We report a case of an 81-year-old female with deep vein thrombosis who developed bilateral spontaneous haemothorax and haemopericardium after rivaroxaban therapy. Diagnostic thoracentesis revealed a grossly bloody pleural effusion. She was treated with factor eight inhibitor bypassing agent, but the result was not satisfactory.. To our knowledge, this is the first case report of a concomitant presentation of spontaneous bilateral haemothorax and haemopericardium due to rivaroxaban use. This case highlights the potential risk of major haemorrhagic complication of NOAC, which could be life-threatening and require emergent reversal.

Topics: Aged, 80 and over; Factor Xa Inhibitors; Female; Hemothorax; Humans; Pericardial Effusion; Rivaroxaban; Venous Thrombosis

We describe the case of an 86-year-old man with a background of severe left ventricular dysfunction and ischaemic cardiomyopathy who, having been optimised for heart failure therapy in hospital, unexpectedly deteriorated again with hypotension and progressive renal failure over the course of 2 days. Common causes of decompensation were ruled out and a bedside echocardiogram unexpectedly diagnosed new pericardial effusion with tamponade physiology. The patient underwent urgent pericardiocentesis and 890 mL of haemorrhagic fluid was drained. Common causes for haemopericardium were ruled out, and the spontaneous haemopericardium was thought to be related to introduction of rivaroxaban anticoagulation. The patient made a full recovery and was well 2 months following discharge. This case highlights the challenges of diagnosing cardiac tamponade in the presence of more common disorders that share similar non-specific clinical features. In addition, this case adds to growing evidence that therapy with direct oral anticoagulants can be complicated by spontaneous haemopericardium, especially when coadministered with other agents that affect clotting, renal dysfunction and cytochrome P3A5 inhibitors.

Topics: Acute Kidney Injury; Aged, 80 and over; Anticoagulants; Cardiac Tamponade; Cytochrome P-450 CYP3A Inhibitors; Diagnosis, Differential; Drainage; Echocardiography; Heart Failure; Humans; Hypotension; Male; Myocardial Ischemia; Pericardial Effusion; Rivaroxaban; Ventricular Dysfunction, Left

An 82-year-old female was admitted with chest pain and non-specific T wave changes on her ECG. After 72 hours of conservative management she deteriorated with non-specific symptoms including nausea and a single episode of vomiting. Abdominal and Chest X-rays were unremarkable, blood tests showed worsening Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD); and raised C-Reactive Protein (CRP) with no obvious symptoms or focus of infection. She rapidly deteriorated going into asystole cardiac arrest and attempts at resuscitation failed. Post-mortem examination suggested the most likely cause of death was acute spontaneous Haemopericardium due to Rivaroxaban therapy which she was on for non-valvular Atrial Fibrillation (AF). We believe that this might be the first reported mortality with Rivaroxaban-associated spontaneous haemopericardium in the UK.

Topics: Aged, 80 and over; Atrial Fibrillation; Electrocardiography; Factor Xa Inhibitors; Fatal Outcome; Female; Humans; Pericardial Effusion; Radiography, Thoracic; Rivaroxaban; Stroke

Rivaroxaban is a novel anticoagulant approved for use in patients with atrial fibrillation for stroke prevention. It is a factor Xa inhibitor, and its activity cannot be monitored with use of the international normalized ratio. A 5.6% chance of major bleeding is associated with rivaroxaban use, including intracranial and gastrointestinal bleeds. We report the first case, to our knowledge, of isolated hemopericardium related to rivaroxaban use, which could potentially lead to death from cardiac tamponade. A 76-year-old man who was receiving rivaroxaban for atrial fibrillation presented to the emergency department with pleuritic chest pain and was found to have a hemopericardium. No signs of tamponade were evident, and his bleed remained stable after discontinuing rivaroxaban. The patient had also been taking saw palmetto, which may have contributed to the bleed by increasing rivaroxaban activity. A work-up for other causes of hemopericardium, including pacemaker lead misplacement and autoimmune disease-related pericarditis, was negative. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between the patient's development of hemopericardium and rivaroxaban use. This case highlights the potential for bleeding complications associated with novel anticoagulants. Herbal products and various drugs may increase rivaroxaban levels by inhibiting P-glycoprotein and cytochrome P450 3A4 activity. Clinicians should be aware of these potential interactions with rivaroxaban and perform a review of not only the patient's drug therapy but also any herbal and food products that could alter the levels of anticoagulants. The lack of an antidote and the inability to dialyze rivaroxaban is a significant concern in situations of life-threatening bleeds. A laboratory test for monitoring rivaroxaban levels may be required for its safe use.

Topics: Aged; Atrial Fibrillation; Chest Pain; Factor Xa Inhibitors; Humans; Male; Morpholines; Pericardial Effusion; Rivaroxaban; Thiophenes