Hemorrhagic Cardiac Tamponade Associated with Apixaban: A Case Report and Systematic Review of Literature

Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Direct oral anticoagulants (DOACs), such as apixaban, are used for the prevention and management of thromboembolic diseases. Here, we present a case of a 72-year-old African American woman who presented to the hospital with shortness of breath and precordial chest pain for three days. The patient was diagnosed with volume overload associated with the progression of chronic kidney disease (CKD) and subsequently admitted to the hospital. Since the patient failed to adequately respond to diuretics, hemodialysis was initiated. During the hospital stay, she developed paroxysmal atrial fibrillation. Along with amiodarone, apixaban was started for primary stroke prophylaxis. Within 72 hours, the patient developed worsening chest pain. An echocardiogram revealed a large pericardial effusion with cardiac tamponade. She was taken for an emergent open pericardial window placement to relieve cardiac tamponade, where 600 mL of blood was drained. Considering the timeline of the development of a large bloody pericardial effusion following initiation of apixaban, spontaneous hemorrhagic cardiac tamponade attributed to the use of apixaban was diagnosed. The patient was eventually taken off all anticoagulants. In considering potential mechanisms, impaired hepatic and renal metabolism of apixaban could be factored in this case. In addition, CKD can increase bleeding risk, due to platelet dysfunction and impaired interaction of von Willebrand factor with GPIIb-IIIa. Moreover, renal secretion of apixaban is mediated by p-glycoprotein and amiodarone is an inhibitor of this protein. Although extremely rare, spontaneous hemorrhagic cardiac tamponade can occur with the use of DOACs, such as apixaban. Prompt recognition and urgent treatment remain keys to avoiding adverse patient outcomes.

Spontaneous Hemorrhagic Pericardial Effusion as a Consequence of Apixaban Utilization for New-Onset Atrial Fibrillation

Although anticoagulation stands as a standardized therapeutic approach for mitigating thrombotic risks in atrial fibrillation, the potential for bleeding associated with direct oral anticoagulants (DOACs) is consistently weighed in the risk/benefit analysis prior to initiating therapy for non-valvular atrial fibrillation. While the typical bleeding risks from DOACs predominantly affect the gastrointestinal system, occurrences of spontaneous hemorrhagic pericardial effusions are rare. This case presentation illustrates a patient developing spontaneous hemorrhagic pericardial effusion four days after commencing apixaban therapy and subsequent management.

Fatal Cardiac Tamponade Due to a Pericardial Inflammatory Myofibroblastic Tumor

The patient was a 34-year-old woman who suddenly collapsed. On arrival, she was in cardiac arrest. Cardiac ultrasound revealed cardiac tamponade; thus, urgent thoracotomy with pericardiotomy was performed. Spontaneous circulation was temporarily obtained; however, her circulation was not stabilized, and she ultimately died. An autopsy revealed a pericardial inflammatory myofibroblastic tumor (IMT) causing bloody cardiac tamponade. There were no signs of cardiac rupture, myocardial infarction or aortic dissection. We reported the first case of fatal bloody cardiac tamponade due to pericardial IMT in an adult. An autopsy is important for clarifying the etiology in cases of fatal cardiac tamponade of unknown cause.

Elevated International Normalized Ratio Due to Apixaban in Patient With End-Stage Renal Disease on Hemodialysis

Apixaban is known to prolong international normalized ratio (INR) per some observational and in vitro studies. In patients with elevated INR secondary to apixaban use, median INR of 1.4-1.7 has been reported. Extreme elevation in INR is rare with apixaban. In patients with end-stage renal disease (ESRD) on hemodialysis (HD), there are no labeled indications for apixaban use; however, there are some pharmacokinetic data supporting its use in such patients.

We present a case of a 68-year-old Hispanic man with ESRD who presented to the emergency room (ER) with INR of 27.42. INR testing was done as a part of routine workup in rehabilitation facility. Medication list was reviewed and included apixaban 2.5 mg twice daily which was recently started for postoperative thromboprophylaxis. INR testing was repeated for confirmation in ER and was reported as >18.5 and prothrombin time >200 seconds. His liver function tests were stable as compared to baseline testing five days ago with normal bilirubin, low normal transaminases, and mild hypoalbuminemia. The patient didn’t have any active bleeding. An elevation of INR to >20 with apixaban is a rare event. No other factors including patient characteristics, laboratory results, co-existing conditions, or other medications except the direct oral anticoagulant (DOAC) were found to be responsible for elevated INR. Liver cirrhosis or vitamin K deficiency as cause for INR elevation was ruled out as the baseline INR was normal prior to starting apixaban, liver function tests were stable and INR normalized again shortly after discontinuing the medication. Plasma concentration of DOACs has been found to be correlating with the INR according to a pharmacokinetic study which potentially means that the high INR likely was secondary to high serum concentration of apixaban in this patient. However, INR monitoring is not recommended for monitoring anticoagulant activity of DOACs. As of note, renal clearance accounts for 27% of apixaban clearance.

Pharmacokinetic studies have concluded that half dose apixaban, i.e., 2.5 mg twice daily in patients on hemodialysis (dose used in this case) results in drug exposure similar to that of the standard dose of 5 mg twice daily in patients with preserved renal function. Future studies are necessary to address questions about safety of DOACs in patients with ESRD, further elucidate the clinical significance of such high INR values associated with DOACs, and establish appropriate management guidelines. Andexanet alfa has since been approved for apixaban reversal in patients with life-threatening bleeding; however, would not be indicated in such cases when there is no evidence of bleeding.

Clinically Ambiguous Hemorrhagic Cardiac Tamponade Associated with Apixaban

Hemorrhagic cardiac tamponade in the setting of direct oral anticoagulants (DOACs) is rare but life-threatening. Presentation in subacute cases can also be nonspecific, which can potentially delay diagnosis. A 60-year-old female with a history of heart failure and chronic obstructive pulmonary disease presented with shortness of breath, chest pain, and cough while on treatment with apixaban after a recent hospitalization for pulmonary embolism. Clinical presentation was consistent with multiple diagnoses, including pneumonia and heart failure exacerbation. However, there were several risk factors for hemopericardium with DOACs such as elevated creatinine, hypertension, elevated international normalized ratio (INR), and concomitant use of medications with similar metabolic pathways as apixaban. In addition, subtle findings on examination such as oximetry paradoxus and electrical alternans were crucial for an early diagnosis and management. In this case, we discuss key characteristics of hemopericardium with DOACs, as well as considerations on its management.

Hemopericardium in the setting of direct oral anticoagulant use: An updated systematic review

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Safety and Efficacy of Non-Vitamin K Oral Anticoagulant Use Early After Cardiac Surgery: A Systematic Review

OBJECTIVE

To determine the safety and efficacy of non-vitamin K oral anticoagulants (NOACs) initiated early after cardiac surgery.

DATA SOURCES:

Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE (database inception to January 20, 2021), www.clinicaltrials.gov, www.who.int/ictrp/search/en/, NOAC trial registries, and bibliographies of relevant guidelines and other reviews were used.

STUDY SELECTION AND DATA EXTRACTION

Observational studies and randomized controlled trials (RCTs) that initiated NOACs within the index hospitalization and that reported bleeding for the primary outcome were included.

DATA SYNTHESIS

A total of 6 cohort studies, 1 RCT, and 3 ongoing RCTs were included. Most studies were single-centered, limited to postoperative atrial fibrillation after coronary artery bypass grafting, and with 30-day follow-up; few studies included patients with isolated bioprosthetic valve replacement or valve repair. Bleeding risk varied (0%-28.6%), and all but one study showed no significantly higher risk with NOAC compared with warfarin.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Overall, NOACs were used in 26% to 37.5% of patients early after cardiac surgery. Starting a NOAC on postoperative day 4 appeared to have similar bleeding rates compared with warfarin, but clinical application is limited by heterogeneity of outcome definitions, confounding, and bias. Compared with warfarin, NOACs may have similar thromboembolism risk, reduced length of stay, and cost.

CONCLUSIONS

There is limited evidence to guide NOAC use early after cardiac surgery. Three ongoing randomized trials will add to the literature and provide guidance for clinicians on whether, in whom, when, and how to use NOACs safely early after cardiac surgery.

An Uncommon Case of Spontaneous Hemopericardium in a Patient Treated with Rivaroxaban

We describe a case of an 88-year-old woman with a severe bluntly ematic pericardial effusion. Radiological and laboratory examinations excluded all the most common causes of hemopericardium, and the diagnosis of spontaneous hemopericardium associated with the treatment with rivaroxaban was made. This is the first case report describing a hemopericardium in a patient treated with rivaroxaban who did not take other herbal products or drugs that may significantly increase rivaroxaban blood levels. This report emphasizes the need for the careful use of new oral anticoagulants, and the importance of taking in mind uncommon side effects. Spontaneous hemopericardium should be considered in these patients.