Direct oral anticoagulants (DOACs) have revolutionized therapy for stroke prophylaxis in patients with nonvalvular atrial fibrillation. These medications are generally well tolerated and are not associated with the inconvenience of repeat international normalized ratio (INR) checks. While bleeding in general is a common side effect associated with DOACs, especially from a gastrointestinal source, spontaneous hemorrhagic pericardial effusions are not seen frequently. Herein, we present a case of a patient who developed a hemorrhagic pericardial effusion three days after the initiation of apixaban. We also summarize the current data that is available showing this side effect and highlight an important risk factor that may predispose patients to this complication.