Hemopericardium in the Setting of Direct Oral Anticoagulant Use: An Updated Systematic Review

Sheikh, Abu Baker; Shah, Ishan; Sagheer, Shazib; Javed, Nismat; Minhas, Abdul Mannan Khan; Lopez, Erick Daniel; Parikh, Charmy; Shekhar, Rahul

doi:10.1016/j.carrev.2021.09.010

Cited by 6 publications

(7 citation statements)

References 54 publications

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“…In addition, the most common risk factors found in these cases were elevated creatinine, older age, hypertension, male gender, elevated INR, and drug interactions [ 4 ], major risk factors also that were present in our patient. In 2022, a systematic review found 41 cases of hemopericardium associated with the use of DOACs with 95% favorable outcomes, but also with cardiac tamponade occurring in 31/41 of them, and 37/41 cases requiring pericardiocentesis [ 3 ]. Thus, the current literature supports the rarity of this complication.…”

Section: Discussionmentioning

confidence: 99%

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Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Ambat,

Patel,

Pathak

et al. 2024

Cureus

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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.

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Section: Discussionmentioning

confidence: 99%

“…When DOACs cause bleeding in patients with these comorbidities, the bleeding sites are most commonly gastrointestinal and intracranial [ 1 ]. Hemopericardium or hemorrhagic cardiac tamponade due to DOACs is extremely rare [ 3 ]. Here, we present a case of spontaneous hemorrhagic cardiac tamponade after the use of apixaban.…”

Section: Introductionmentioning

confidence: 99%

Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Ambat,

Patel,

Pathak

et al. 2024

Cureus

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“…Our patient presented with palpitations and episodes of lightheadedness that are usually less common presentations; however, this could be explained by the fact that she was in a state of unstable supraventricular tachycardia. Sheikh et al [10] in their systematic review of 41 case reports found shortness of breath as the most common presentation (75.2%) followed by chest pain (57.2%) in patients who developed hemopericardium in the setting of DOAC use. Most of the patients were hemodynamically unstable on presentation, similar to ours.…”

Section: Discussionmentioning

confidence: 99%

“…Based on our literature review, there appears to be a temporal correlation between the onset of symptoms and the timing of anticoagulation initiation. Patients generally become symptomatic within two to 12 weeks after the initiation of DOACs, although there were some cases in which symptoms only presented after months of treatment [10].…”

Section: Discussionmentioning

confidence: 99%

“…Apixaban reversibly inhibits free factor Xa and has a half-life of eight to 15 hours [9]. It has been the second most frequently used anticoagulation next to rivaroxaban, with the least used anticoagulant being edoxaban [10]. Herein, we present a case of a 93-year-old female with chronic lymphocytic leukemia (CLL), in remission with ibrutinib maintenance therapy, who was diagnosed with new-onset atrial fibrillation and who developed spontaneous hemopericardium following initiation of anticoagulation with apixaban.…”

Section: Introductionmentioning

confidence: 99%

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Hemorrhagic Pericardial Effusion From Apixaban Use: Case Report and Literature Review

Nasir¹,

Pokhrel²,

Baig³

2022

Cureus

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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.

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Recurrent Thromboembolism Due to Direct Oral Anticoagulation Interruption Postpericardial Window for a Hemopericardium

et al. 2023

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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.

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Hemopericardium in the Setting of Direct Oral Anticoagulant Use: An Updated Systematic Review

Cited by 6 publications

References 54 publications

Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Apixaban-Induced Spontaneous Hemorrhagic Cardiac Tamponade

Hemorrhagic Pericardial Effusion From Apixaban Use: Case Report and Literature Review

Recurrent Thromboembolism Due to Direct Oral Anticoagulation Interruption Postpericardial Window for a Hemopericardium

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