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

Spontaneous Hemopericardium Associated With Apixaban Use With Newly Diagnosed Malignancy and Acute Kidney Injury: A Case Report

Direct oral anticoagulants have simplified the use of anticoagulation for patients and clinicians. These medications now have indications for non-valvular atrial fibrillation and venous thromboembolism and carry a lower risk of bleeding than warfarin. While bleeding complications are common amongst all anticoagulants, spontaneous hemopericardium is a rarely reported side effect of direct oral anticoagulants, previously reported in patients with concomitant malignancy or kidney injury. We present a case of a patient with recently diagnosed renal malignancy and atrial fibrillation on apixaban who developed a spontaneous hemopericardium that required a pericardial window.

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.