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.

Hemopericardium: A Comprehensive Clinical Review of Etiology and Diagnosis

Hemorrhagic pericardial effusion (HPE) is a subtype of pericardial effusion marked by the accumulation of serosanguineous or bloody fluid within the pericardial cavity. We present a case of a 65-year-old female who presented to the hospital with abdominal pain and was found to have pericardial effusion. The patient's condition evolved into cardiac tamponade, and employing diagnostic techniques such as imaging and pericardiocentesis, a substantial bloody effusion was uncovered, indicative of HPE. This report underscores the complexity of HPE diagnosis and examines the non-iatrogenic etiological factors contributing to HPE, focusing on three primary causes: malignancy, infection, and autoimmune disorders. It offers a detailed exploration of each etiology, backed by current medical literature and case studies. It outlines the diagnostic strategies pertinent to each cause, underscoring the need for a tailored approach to manage such cases. It emphasizes the importance of a meticulous and individualized diagnostic process, vital for accurate identification and effective management of this condition.

A case report of hemorrhagic cardiac tamponade with rapid blood clot formation: A serious complication of acute type a aortic dissection

RATIONALE

Acute type A aortic dissection (AAAD) remains a life-threatening disease. We previously reported a case with ultrasound findings of a homogeneous hemopericardium and evidence highly indicative of hemorrhagic cardiac tamponade complicated by AAAD. Here, we report a similar case who presented with a more serious situation and for whom critical care ultrasound revealed fast blood clot formation within the hemopericardium.

PRESENTING CONCERNS

A 63-year-old man was admitted to our emergency department with a complaint of a tearing chest pain for 10 minutes. Asymmetric blood pressure was detected in the upper limbs and AAAD was highly suspected. An electrocardiogram (ECG) monitor was placed in a timely manner. However, during this procedure, he went into cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated.

DIAGNOSES

Critical care ultrasound revealed hemorrhagic cardiac tamponade with blood clot formation surrounding the epicardium, strongly indicating the rupture of an ascending aortic root dissection.

INTERVENTIONS

Standard CPR continued for 30 minutes.

OUTCOMES

Spontaneous cardiac rhythm was not restored and the patient died.

LESSONS

Critical care ultrasound is a useful tool for assessing emergency cardiac arrest. Ultrasound findings of fast clot formation within the hemopericardium may indicate faster bleeding due to the rupture of an AAAD and may predict poor clinical outcomes.

Hemorrhagic cardiac tamponade complicated by acute type A aortic dissection: A case report with critical care ultrasound findings

RATIONALE

Acute type A aortic dissection (AAAD) is a potentially fatal clinical crisis. Hemorrhagic cardiac tamponade due to the rupture of an ascending aortic root dissection is extremely dangerous and often lacks timely clinical evidence. We report sudden death in a patient diagnosed with AAAD and in whom critical care ultrasound highly indicated hemorrhagic cardiac tamponade.

PRESENTING CONCERNS

A 75-year-old man was admitted to our emergency department with a complaint of chest pain for 8 hours. Computed tomography angiography findings indicated AAAD with a wide range of lesions. During the preoperative preparation process, he suddenly lost consciousness with a pulseless femoral artery.Diagnoses: Cardiopulmonary resuscitation was initiated and critical care ultrasound revealed hemorrhagic cardiac tamponade, strongly indicating the rupture of an ascending aortic root dissection.

INTERVENTIONS

However, family members refused further surgical interventions.

OUTCOMES

The etiology could not be reversed and the patient died.

LESSONS

Critical care ultrasound is an important skill that intensivists should master for fast screening of life-threatening complications in patients with AAAD.