Page 15 - Delaware Medical Journal July 2015
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CASE REPORT
echocardiogram that showed preserved LV function and a trace pericardial effusion. He was treated with intravenous usual medications, which included rivaroxaban, metoprolol, levothyroxine, and aspirin. Rivaroxaban had been initiated approximately two months prior to this hospital admission for
In the emergency department he was found to have labored breathing and bibasilar rales. He was also noted to have a multi- component friction rub upon auscultation and an EKG showed diffuse ST-segment elevation consistent with pericarditis. Laboratory evaluation was notable for an international normalized ratio (INR) of 2.3 and serum creatinine of 2.1 mg/dl (elevated from 1.2 mg/dl on prior discharge). The patient was admitted to the hospital for further evaluation and treatment. He underwent transthoracic echocardiography which revealed
a large circumferential pericardial effusion along with
consistent with tamponade physiology. He underwent urgent pericardiocentesis and pigtail catheter placement with removal well and with great improvement in symptoms. Repeated echocardiography in the following days revealed only trace Further anti-thrombotic therapy was deferred to his cardiologist upon outpatient follow-up.
DISCUSSION
This case demonstrated a dangerous complication of hemorrhagic pericardial effusion and tamponade likely secondary to pericarditis in the setting of anticoagulation with Rivaroxaban. Serious bleeding events have been reported with this medication,4 hemopericardium leading to tamponade. Several factors may
have played a role in increasing this patient’s bleeding risk. Patients older than 75 years have been shown to have higher overall bleeding risk when taking rivaroxaban. Furthermore, renal of serious bleeding.5 Dosage adjustments are recommended for reductions in creatinine clearance. Additionally, the concomitant use of azithromycin, which may increase serum concentrations of Rivaroxaban through its actions on the cytochrome P-450 system,5 may have placed this patient at higher risk for hemorrhagic complications.
Clinicians should be aware of this potential complication in patients receiving any currently available anticoagulant therapy. Unfortunately, at this time, there is no reliable laboratory test to assess the degree of anticoagulant effect of factor Xa inhibitors and there is no effective reversal agent available to clinicians in the United States. Prescribers should be particularly cautious receiving additional drug therapies that may affect serum drug concentrations.
AUTHOR
■ STEPHEN BOONE, MD is an Emergency Medicine and Internal Medicine Resident at Christiana Care Health System in Newark, Del.
REFERENCES
1. Miller RL. Hemopericardium with use of oral anticoagulant therapy. JAMA. 1969;209:1362-1364.
2. Barton CA, McMillian WD, Raza SS, Keller RE. Hemopericardium in a patient treated with dabigatran etexilate. Pharmacotherapy. 2012;32:e103-107.
3. Shivamurthy P, Brar N, Therrien ML. Isolated hemopericardium associated with Rivaroxaban: first case report. Pharmacotherapy. 2014;34:e169-172.
4. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883.
5. Gulseth MP, Michaud J, Nutescu EA. Rivaroxaban: an oral direct inhibitor of factor Xa. Am J Health Syst Pharm. 2008;65):1520-1529.
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