Abstract 10436: Spontaneous Hemopericardium After Rivaroxaban

Abstract

Direct oral anticoagulants (DOACs) such as rivaroxaban have become the drugs of choice when treating a variety of conditions requiring anticoagulation. We describe a case of a patient found to have hemopericardium with tamponade physiology on a routine echo ordered for evaluation of tachycardia. A 49-year-old man with systemic hypertension was found to have a right lower lobe pulmonary embolus (PE) during a hospitalization for diabetic ketoacidosis complicated by pneumoperitoneum s/p small bowel resection. Rivaroxaban 15 mg twice daily was initiated for treatment of PE. On day 2 rivaroxaban, patient became tachycardic. Chest CT showed a small to moderate pericardial effusion with pericardial enhancement. On day 7, a echo showed trivial pericardial effusion without hemodynamic compromise. Tachycardia persisted after hospital discharge, but patient was otherwise asymptomatic. Patient transitioned to rivaroxaban 20 daily after 3 weeks. Outpatient echo done 2 months after discharge showed a large pericardial effusion with tamponade physiology. Patient was instructed to go to hospital for admission. Labs were significant for Hgb 7.8, and elevated PT 52.50, INR 4.5 and PTT 33.80. Rivaroxaban was held, and patient was given 2 units FFP, Vitamin K 10 mg oral, Kcentra 4208 units and 2 units pRBCs. Patient underwent a pericardiocentesis with removal of 600 cc of sanguineous fluid. Fluid analysis was consistent with hemorrhagic effusion. Repeat echo showed a small residual, anterior pericardial effusion with constrictive physiology. Patient was discharged on reduced dose of rivaroxaban 10 daily and Vitamin K 5 mg daily until outpatient follow up. Our case of hemopericardium occurring in a middle-aged man without confounding issues is unusual. Although hemopericardium with DOACs have been reported, the majority of cases have occurred in patients with pre-disposing risk factors. A systemic review of 26 cases by Asad, et al. described risks associated with cardiac tamponade with DOACs. The incidence of hemopericardium and tamponade appeared highest in elderly men with renal and coagulation abnormalities. Our case highlights the importance of vigilance in patients on DOACs who present with subtle symptoms suggestive of hemodynamic compromise or instability.