Rivaroxaban is a novel oral anticoagulant which is widely used for treatment for venous thromboembolism and stroke prophylaxis in non-valvular atrial fibrillation. Spontaneous hemopericardium with cardiac tamponade due to rivaroxaban is a new entity and only a handful of cases have been reported in literature so far.
Discussion:
A 56-year- old female with history of remote pulmonary embolism, myotonic dystrophy, complete heart block on pacemaker presented to the emergency department (ED) with sudden onset shortness of breath and substernal chest pain radiating to back. She had history of deep vein thrombosis of left upper extremity few weeks ago and was started on rivaroxaban. She denied any history of fever, chills, cough, sore throat or chest trauma. There was no prior history of tuberculosis, chest irradiation or chemotherapy. She was not on any medications that had CYP 3A4 inhibiting activity. In the ED, her blood pressure was 78/48 mm Hg, pulse 106/minute, temperature 36.5°C, respiratory rate 18/min with saturation of 87%. Cardiac and pulmonary examination were within normal limits. Troponin was negative. Electrocardiogram revealed ventricular paced rhythm similar to before. Computed tomography (CT) chest showed no pulmonary embolism but revealed a large pericardial effusion. Echocardiogram showed moderate-sized circumferential effusion with a swinging heart consistent with pericardial effusion (prior echo in 2012 showed no pericardial effusion). She was diagnosed with cardiac tamponade and was taken to operating room for emergency subxiphoid pericardial window with removal of 300 mL of bloody fluid with immediate improvement in her hemodynamic status. Further workup to find an etiology was unrevealing. Pericardial fluid culture was negative with normal cytology. Pericardial tissue biopsy was negative for malignancy. Thyroid and liver function tests were normal. ANA, rheumatoid factor, Anti-saccharomyces cerevisae antibody, anti-mitochondrial antibody, C3, C4, anti- liver kidney muscle antibody were negative. Post procedure, she was stable but unfortunately she developed nosocomial pneumonia, septic shock and multi-organ failure and passed away.
Conclusions:
Rivaroxaban, like other anticoagulants, is associated with increased bleeding risk. Spontaneous hemopericardium, including cardiac tamponade due to novel oral anticoagulants is an emerging entity and only few cases have been reported so far. Currently, there is no FDA approved reversal agent or any lab test to predict the anticoagulant effect of rivaroxaban. Clinicians should be aware of this little known but life threatening adverse effect of rivaroxaban, so that they would be able to identify these patients early and institute appropriate interventions which can be life saving. More research is required to monitor these patients as well as hasten the development of reversal agent. Whether periodic echocardiogram should be done in these patients to identify early pericardial effusion is not known.