Dabigatran-etexilate
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Dabigatran-etexilate Treatment failure: case report
A 73-year-old woman exhibited treatment failure during treatment with dabigatran-etexilate for stroke prevention in non-valvular atrial fibrillation. The woman presented to the emergency department an hour after the onset of acute ischaemic stroke, which manifested as total left anterior circulation syndrome with right-sided hemiplegia, global aphasia, right-sided hemianopsia, forced left-sided eye deviation. She had a significant medical history of hypertension, type 2 diabetes mellitus, permanent non-valvular atrial fibrillation and hypercholesterolaemia. She had received warfarin for stroke prevention in non-valvular atrial fibrillation for many years, but her warfarin therapy was changed to dabigatran-etexilate [dabigatran; route not stated] 150mg twice a day a year prior to current presentation. It was found that, she administered the last dose of dabigatran-etexilate around 10 hours prior to the onset of stroke. Her concomitant medications included metformin, telmisartan, furosemide, rosuvastatin, atenolol, doxazosin and ezetimibe. At the emergency department, electrocardiogram revealed atrial fibrillation with a ventricular response of 80 beats/minute. Subsequent coagulation analysis revealed prothrombin time (PT) ratio of 1.24 and activated partial thromboplastin time (aPTT) ratio of 1.6. Additionally, the brain CT angio revealed occlusion of the left middle cerebral artery. Thereafter, she received off-label treatment with IV idarucizumab bolus to reverse the anticoagulant effect of dabigatran-etexilate before performing intravenous thrombolysis. Thereafter (2 hours from the onset of symptoms), she received IV recombinant tissue plasminogen activator (rt-PA) for thrombolysis. Immediate diagnostic angiography showed complete middle cerebral artery recanalisation by the end of intravenous thrombolysis. Her neurological conditions progressively improved. Thereafter, transesophageal echocardiography was performed which showed a left atrial appendage (LAA) thrombus even after full-dose of dabigatran-etexilate and adequate therapy adherence (treatment failure). She refused LAA closure and warfarin was started. Follow-up echocardiography revealed the complete resolution of her LAA thrombus. Candelaresi P, et al. Left atrial appendage thrombus on full-dose dabigatran treatment: A case report. European Heart Journal - Case Reports 4: 1-4, No. 3, Jun 2020. Available from: URL: http://doi.org/10.1093/ehjcr/ytaa057
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Reactions 28 Nov 2020 No. 1832
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