Rivaroxaban
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Haemorrhagic pericardial tamponade following off-label use: case report A 74-year-old man developed haemorrhagic pericardial tamponade during off-label treatment with rivaroxaban for non-valvular atrial fibrillation. The man, who had end-stage renal disease (ESRD), was admitted with one week history of fatigue and shortness of breath on exertion. Two weeks prior to the current presentation, he had started receiving off-label treatment rivaroxaban 15 mg/day [route not stated] for a new-onset non-valvular atrial fibrillation (rivaroxaban was considered as an off-label therapy for non-valvular atrial fibrillation in patients with ESRD). Initial vital signs were unremarkable. Physical examination was significant for muffled S1 and S2 on auscultation and 12cm jugular venous distention. Pulsus paradoxus was not appreciated. Laboratory work-up revealed creatinine 6.60 mg/dL, blood urea nitrogen (BUN) 26 mg/dL, INR 1.3 and activated partial thromboplastin time (APTT) 34.8. Electrocardiogram showed sinus rhythm with low voltage QRS. Chest x-ray revealed an enlarged cardiac silhouette. A subsequent non-contrast chest CT scan revealed a moderate pericardial effusion. Within 24 hour of admission, he became haemodynamically unstable with lowest BP of 74/41mm Hg. Transthoracic echocardiogram (TTE) confirmed a new occurrence of tamponade physiology with moderate to large pericardial effusion and right ventricular diastolic collapse. The man therefore underwent an emergency left thoracotomy with a pericardial window and chest tube placement. Around 500cc of haemorrhagic pericardial fluid was removed. Further work-up was found to be negative for infectious and autoimmune aetiology. Pericardial fluid analysis excluded uraemic pericarditis. Cytology/pericardial biopsy ruled out malignancy. Repeat TTE following chest tube removal showed resolution of the pericardial effusion. A haemorrhagic pericardial tamponade was thus diagnosed, which was thought to be related to rivaroxaban. Post-procedure, he remained haemodynamically stable and was discharged to home two weeks later. Rapista N, et al. Rivaroxaban-induced hemorrhagic pericardial tamponade in end-stage renal disease. Journal of Thrombosis and Thrombolysis 50: 982-983, No. 4, Nov 2020. 803518162 Available from: URL: http://doi.org/10.1007/s11239-020-02164-x
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Reactions 28 Nov 2020 No. 1832
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