Spontaneous hemopericardium in the setting of end-stage renal disease and concurrent apixaban use

SESSION TITLE: Critical Care Case Report Posters 5 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: In the evaluation of hemodynamically unstable patients presenting in shock, cardiac tamponade is frequently considered as a possible etiology. For patients with underlying malignancy, autoimmune disease, recent invasive cardiac procedures or end-stage renal disease (ESRD), suspicion of pericardial effusion quickly rises. However, this diagnosis can often be initially overlooked in the absence of those risk factors. Here we present a case of spontaneous hemopericardium in the setting of direct oral anticoagulant (DOAC) use, ESRD, and chronic, ongoing infection. CASE PRESENTATION: A 56-year old woman with a history of ESRD on hemodialysis and diabetes complicated by bilateral lower extremity amputation and chronic osteomyelitis was admitted to the ICU for initially suspected septic shock. Her admission vitals were a blood pressure of 89/74mmHg, heart rate of 120, respiration rate of 24 and temperature of 99.2° Fahrenheit. The physical exam was significant for altered mental status, labored breathing, a wound on the right lower extremity stump, tachycardia and distant heart sounds. Labwork demonstrated an anion gap of 31, lactic acid of 14 mmol/L, INR of 5 and WBC of 17.0 10^3/uL. The patient's presentation was at first attributed to an underlying infection given her chronic osteomyelitis and an open wound at the right below knee amputation site. Shen then underwent emergent dialysis the same day of admission with the goal of 2 liters of volume removal. This session was ended early as the patient became further hypotensive necessitating vasopressor support and intubated for concern of airway protection, worsening encephalopathy and increased work of breathing. Transthoracic echocardiogram (TTE) and electrocardiogram (ECG) demonstrated tamponade physiology with electrical alternans, respectively. The patient was taken for a pericardiocentesis with 1 liter of bloody fluid removed. She made quick hemodynamic and clinical improvement, extubated within 48 hours, taken off vasopressor support and able to be stepped down to the medical floor. DISCUSSION: Limited data exist in evaluating the safety of DOACs for those with underlying ESRD. While these patients often take the medication at a reduced dose, there are a growing number of case reports demonstrating increased rates of bleeding and even hemopericardium. Prescribers should take caution and enable shared decision making when initiating DOACs in high-risk patients. Equally important, physicians cannot exclude tamponade in the absence of typical risk factors. While TTE, ECG, physical exam findings and abnormal vitals remain the mainstay of diagnosis, DOAC use in ESRD patients should raise the pre-test probability of pericardial effusion. Elevated INR greater than 5 can also be an early clue for increased risk of bleeding into pericardial space and a transthoracic echocardiogram should be considered in all patients with hemodynamic instability. In the prevention of the development of adverse bleeding events, further research could be conducted on intermittent laboratory monitoring in identified high-risk patients. CONCLUSIONS: The use of DOACs in patients with ESRD can increase the risk of spontaneous bleeding, even when the dose is adjusted. When these patients have a clinical presentation suggestive of cardiac tamponade without other risks for pericardial effusions, spontaneous hemopericardium should be considered. REFERENCE #1: Shah A, van den Brink A, de Mol B. Raised international normalized ratio: an early warning for a late cardiac tamponade? Ann Thorac Surg. 2006 Sep;82(3):1090-1. doi: 10.1016/j.athoracsur.2006.01.035. PMID: 16928545. REFERENCE #2: Zain Ul Abideen Asad, Sardar Hassan Ijaz, Amna Mohyud Din Chaudhary, Safi U. Khan, Aneesh Pakala, Hemorrhagic Cardiac Tamponade Associated with Apixaban: A Case Report and Systematic Review of Literature, Cardiovascular Revascularization Medicine, Volume 20, Issue 11, Supplement, 2019, Pages 15-20, ISSN 1553-8389, https://doi.org/10.1016/j.carrev.2019.04.002. DISCLOSURES: No relevant relationships by Besim Ademi No relevant relationships by Allison Ariatti No relevant relationships by Jacqueline Choa No relevant relationships by Yasin Khan