PDF(Pubmed)
Abstract：
Direct oral anticoagulants (DOACs), such as apixaban, are used for the prevention and management of thromboembolic diseases. Here, we present a case of a 72-year-old African American woman who presented to the hospital with shortness of breath and precordial chest pain for three days. The patient was diagnosed with volume overload associated with the progression of chronic kidney disease (CKD) and subsequently admitted to the hospital. Since the patient failed to adequately respond to diuretics, hemodialysis was initiated. During the hospital stay, she developed paroxysmal atrial fibrillation. Along with amiodarone, apixaban was started for primary stroke prophylaxis. Within 72 hours, the patient developed worsening chest pain. An echocardiogram revealed a large pericardial effusion with cardiac tamponade. She was taken for an emergent open pericardial window placement to relieve cardiac tamponade, where 600 mL of blood was drained. Considering the timeline of the development of a large bloody pericardial effusion following initiation of apixaban, spontaneous hemorrhagic cardiac tamponade attributed to the use of apixaban was diagnosed. The patient was eventually taken off all anticoagulants. In considering potential mechanisms, impaired hepatic and renal metabolism of apixaban could be factored in this case. In addition, CKD can increase bleeding risk, due to platelet dysfunction and impaired interaction of von Willebrand factor with GPIIb-IIIa. Moreover, renal secretion of apixaban is mediated by p-glycoprotein and amiodarone is an inhibitor of this protein. Although extremely rare, spontaneous hemorrhagic cardiac tamponade can occur with the use of DOACs, such as apixaban. Prompt recognition and urgent treatment remain keys to avoiding adverse patient outcomes.
摘要：
直接口服抗凝剂(DOACs),比如阿哌沙班，用于预防和管理血栓栓塞性疾病。这里,我们介绍了一例72岁的非洲裔美国妇女,她因呼吸急促和心前区胸痛住院3天.患者被诊断为与慢性肾脏疾病（CKD）进展相关的容量超负荷，随后入院。由于患者对利尿剂没有足够的反应，开始血液透析。住院期间,她出现了阵发性心房颤动.和胺碘酮一起,阿哌沙班开始用于初级预防卒中.在72小时内,患者出现胸痛加重。超声心动图显示大量心包积液伴心脏压塞。她被带去紧急开放心包窗口以缓解心脏压塞，600毫升的血液被排出。考虑到阿哌沙班开始后大量血性心包积液的发展时间表，诊断为使用阿哌沙班所致的自发性出血性心包填塞.患者最终停用了所有抗凝剂。在考虑潜在机制时，在这种情况下，可以考虑阿哌沙班的肝和肾代谢受损。此外,CKD可增加出血风险,由于血小板功能障碍和血管性血友病因子与GPIIb-IIIa的相互作用受损。此外，阿哌沙班的肾脏分泌由P-糖蛋白介导，胺碘酮是该蛋白的抑制剂。虽然极为罕见,使用DOAC可发生自发性出血性心脏填塞，比如阿哌沙班。及时识别和紧急治疗仍然是避免不良患者预后的关键。
