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Left atrial thrombus formation after brief interruption of rivaroxaban
American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Left atrial thrombus formation after brief interruption of rivaroxaban☆,☆☆ Every year, nearly 250000 atrial fibrillation patients require temporary interruption of anticoagulation therapy for invasive procedures, acute illness, or bleeding events [1]. Rivaroxaban is an oral anticoagulant that works by inhibiting factor Xa leading to a blockage of thrombin production, which inhibits platelet aggregation and thrombus formation. As with other anticoagulants, there is an increased risk of a thrombotic event occurring when rivaroxaban therapy is temporarily interrupted (TI) or prematurely discontinued. The 30-day rate of stroke or systemic embolism for rivaroxaban TI is 0.36% [2]. Possible factors for higher than expected rates of embolic events include a prothrombotic perioperative environment among patients having TI for surgery and a prothrombotic environment associated with TI due to bleeding. The ROCKET AF study showed that there was no detectable difference in the risk of stroke and systemic embolism for participants treated with rivaroxaban vs warfarin undergoing TI [2]. Another analysis suggested that the risk for stroke from TI is probably higher in the rivaroxaban group with 3 to 30 days discontinuation [3]. Alternative anticoagulation therapy such as bridging should always be considered when stopping rivaroxaban. A 66-year-old man with a history of hypertension and atrial fibrillation was being treated with rivaroxaban. He developed epigastric discomfort and presented to the hospital where he was noted to be hypertensive and bradycardic with a large pericardial effusion of unknown etiology. The patient underwent a pericardiocentesis and was scheduled for a pacemaker placement. The rivaroxaban was discontinued. The day after the pericardiocentesis, the patient developed acute onset of right upper and lower extremity hemiparesis and aphasia. Imaging revealed an ischemic stroke with a large left middle cerebral artery (MCA) infarct. He was not a candidate for thrombolysis given his recent pericardiocentesis and concern for hemorrhagic conversion of a large MCA stroke. Thus, he underwent transcatheter thrombectomy of the left MCA thrombus (Fig. 1). The patient was transferred to a rehabilitation facility and made progress in recovery with increased right-sided strength and renewed ability to follow simple commands. The patient underwent a head computed tomography to assess for hemorrhagic conversion of his left MCA infarct before restarting anticoagulation therapy. The study noticed increased attenuation of the cortex in the large MCA territory with petechial hemorrhages. There was moderate mass effect on the left lateral ventricle with mild rightward midline shift. A decision was made to defer anticoagulation. Ten days later, the patient developed acute leftsided weakness and became unresponsive.
☆ No conflicts of interest. ☆☆ No funding.
The patient was brought to the emergency department and, on examination, was found to have a blood pressure of 229/115, and an electrocardiogram showed atrial fibrillation and no acute ischemic changes. He underwent a head computed tomography demonstrating worsening of the left MCA infarct and increased edema and midline shift. Given the cerebral edema, the patient was started on levetiracetam and dexamethasone. The patient was also started on aspirin, and his left-sided weakness began to improve. The next day, the patient underwent an echocardiogram, which demonstrated a large mobile left atrial thrombus 2 cm in diameter (Figs. 1 and 2). Given the recent stroke, the patient was emergently transferred and underwent a left atrial thrombectomy. He recovered and was transitioned to aspirin 81 mg and apixaban 5 mg twice daily. (See Fig. 3.) Interruption and discontinuation of rivaroxaban is common and associated with a substantial increased risk of stroke and embolic events. In the ROCKET AF study, a significantly higher event rate was seen with rivaroxaban when compared to warfarin patients with 3 to 30 days discontinuation. The number needed to harm for 3 to 30 days after discontinuation of rivaroxaban therapy is 286 [3]. In patients at high risk for stroke, we recommend consideration of bridging with an alternative anticoagulant. Matthew Turner MD candidate* David Solarz MD Columbia University College of Physicians and Surgeons New York, NY 10032 *Corresponding author. Columbia University Medical Center 15 North Broadway, White Plains, NY 10601 E-mail addresses: [email protected] [email protected] (D. Solarz)
http://dx.doi.org/10.1016/j.ajem.2015.05.030 References [1] Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published erratum appears in Chest 2012;141(4):1129]. Chest 2012;141(2 Suppl):e326S–50S. [2] Sherwood MW, Douketis JD, Patel MR, Piccini JP, Hellcamp AS, Lokhnygina Y, et al. Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation 2014;129(18):1850–9. [3] Patel MR, Hellkamp AS, Lokhnygina Y, Piccini JP, Zhang Z, Mohanty S, et al. Outcomes of discontinuing rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: analysis from the ROCKET AF trial. J Am Coll Cardiol 2013;61:651–8.
http://dx.doi.org/10.1016/j.ajem.2015.05.030 0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Turner M, Solarz D, Left atrial thrombus formation after brief interruption of rivaroxaban, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.030
2
M. Turner, D. Solarz / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Fig. 1. Parasternal long-axis view on transthoracic echocardiogram before discontinuation of rivaroxaban. Fig. 3. Left atrial thrombus specimen.
Fig. 2. Parasternal long-axis view on transthoracic echocardiogram after stroke.
Please cite this article as: Turner M, Solarz D, Left atrial thrombus formation after brief interruption of rivaroxaban, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.030
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Left atrial thrombus formation after brief interruption of rivaroxaban☆,☆☆ Every year, nearly 250000 atrial fibrillation patients require temporary interruption of anticoagulation therapy for invasive procedures, acute illness, or bleeding events [1]. Rivaroxaban is an oral anticoagulant that works by inhibiting factor Xa leading to a blockage of thrombin production, which inhibits platelet aggregation and thrombus formation. As with other anticoagulants, there is an increased risk of a thrombotic event occurring when rivaroxaban therapy is temporarily interrupted (TI) or prematurely discontinued. The 30-day rate of stroke or systemic embolism for rivaroxaban TI is 0.36% [2]. Possible factors for higher than expected rates of embolic events include a prothrombotic perioperative environment among patients having TI for surgery and a prothrombotic environment associated with TI due to bleeding. The ROCKET AF study showed that there was no detectable difference in the risk of stroke and systemic embolism for participants treated with rivaroxaban vs warfarin undergoing TI [2]. Another analysis suggested that the risk for stroke from TI is probably higher in the rivaroxaban group with 3 to 30 days discontinuation [3]. Alternative anticoagulation therapy such as bridging should always be considered when stopping rivaroxaban. A 66-year-old man with a history of hypertension and atrial fibrillation was being treated with rivaroxaban. He developed epigastric discomfort and presented to the hospital where he was noted to be hypertensive and bradycardic with a large pericardial effusion of unknown etiology. The patient underwent a pericardiocentesis and was scheduled for a pacemaker placement. The rivaroxaban was discontinued. The day after the pericardiocentesis, the patient developed acute onset of right upper and lower extremity hemiparesis and aphasia. Imaging revealed an ischemic stroke with a large left middle cerebral artery (MCA) infarct. He was not a candidate for thrombolysis given his recent pericardiocentesis and concern for hemorrhagic conversion of a large MCA stroke. Thus, he underwent transcatheter thrombectomy of the left MCA thrombus (Fig. 1). The patient was transferred to a rehabilitation facility and made progress in recovery with increased right-sided strength and renewed ability to follow simple commands. The patient underwent a head computed tomography to assess for hemorrhagic conversion of his left MCA infarct before restarting anticoagulation therapy. The study noticed increased attenuation of the cortex in the large MCA territory with petechial hemorrhages. There was moderate mass effect on the left lateral ventricle with mild rightward midline shift. A decision was made to defer anticoagulation. Ten days later, the patient developed acute leftsided weakness and became unresponsive.
☆ No conflicts of interest. ☆☆ No funding.
The patient was brought to the emergency department and, on examination, was found to have a blood pressure of 229/115, and an electrocardiogram showed atrial fibrillation and no acute ischemic changes. He underwent a head computed tomography demonstrating worsening of the left MCA infarct and increased edema and midline shift. Given the cerebral edema, the patient was started on levetiracetam and dexamethasone. The patient was also started on aspirin, and his left-sided weakness began to improve. The next day, the patient underwent an echocardiogram, which demonstrated a large mobile left atrial thrombus 2 cm in diameter (Figs. 1 and 2). Given the recent stroke, the patient was emergently transferred and underwent a left atrial thrombectomy. He recovered and was transitioned to aspirin 81 mg and apixaban 5 mg twice daily. (See Fig. 3.) Interruption and discontinuation of rivaroxaban is common and associated with a substantial increased risk of stroke and embolic events. In the ROCKET AF study, a significantly higher event rate was seen with rivaroxaban when compared to warfarin patients with 3 to 30 days discontinuation. The number needed to harm for 3 to 30 days after discontinuation of rivaroxaban therapy is 286 [3]. In patients at high risk for stroke, we recommend consideration of bridging with an alternative anticoagulant. Matthew Turner MD candidate* David Solarz MD Columbia University College of Physicians and Surgeons New York, NY 10032 *Corresponding author. Columbia University Medical Center 15 North Broadway, White Plains, NY 10601 E-mail addresses: [email protected] [email protected] (D. Solarz)
http://dx.doi.org/10.1016/j.ajem.2015.05.030 References [1] Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published erratum appears in Chest 2012;141(4):1129]. Chest 2012;141(2 Suppl):e326S–50S. [2] Sherwood MW, Douketis JD, Patel MR, Piccini JP, Hellcamp AS, Lokhnygina Y, et al. Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation 2014;129(18):1850–9. [3] Patel MR, Hellkamp AS, Lokhnygina Y, Piccini JP, Zhang Z, Mohanty S, et al. Outcomes of discontinuing rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: analysis from the ROCKET AF trial. J Am Coll Cardiol 2013;61:651–8.
http://dx.doi.org/10.1016/j.ajem.2015.05.030 0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Turner M, Solarz D, Left atrial thrombus formation after brief interruption of rivaroxaban, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.030
2
M. Turner, D. Solarz / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Fig. 1. Parasternal long-axis view on transthoracic echocardiogram before discontinuation of rivaroxaban. Fig. 3. Left atrial thrombus specimen.
Fig. 2. Parasternal long-axis view on transthoracic echocardiogram after stroke.
Please cite this article as: Turner M, Solarz D, Left atrial thrombus formation after brief interruption of rivaroxaban, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.030