Spontaneous Hemorrhagic Tamponade Associated with Rivaroxaban Use

A 69-year-old female with a past medical history of severe aortic stenosis, heart failure with preserved ejection fraction and paroxysmal atrial fibrillation on rivaroxaban and diltiazem presented to the emergency department with shortness of breath and lightheadedness. Her vital signs were significant for hypotension. Cardiovascular examination revealed muffled heart sounds and an elevated jugular venous pressure. An electrocardiogram was done which showed atrial fibrillation with rapid ventricular response. The echocardiogram revealed a large pericardial effusion (Image 1 and Image 2) and plethora of the inferior vena cava (Image 3). M mode showed diastolic collapse of the right ventricle. Doppler interrogation of mitral inflow showed >30% change in velocity with respiration. Pericardiocentesis was performed with removal of 650 milliliters of bloody fluid. Her symptoms resolved. Analysis of the pericardial fluid revealed 1.5 million RBCs/μl and 5700 WBCs/μl with 74% neutrophils, 16% lymphocytes and 10% monocytes. Cytology was negative for malignant cells. Repeat echocardiogram showed resolution of the pericardial fluid. Of note, she did not have a prior history of a pericarditis or previous cardiac procedure.

Image 1: Parasternal Long Axis View

Image 1

Image 2: Parasternal Short Axis View

Image 2

Image 3: IVC Plethora

Image 3

Which of the following predisposed the patient to develop a hemorrhagic pericardial effusion?

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