Abstract 13722: There Will be Blood: A Cautionary Tale of Triple Therapy

A 54-year-old man with coronary artery disease, chronic kidney disease, atrial flutter, and chronic right internal carotid artery (ICA) occlusion was transferred to our institution for management of cardiogenic shock following an anterior ST-elevation myocardial infarction status post percutaneous coronary intervention of the left main coronary artery (LMCA). He was placed on short-term triple antithrombotic therapy. On the day before discharge, he acutely developed left sided neurological deficits and hypotension. Exam was concerning for a right hemispheric stroke. Labs revealed a creatinine of 2.8 mg/dL, INR of 3.7, and a hemoglobin of 6.6 g/dL (previously 10 g/dL). Prior to sending the patient for brain imaging, we performed a bedside echocardiogram to further evaluate his hypotension. This revealed a large pericardial effusion with tamponade physiology. We suspected hemorrhagic cardiac tamponade secondary to triple antithrombotic therapy. His hypotension initially responded to intravenous fluids and packed red blood cells, resulting in an improved neurologic exam and supporting our hypothesis that his deficits represented right cerebral hemispheric hypoperfusion in the setting of a known right ICA occlusion and tamponade. Pericardiocentesis was initially deferred, as the risk of bleeding appeared prohibitive without reversal of apixaban and his coagulopathy, and these measures would subject the patient to a significant risk of thrombosis (e.g. LMCA stent thrombosis). Unfortunately, the patient developed progressive shock. After careful informed consent, we proceeded with high-risk pericardiocentesis involving pre-procedural reversal of apixaban with andexanet alfa and successful evacuation of 300 ml of hemorrhagic fluid. The pericardial pressure improved from 24 mmHg to 4 mmHg with complete resolution of the patient’s shock and neurological deficits. Our case demonstrates the risks associated with triple antithrombotic therapy as well as the nuanced clinical decision-making and risk-benefit assessment required when considering the use of anticoagulant reversal agents to prevent bleeding complications in the context of recent ischemic events and the need for urgent invasive procedures.