Key result
Administration of andexanet alfa for the reversal of anticoagulation in a 76-year-old male with intracerebral haemorrhage was followed by a fatal ST-segment elevation myocardial infarction.
Why the study?
The clinical use of andexanet alfa to reverse direct factor Xa inhibitors is limited by the risk of thromboembolism, cost, and an uncertain risk profile lacking specific recommendation in current guidelines.
Case Report (n=1)
This case highlights the severe thrombotic risk, specifically STEMI, associated with the use of andexanet alfa for reversing direct factor Xa inhibitors.
Should prompt individualized risk assessment before andexanet use; leaves open whether thrombotic harms outweigh hemostatic benefit.
Background: Direct oral anticoagulants, such as direct factor Xa inhibitors, are commonly used to treat and prevent blood clots in patients with atrial fibrillation. Andexanet alfa reverses direct factor Xa inhibitors to help treat various thromboembolic conditions. Although it efficiently reverses anticoagulation by preventing life-threatening bleeding events, the use of andexanet alfa in today's clinical practice is limited due to the risk of thromboembolism and cost. Case summary: A 76-year-old male presented with atrial fibrillation with rapid ventricular response and was started on Eliquis after a successful direct current cardioversion. Subsequently, the patient developed intracerebral haemorrhage, which required the administration of andexanet alfa. Ultimately, the patient suffered an ST-segment elevation myocardial infarction from complete occlusion of the mid-left anterior descending artery. His hospital course was complicated by acute hypoxic respiratory failure, septic shock, and renal failure. The family elected for comfort care measures and the patient expired shortly after. Discussion: This case emphasizes the need for individualized clinical assessment and collaboration with an interdisciplinary team regarding the use of andexanet alfa, as well as strategies to ensure thrombotic risk is effectively minimized. Current European Society of Cardiology Guidelines do not have recommendations for the use of andexanet alfa for the reversal of anticoagulation due to its uncertain risk profile. This case emphasizes the increased risk of thrombotic complications associated with andexanet alfa and highlights the importance of the continued need to research its use, which may help elucidate or revise current guidelines.
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Mehrara et al. (2025) conducted a case report in Intracerebral haemorrhage and atrial fibrillation (n=1). Andexanet alfa was evaluated on ST-segment elevation myocardial infarction. Administration of andexanet alfa for the reversal of anticoagulation in a 76-year-old male with intracerebral haemorrhage was followed by a fatal ST-segment elevation myocardial infarction.
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