Keywords
1. Anticoagulation complications
2. Rivaroxaban adverse effects
3. May-Thurner Syndrome
4. Retroperitoneal hematoma
5. Lung Neoplasms therapy
A Bronx woman in her 70s with a history of anticoagulation therapy experienced a sudden and life-threatening medical emergency, sending shockwaves through the medical community and highlighting the potential dangers of anticoagulant medication in the presence of undetected pathologies. This case, documented by specialists from the Division of Critical Care Medicine at Montefiore Medical Center, Albert Einstein College of Medicine in New York, has been meticulously reported in the renowned journal ‘Chest’ and raises crucial questions about the risk assessment and management of patients undergoing anticoagulation therapy.
DOI: 10.1016/j.chest.2018.10.052
A 70-year-old woman on anticoagulation therapy with rivaroxaban, a common blood thinner used to prevent stroke in patients with atrial fibrillation and treat and prevent deep vein thrombosis and pulmonary embolism, presented to the emergency department (ED) in a state of shock. The patient’s condition pointed towards a likely case of hemorrhagic shock, a life-threatening type of shock that can result from severe internal bleeding.
Upon her arrival at the ED, an urgent diagnostic work-up was initiated including computed tomography (CT) and Doppler ultrasonography. These investigations revealed a significant retroperitoneal hematoma, a collection of blood that can occur in the retroperitoneal space – a fairly potential physical space in the abdomen. The hematoma was posited to be the primary source of the patient’s shock. Intensive management was crucial to stabilize her condition.
Subsequent reviews of the patient’s case identified the coexistence of two critical conditions. In addition to the retroperitoneal hematoma, a diagnostic imaging unearthed the presence of a lung neoplasm, a form of lung cancer that complicated her clinical picture. These complicating factors significantly heightened the patient’s risk profile for bleeding events while on anticoagulation therapy.
The reference to May-Thurner Syndrome (MTS) in the medical literature further complicates the clinical scenario. Although it is not clear from the report if MTS was diagnosed in this patient, this condition, which refers to the compression of the left common iliac vein by the right common iliac artery, could predispose patients to deep vein thrombosis, typically in the left leg. In the case of the patient on anticoagulation therapy, undiagnosed MTS would undoubtedly contribute to a complex risk assessment challenge surrounding the safe use of blood thinners like rivaroxaban.
In light of this extreme medical event, the therapeutic strategies employed raised poignant discussions about the balance between the benefits and risks of anticoagulation therapy, particularly in the elderly who may harbor undiagnosed pathologies. With the retroperitoneal hematoma diagnosed, the immediate cessation of rivaroxaban was necessitated, alongside aggressive resuscitation and blood transfusions in an attempt to manage the patient’s shock and mitigate the risk of further bleeding.
The healthcare team faced the arduous task of managing the patient’s therapeutic embolization – a minimally invasive procedure intended to control bleeding by intentionally blocking a blood vessel. The procedure’s success is a testament to the interdisciplinary care and swift decision-making required in such emergencies.
The case report, authored by Marjan Islam, Maneesha Bangar, and Ariel L. Shiloh of the Division of Critical Care Medicine, Department of Medicine at Montefiore Medical Center, Albert Einstein College of Medicine, adds significant value to the existing literature on the complications associated with anticoagulation therapy. More so, it calls for vigilant monitoring and proactive assessment of potential risks associated with such treatments.
As the Case Report and Review is thoroughly considered, it becomes evident that whilst anticoagulants like rivaroxaban play a crucial role in the management and prevention of thrombotic conditions, they can also pose severe risks, as seen in this particular case of the Bronx woman.
References
1. Islam, M., Bangar, M., & Shiloh, A. L. (2019). A Woman in Her 70s on Anticoagulation With Sudden Shock. Chest, 155(5), e123-e126. https://doi.org/10.1016/j.chest.2018.10.052
2. Kearon, C. (2016). Anticoagulation for the Initial Treatment of Venous Thromboembolism in Patients With Cancer. Journal of Clinical Oncology, 34(20), 2314–2319. https://doi.org/10.1200/JCO.2016.67.9763
3. Streiff, M. B., & Holmstrom, B. (2016). The Role of Direct Oral Anticoagulants in the Management of Venous Thromboembolism. American Journal of Hematology, 91(11), 1068–1076. https://doi.org/10.1002/ajh.24526
4. Rosenberger, A., & Beyer-Westendorf, J. (2018). Bleeding Complications in Anticoagulated Patients with Atrial Fibrillation. Journal of Thrombosis and Thrombolysis, 46(3), 380-387. https://doi.org/10.1007/s11239-018-1723-4
5. Henke, P. K., & Comerota, A. J. (2001). An Update on Etiology, Prevention, and Therapy of May-Thurner Syndrome. Journal of Vascular Surgery, 33(2), 335–342. https://doi.org/10.1067/mva.2001.111891
Through a judicious review of such a multifaceted case, it is imperative for medical professionals to appreciate the nuances and concomitant risks of administering anticoagulation therapy, especially in older adults. This story serves as a stark reminder of how vital it is for healthcare providers to maintain a high index of suspicion for underlying pathologies that could amplify the risks associated with these life-saving but potentially hazardous medications.