Pulmonary embolism four days after interruption of therapy with rivaroxaban

Summary

Thrombosis after cessation of anticoagulation, also named rebound thrombosis, is a matter of concern and controversy. There are only few published data about occurrence of rebound thrombosis associated with non-vitamin K-antagonist oral anticoagulant drugs (NOACs). We report on a 58-year-old male with paroxysmal atrial fibrillation (AF) with a CHA₂DS₂VASC score of 4 who developed central pulmonary embolism four days after interruption of rivaroxaban because of parotid surgery. He had received 40 mg enoxaparin/d. The parotid gland was partially resected within 6 hours without blood loss. Pulmonary embolism and AF occurred on the first postoperative day. He recovered with low-molecular-weight heparin in therapeutic dosages and amiodarone and was discharged with phenprocoumon. The relevance of a rivaroxaban rebound phenomenon, manifesting as arterial embolism, stroke or venous thromboembolism should be clarified. It should be assessed if rebound-phenomena also exist for the NOACs dabigatran, apixaban and edoxaban. Thus, the randomized trials and registries investigating patients with AF or venous thromboembolism should be re-analysed and, based on these data, recommendations should be developed for situations in which NOAC-therapy has to be interrupted or ceased.

Zusammenfassung

Ob es nach Beendigung einer Antikoagulationstherapie zu einer neuerlichen Thromboembolie, auch “Rebound” genannt, kommen kann, ist umstritten und es gibt nur wenige Daten über dieses Phänomen nach einer Therapie mit nicht Vitamin K-Antagonisten oralen Antikoagulantien (NOAKs). Ein 58-jähriger Mann mit paroxysmalem Vorhofflimmern (AF) und einem CHA₂DS₂VASC Score von 4 erlitt eine zentrale Pulmonalarterienembolie vier Tage nach Unterbrechung der Therapie mit Rivaroxaban wegen eines chirurgischen Eingriffs an der Parotis. Zum Zeitpunkt des Ereignisses stand er unter einer Therapie mit 40 mg Enoxaparin/Tag. Die Parotis wurde in einer 6-stündigen Operation ohne relevanten Blutverlust partiell reseziert. Am ersten postoperativen Tag traten eine Pulmonalembolie und tachykardes AF auf. Er erholte sich unter einer Therapie mit niedermolekularem Heparin in therapeutischer Dosis und Amiodaron und wurde mit einer Therapie mit Phenprocoumon entlassen. Die Relevanz eines “Rivaroxaban-Rebound-Phänomens”, das als arterielle Embolie, Schlaganfall oder venöse Thromboembolie auftreten kann, sollte genauer erforscht werden. Es sollte festgestellt werden, ob ähnliche Phänomene auch bei den NOAKs Dabigatran, Apixaban und Edoxaban auftreten. Randomisierte Studien und Register, die Patienten mit AF oder venöser Thromboembolie eingeschlossen haben, sollten unter diesem Gesichtspunkt ausgewertet werden. Es sollten Empfehlungen ausgearbeitet werden für die Antikoagulation in Situationen, in denen die Therapie mit NOAKs unterbrochen oder beendet wird.

Keywords

Non-vitamin K-antagonist - oral anticoagulants - rivaroxaban rebound phenomenon - atrial fibrillation - pulmonary embolism

Schlüsselwörter

Nicht Vitamin K-Antagonisten - orale Antikoagulantien - Rivaroxaban - Rebound-Phänomen - Vorhofflimmern - Pulmonalembolie

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