92-year-old male with past medical history for paroxysmal atrial fibrillation and sick sinus syndrome s/p dual chamber pacemaker was maintained in sinus rhythm with sotalol. Prior attempts at anticoagulation with warfarin lead to spontaneous hematoma in the upper extremity leading to discontinuation of the drug. He was started on apixaban renally dosed at 2.5 mg oral twice daily. However, the next morning he subsequently developed periorbital facial edema, circumoral pruritis, symmetric swelling of his oral mucosa and tongue. Suspecting a hypersensitivity reaction, apixaban was discontinued. The following morning all signs of swelling and pruritis had resolved without the use of corticosteroids. This case demonstrates the unusual occurrence of angioedema with apixaban.
Atrial Fibrillation, Left Atrial Clot, Anticoagulation for Stroke Prevention, and Recurrent Gastrointestinal Bleeding: The Value of an Implantable Loop Recorder
74-year-old male with history of recurrent life-threatening gastrointestinal bleeding, presented with atrial fibrillation (AF). He was started on oral anticoagulation (OAC). Initial TEE revealed a left atrial clot. After 3 months of treatment with OAC, repeat TEE revealed no left atrial clot. The patient was started on oral amiodarone and electrically cardioverted. An implantable loop recorder (ILR) was placed to monitor AF burden. OAC was discontinued when ILR revealed only NSR for 3 months, and patient remains asymptomatic in NSR to date. ILR monitored rhythm control can be used to safely discontinue OAC in patients at high risk for bleeding.
New target specific anticoagulants (TSOACs) are convenient to use and are effective in managing the prophylaxis against thromboembolic sequela of atrial fibrillation (AF). However, without a test to monitor therapeutic efficacy, non-responders may not be detected until they suffer complications. We present a case where one year of dabigatran treatment failed to prevent development of a left atrial clot in the setting of AF.
Case of an 84-year-old male with history of colon cancer s/p colectomy, hypertension, and persistent atrial fibrillation on oral anticoagulation with dabigatran, presented with worsening anemia of unknown etiology.