71-year old male Admitted with worsening shortness of breath PMHx: Severe COPD, A.Fib, CHF/ischemic, PE On long term anticoagulation with Pradaxa 150.

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Presentation transcript:

71-year old male Admitted with worsening shortness of breath PMHx: Severe COPD, A.Fib, CHF/ischemic, PE On long term anticoagulation with Pradaxa 150 mg twice daily. Compliant with medications. COPD exacerbation/pneumonia were diagnosed Treatment for both issues was started Labs on admission: Hgb 12.7, WBC 15K, Plts 154K Creatinine 1.2 Metabolic panel otherwise normal CXR – b/l infiltrates consistent with pneumonia

Additional tests Lower extremity swelling was noted on hospital day #2 Lower extremity venous doppler : acute DVT in right posterior tibial and pernoneal veins

Question 1 New VTE in a patient who is being treated with Pradaxa. What additional diagnostic tests would you recommend?

Results: D-Dimer is negative Pradaxa was stopped LMWH was started Lupus anticoagulant is positive

Question 2: What are your plans regarding long term anticoagulation and with what agent?

51-year old female Admitted with lower extremity swelling Prior history of unprovoked PE one month ago F/U CT confirmed clearance of PE 2 weeks prior to admission. Hypercoagulable workup negative at outside hospital Maintained on Xarelto 20 mg daily and compliant with therapy Doppler study – acute DVT in left posterior tibial vein Labs on admission: Hgb 10.8, WBC 7.6K, Platelets 206K INR 1.4 PTT 33 Metabolic panel WNL

Now what? New VTE despite Xarelto?

Hospital course Started on therapeutic Lovenox q 12 hours. D/C Xarelto Hospital day 2 – worsening chest pain, SOB EKG: OK Echo reveals large pericardial effusion IVC filter placed prior to pericardiocentesis

Thoughts please!??

Hospital course continued CT chest – bilateral PE, pleural effusion, mediastinal adenpathy, adrenal mass, apical mass/infiltrate Now what??

Findings Pericardial fluid bloody with evidence of malignant cells (adenocarcinoma) in this patient with recent PE, acute DVT,IVC filter placement and now new evidence of malignancy…

Questions…questions…. How would you approach continued long term anticoagulation? For how long? With what agent? And what additional work up would you do?

THANK YOU