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:
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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:
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

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


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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