Abstract
BACKGROUND: Direct oral anticoagulants, such as direct factor Xa inhibitors, are commonly used to treat and prevent blood clots in patients with atrial fibrillation. Andexanet alfa reverses direct factor Xa inhibitors to help treat various thromboembolic conditions. Although it efficiently reverses anticoagulation by preventing life-threatening bleeding events, the use of andexanet alfa in today's clinical practice is limited due to the risk of thromboembolism and cost. CASE SUMMARY: A 76-year-old male presented with atrial fibrillation with rapid ventricular response and was started on Eliquis after a successful direct current cardioversion. Subsequently, the patient developed intracerebral haemorrhage, which required the administration of andexanet alfa. Ultimately, the patient suffered an ST-segment elevation myocardial infarction from complete occlusion of the mid-left anterior descending artery. His hospital course was complicated by acute hypoxic respiratory failure, septic shock, and renal failure. The family elected for comfort care measures and the patient expired shortly after. DISCUSSION: This case emphasizes the need for individualized clinical assessment and collaboration with an interdisciplinary team regarding the use of andexanet alfa, as well as strategies to ensure thrombotic risk is effectively minimized. Current European Society of Cardiology Guidelines do not have recommendations for the use of andexanet alfa for the reversal of anticoagulation due to its uncertain risk profile. This case emphasizes the increased risk of thrombotic complications associated with andexanet alfa and highlights the importance of the continued need to research its use, which may help elucidate or revise current guidelines.