We present a female patient with a history of systolic heart failure with an ejection fraction of 25-30%, and unprovoked pulmonary embolism on extended anticoagulation therapy with rivaroxaban who underwent a pericardial window for cardiac tamponade due to hemopericardium in the setting of direct oral anticoagulant (DOAC). The rivaroxaban was held following the pericardial window, and she experienced another episode of pulmonary embolism before the rivaroxaban could be restarted. Currently, there are no guidelines on when to restart anticoagulation postpericardial window for DOAC-associated hemopericardium. Studies are needed to help solve this dilemma.
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