Fatal bleeding associated with Rivaroxaban in patient with gastric lymphoma

44-year-old gentleman with history of gastric lymphoma status-post multiple cycles of chemotherapy, atrial fibrillation (AF) and hypertension was brought to the hospital in an unconscious state after a syncopal episode. He was tachycardic in the 130s-140s with systolic blood pressure in the 70s. He was given intravenous fluids and vasopressors. Naso-gastric tube placement brought back blood. Patient was on rivaroxaban for primary prevention of stroke. Patient reported one episode of dark colored stool and was complaining of epigastric discomfort. Gastroenterology was consulted and a pantoprazole drip was started. His creatinine was 4.8, baseline value was 0.9. Esophago-gastro-duodenoscopy showed blood in proximal stomach and tumor mass in distal body of the stomach. No point source was found amenable to endoscopic treatment. Surgical consultation was requested but patient developed cardiac arrest with asystole. Resuscitation attempts failed, and patient died of hemorrhagic shock. Rivaroxaban was approved in November 2011 by the US Food and Drug Administrationfor stroke prevention in non-valvular AF. Thispatient had a score of 1, for hypertension and had gastric lymphoma which increased his bleeding risk. The risk outweighed benefit of anticoagulation, especially with an irreversible agent. Physician education is thus necessary to ensure appropriate patient selection and safety for use of irreversible oral anticoagulants.