Tranexamic Acid Is Safe in Patients with a History of Coronary Artery Disease Undergoing Total Joint Arthroplasty

Abstract

Background:Tranexamic acid (TXA) is increasingly used to minimize blood loss during total joint arthroplasty (TJA). Although TXA has been shown to be highly effective in reducing operative blood loss, many surgeons believe that it places patients with coronary artery disease (CAD) or a history of coronary stents at an increased risk for myocardial infarction. The purpose of this study was to determine if TXA is safe to use in patients with a history of CAD or coronary stents.Methods:We performed a retrospective analysis at a single, tertiary academic medical center identifying consecutive total hip and knee arthroplasty cases over an 8-year period. From this cohort who received TXA intraoperatively, we identified patients with a history of CAD or coronary stents and determined the total myocardial infarction and venous thromboembolism (VTE) rates within a 90-day postoperative period. Chi-square analyses were used to identify differences in VTE rates between cohorts. A post hoc power analysis was also performed to determine whether our results were powered to detect a difference in VTE rates.Results:In the 26,808 identified at-risk patients, there were no postoperative myocardial infarctions. No significant differences were observed for VTE rates compared with the control cohort using either topical or intravenous TXA, with regard to CAD (0.29% compared with 0.76%; p = 0.09) or coronary stents (0% compared with 0.76%; p = 0.14). Moreover, there was no significant difference observed in VTE rates when administration was subcategorized into intravenous and topical methods with regard to CAD (0.13% compared with 0.72%; p = 0.12) or coronary stents (0% compared with 0%; p = 1.0).Conclusions:In our series, topical and intravenous TXA were equally safe when used in patients with a history of CAD and coronary stents in comparison with the control cohort. With equal efficacy and risk of adverse events, we recommend intravenous TXA, which may enable easier institutional implementation.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Recommendations from the ICM-VTE: General

“…This analysis is supported by a retrospective chart review of 38,220 TJA patients, where Porter et al, concluded that high-risk patients that receive TXA are not associated with an increase in adverse outcomes. Similar VTE risk profiles have been noted in orthopaedic patients with comorbid CAD and cancer patients undergoing endoprosthetic reconstruction for primary bone sarcoma or metastatic carcinoma to bone 465,466 . The decision to utilize TXA must not be solely based on the theoretical risk of VTE, but instead must weigh all risks and benefits to the medication.…”

Tranexamic acid: Beyond antifibrinolysis

“…18 In addition, evidence supports there is no increased associated risk of venous thromboembolism (VTE) with TXA usage in orthopedic surgical patients who have known coronary artery disease and/or coronary stents. 19…”

“…Recent studies have shown between a 30%–60% reduction in the need for perioperative transfusions with the use of TXA 18 . In addition, evidence supports there is no increased associated risk of venous thromboembolism (VTE) with TXA usage in orthopedic surgical patients who have known coronary artery disease and/or coronary stents 19 …”

Efficacy of intravenous tranexamic acid administration in medial opening wedge distal tuberosity osteotomy (MOWDTO) for varus knee osteoarthritis: a randomized control trial

“…As for potential risks of the use of TXA, previous studies in patients undergoing total joint arthroplasty have shown that TXA administration is not associated with increased incidence of DVT and PE [29,30].…”