TXA OK in Cardiac/Knee Replacement Patients?

Citing controversy on the use of tranexamic acid (TXA) in patients with coronary artery disease who undergo total joint arthroplasty (TJA), researchers from the New York University (NYU) Langone Orthopedic Hospital/Hospital for Joint Diseases in Manhattan decided to organize what became a first-of-a-kind study.

Their work, “Tranexamic Acid Is Safe in Patients with a History of Coronary Artery Disease Undergoing Total Joint Arthroplasty,” was published in the May 19, 2021, edition of The Journal of Bone and Joint Surgery.

Co-author Ran Schwarzkopf M.D., M.Sc. associate chief of the division of adult reconstruction at the New York University Langone Orthopedic Hospital/Hospital for Joint Diseases in Manhattan, explained to OTW that this particular study was truly a first of its kind.

“This was the first paper looking at the relationship of coronary artery disease patients and treatment with intravenous (IV) TXA and topical administration. We wanted to see if there is an increase in complications among these patients (such as myocardial infarction or cardiac issues). Previous papers that looked at TXA and risk factors may have looked at patients with coronary artery disease as a sub analysis and not as main goal.”

The researchers did a retrospective chart review of cases from June 2011 to September 2019, identifying the total number of consecutive patients who underwent a primary total joint arthroplasty. Of those who were given intraoperative TXA, they identified 26,808 patients at risk of a cardiac event.

The team found no postoperative myocardial infarctions and no significant differences in terms of venous thromboembolism rates “compared with the control cohort using either topical or intravenous TXA, with regard to coronary artery disease (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 venous thromboembolism rates rates when administration was subcategorized into intravenous and topical methods with regard to coronary artery disease (0.13% compared with 0.72%; p = 0.12) or coronary stents (0% compared with 0%; p = 1.0).”

“The most important thing,” said Dr. Schwarzkopf to OTW, “is that we saw no increased complications among coronary artery disease patients that were treated with either IV or topical TXA. This allows us to use TXA freely with these patients, we are well aware of the advantages of TXA on blood loss recovery and decreased infections.”

Regarding the clinical implications of this work, Dr. Schwarzkopf commented to OTW, “The main clinical benefit is removing one of the last contra or partial contra indications for TXA use in total joint patients. This will allow hospitals to update their protocols to allow TXA use freely in coronary artery disease.”

When OTW asked if orthopedic surgeons might wait for further research in this area, Dr. Schwarzkopf stated, “I think this study will help solidify the common belief that TXA is safe in coronary artery disease patients. I do not think that surgeons will keep waiting for more papers to feel comfortable with this conclusion.”