Tranexamic acid precipitating onset of acute myocardial infarction

Background: Tranexamic acid is an antifibrinolytic agent used to reduce bleeding in surgeries with high postoperative bleeding risk and conditions such as menorrhagia. Due to increased risk of thrombosis it is contraindicated in patients with past history of venous thrombosis. What is less clear is the association of tranexamic acid with arterial thrombosis such as acute myocardial infarction. To date, there are five published case reports describing this association in patients with pre-existing cardiovascular risk factors. Aim: To increase awareness of the association between tranexamic acid and acute myocardial infarction. Clinical details: A 41-year-old female presented with non-ST elevation myocardial infarction 7 days post a course of oral tranexamic acid 1 g three times a day taken on day 1 of menses until completion of menses. She had no known cardiovascular risk factors. Outcome: The angiogram revealed a 70% stenosis within the proximal and mid segment of the first diagonal of the left anterior descending artery (LADD1). The presence of a 70% stenosis suggests pre-existing disease prior to tranexamic acid use, complicated by thrombus formation leading to the non-ST elevation myocardial infarction. The lesion was stented with a drug eluting stent and the patient was commenced on aspirin, ticagrelor, metoprolol and atorvastatin. Future use of tranexamic acid was discouraged and a levonorgestrol intra-uterine device was suggested as an alternative treatment for menorrhagia. Conclusion: This case adds to existing literature that tranexamic acid may precipitate the onset of acute myocardial infarction and this should be considered especially when it is prescribed in patients with cardiovascular risk factors.