Tranexamic Acid and Myocardial Infarction Risk
Tranexamic acid does not lead to myocardial infarction and is safe to use across diverse clinical settings, including in patients with pre-existing coronary artery disease. The most recent and comprehensive evidence demonstrates no increased risk of cardiovascular thromboembolic complications, including MI, with TXA use.
Evidence from Large-Scale Meta-Analyses
The highest quality evidence comes from recent systematic reviews examining this exact question:
A 2025 meta-analysis of 191 randomized controlled trials (40,621 participants) in non-cardiac surgery found no evidence of increased risk of cardiovascular thromboembolic complications, seizures, or mortality at 30 days with tranexamic acid use 1.
An even larger meta-analysis of 216 trials (125,550 participants) across all clinical settings found no evidence of increased risk of thromboembolic complications, supporting the general safety of TXA 1.
A 2021 systematic review and meta-analysis of 216 studies (125,550 patients) specifically examining thromboembolic events found no association between intravenous TXA and risk for total thromboembolic events, including myocardial infarction or ischemia (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = 0.49) 2.
Evidence from Trauma Literature
The landmark CRASH-2 trial provides particularly compelling evidence:
In 20,211 trauma patients, TXA actually showed a lower rate of thrombosis, especially myocardial infarction, compared to placebo 1.
While theoretical concerns about precipitated thrombosis with lysine analogues like TXA existed, the CRASH-2 data demonstrated the opposite effect 1.
No adverse events related to thrombosis were described with TXA use in this massive trial 1.
Safety in High-Risk Cardiac Populations
TXA is safe even in patients with established coronary artery disease:
A retrospective analysis of 26,808 total joint arthroplasty patients with history of CAD or coronary stents who received TXA found zero postoperative myocardial infarctions 3.
No significant differences in venous thromboembolism rates were observed in patients with CAD (0.29% vs 0.76%; p = 0.09) or coronary stents (0% vs 0.76%; p = 0.14) compared to controls 3.
A national claims database study of 765,011 hip/knee arthroplasties found no increased odds of composite complications (including MI) in high-risk patients with history of MI who received TXA (odds ratio 0.89; 99.9% CI, 0.49 to 1.59) 4.
In patients undergoing coronary endarterectomy during CABG—a particularly high-risk scenario—TXA showed no increased perioperative MI rates (2% vs 5%, p = 0.49) 5.
Important Caveats and Special Circumstances
The one documented exception involves complex coronary stent anatomy:
A single case report documented acute STEMI due to in-stent thrombosis after TXA in a patient with five drug-eluting stents, including overlapping stents in two locations 6.
Both overlapping stent locations thrombosed, while single stents remained patent 6.
TXA should be administered cautiously in patients with overlapping stents, bifurcation stents, excessive stent length, or previous in-stent restenosis/thrombosis 6.
FDA Labeling and Contraindications
The FDA label for TXA provides important context:
TXA is contraindicated in patients with active intravascular clotting and may increase risk of thromboembolic events 7.
Avoid concomitant use with pro-thrombotic medications including Factor IX concentrates and hormonal contraceptives 7.
However, history of MI alone is not listed as a contraindication 7.
Clinical Bottom Line
TXA does not cause myocardial infarction in the vast majority of patients, including those with pre-existing coronary disease. The only scenario requiring extreme caution is patients with complex coronary stent anatomy (overlapping or bifurcation stents). In all other contexts, including patients with history of MI or single coronary stents, TXA is safe and effective for reducing bleeding without increasing cardiac ischemic risk 1, 2, 3, 4.