From the Guidelines
Tranexamic acid can be safely used in STEMI patients with active bleeding, as it has been shown to reduce bleeding in various clinical settings without increasing the risk of thromboembolic complications, as supported by a meta-analysis of 216 trials 1.
Key Considerations
- The decision to use tranexamic acid should consider the severity of bleeding, the patient's thrombotic risk, and timing relative to reperfusion therapy.
- Tranexamic acid works by inhibiting plasminogen activation and fibrinolysis, which stabilizes clots and reduces bleeding.
- In STEMI patients receiving antiplatelet and anticoagulant therapies, this antifibrinolytic effect could potentially be beneficial for managing bleeding complications, but may theoretically worsen coronary thrombosis.
Administration and Monitoring
- For patients with life-threatening bleeding, tranexamic acid may be administered at a dose of 1 gram IV over 10 minutes, followed by 1 gram IV over 8 hours.
- Close cardiac monitoring is essential during administration, and tranexamic acid should be avoided in patients with known hypersensitivity, active intravascular clotting, or severe renal impairment.
- The medication should be used as part of a comprehensive approach to bleeding management that may include blood product transfusion and addressing the underlying cause of bleeding.
Evidence Summary
- A study published in Anaesthesia in 2025 1 found no evidence of an increased risk of thromboembolic complications associated with the use of tranexamic acid, supporting the general safety of the drug.
- Another study published in Anaesthesia in 2019 1 recommended the use of tranexamic acid in cases of severe bleeding, as it is an inexpensive and safe antifibrinolytic agent.
- The 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1 emphasized the importance of careful management of bleeding complications in STEMI patients, but did not specifically address the use of tranexamic acid.
From the Research
Safety of Tranexamic Acid in STEMI Patients with Active Bleeding
- The use of tranexamic acid (TXA) in patients with ST-elevation myocardial infarction (STEMI) and active bleeding is a complex issue, with limited direct evidence available 2, 3, 4, 5, 6.
- A case report suggests that TXA may increase the risk of thrombotic events in patients with complex stent anatomy, such as overlapping or bifurcation stents 2.
- However, other studies suggest that TXA may be safe and effective in reducing bleeding in patients with major bleeding, including those with STEMI, without increasing the risk of thrombotic events overall 4, 5.
- The optimal antithrombotic therapy for patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) is a topic of ongoing research, with various anticoagulant and antiplatelet agents available, including bivalirudin, prasugrel, and ticagrelor 3, 6.
- The use of TXA in patients with STEMI and active bleeding should be carefully considered, taking into account the individual patient's risk of bleeding and thrombosis, as well as the specific clinical context 4, 5.
- There is evidence that TXA increases the risk of venous thrombosis in patients with gastrointestinal bleeding and the risk of seizures with the use of higher doses 4.
- Clinical trials conducted in serious haemorrhage or in patients undergoing surgery with a high risk of bleeding have not shown an increased risk of thrombosis with TXA 5.