Hemostatic effects of tranexamic acid in cardiac surgical patients with antiplatelet therapy: a systematic review and meta-analysis

Abstract

Background The purpose of the current study was to assess the efficacy of tranexamic acid (TXA) on reducing bleeding in cardiac surgical patients with preoperative antiplatelet therapy (APT). Methods Five electronic databases were searched systematically for randomized-controlled trials (RCTs) assessing the impact of intravenous TXA on post-operative bleeding on cardiac surgical patients with preoperative APT until May 2024. Primary outcome of interest was post-operative blood loss. Secondary outcomes of interest included the incidence of reoperation due to post-operative bleeding, post-operative transfusion requirements of red blood cells (RBC), fresh-frozen plasma (FFP), and platelet concentrates. Mean difference (MD) with 95% confidence interval (CI) or odds ratios (OR) with 95% CI was employed to analyze the data. Subgroup and meta-regression analyses were performed to assess the possible influence of TXA administration on reducing bleeding and transfusion requirements. Results A total of 12 RCTs with 3018 adult cardiac surgical patients (TXA group, 1510 patients; Control group, 1508 patients) were included. The current study demonstrated that TXA significantly reduced post-operative blood loss (MD = − 0.38 L, 95% CI: − 0.73 to − 0.03, P = 0.03; MD = − 0.26 L, 95% CI: − 0.28 to − 0.24, P < 0.00001; MD = − 0.37 L, 95% CI: − 0.63 to − 0.10, P = 0.007) in patients receiving dual antiplatelet therapy (DAPT), aspirin, or clopidogrel, respectively. Patients in TXA group had significantly lower incidence of reoperation for bleeding as compared to those in Control group. The post-operative transfusion of RBC and FFP requirements was significantly lower in TXA group than Control group. Subgroup analyses showed that studies with DAPT discontinued on the day of surgery significantly increased the risk of post-operative blood loss [(MD: − 1.23 L; 95% CI: − 1.42 to − 1.04) vs. (MD: − 0.16 L; 95% CI: − 0.27 to − 0.05); P < 0.00001 for subgroup difference] and RBC transfusion [(MD: − 3.90 units; 95% CI: − 4.75 to − 3.05) vs. (MD: − 1.03 units; 95% CI: − 1.96 to − 0.10); P < 0.00001 for subgroup difference] than those with DAPT discontinued less than 5–7 days preoperatively. Conclusions This meta-analysis demonstrated that TXA significantly reduced post-operative blood loss and transfusion requirements for cardiac surgical patients with preoperative APT. These potential clinical benefits may be greater in patients with aspirin and clopidogrel continued closer to the day of surgery. Trial registration number CRD42022309427.