Clinical Outcomes with High- versus Low-Dose Tranexamic Acid Infusion in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis.

Abstract

Objectives:  Antifibrinolytics, such as tranexamic acid (TXA), are widely used in cardiac surgery to reduce bleeding risks; however, the optimal dosage for TXA infusion remains a subject of debate. Hence, this study aims to evaluate the safety and efficacy of high-dose compared with low-dose TXA infusion in cardiac surgery patients.

Methods:  PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched until June 10, 2023, for studies assessing efficacy outcomes (e.g., blood loss, transfusions) and safety outcomes (e.g., mortality, complications).

Results:  Results were analyzed via random-effects model, using Mantel-Haenszel risk ratio (RR) and standard mean difference (SMD). P-value < 0.05 was considered significant. We analyzed 17 studies involving 93,206 participants (mean age 59.3 years, study duration 3 months to 10 years). Our analysis found significant reductions in total blood loss (SMD, -0.17 g; CI, -0.34 to -0.01; p = 0.04), 24-hour blood loss (SMD, -0.23 g; p = 0.005), and the need for fresh frozen plasma (FFP) transfusions (RR: 0.94; CI, 0.89 to 1.00; p = 0.05) with high-dose TXA. Chest tube output was also lower (SMD, -0.12 g; p = 0.0006), but postoperative seizures increased (RR: 2.23; CI, 1.70 to 2.93; p < 0.00001) with high-dose TXA. For other outcomes like blood transfusions, hospital/ICU stay, mortality, stroke, myocardial infarction, pulmonary embolism, renal dysfunction, and reoperation, no significant differences were found between high-dose and low-dose TXA regimens.

Conclusion:  Our study showed that high TXA dose effectively reduce postoperative bleeding, chest tube drainage, and the need for FFP transfusion, but it increases the risk of seizures. Increasing TXA dose did not affect thromboembolic events or mortality. This emphasizes the importance of weighing the benefits and risks when selecting the appropriate TXA regimen for each patient.