TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tranexamic acid is an antifibrinolytic drug used to control bleeding in various situations, including dental bleeding in hemophilia, postpartum hemorrhage, and hemoptysis. (1) Side effects associated with tranexamic acid are rare. There are five reported cases of tranexamic acid anaphylaxis. (2) We report a case of a patient who developed Takotsubo cardiomyopathy after its use. To our knowledge, this is the first reported case of Takotsubo cardiomyopathy associated with tranexamic acid. CASE PRESENTATION: A 68-year-old female with a past medical history significant for chronic obstructive pulmonary disease, coronary artery disease with a left circumflex stent placed in 2019, and previous Takotsubo cardiomyopathy in 2019 presented to the hospital with complaints of dyspnea. COVID-19 PCR was positive and she was treated with convalescent plasma, remdesivir, and dexamethasone. She developed mild but persistent hemoptysis during her stay at the hospital. CT chest revealed chronic bronchiectasis and her hemoglobin levels remained stable. Enoxaparin was stopped and inhaled tranexamic acid was prescribed by the pulmonary team as she was deemed high risk for bronchoscopy and her known bronchiectasis was thought to be contributing to her hemoptysis. Immediately following the first treatment with tranexamic acid, she became hypertensive, dyspneic, and a chest x-ray revealed new pulmonary edema. EKG revealed ST-segment elevations in leads V2-V4.(fig 1) She was placed on BiPAP which did not help her respiratory status and was subsequently intubated with improved blood pressures. Cardiac catheterization was emergently performed and was negative for coronary artery obstruction;however, it showed apical ballooning of the left ventricle with a reduced ejection fraction of 20%. (Fig 2, 3 ) A few hours after her return from the catheterization procedure, she developed cardiogenic shock requiring both ionotropic and vasopressor therapy. Swan Ganz catheter was placed that showed elevated filling pressure and low cardiac index. Over the next 24 hours, the patient developed acute renal and liver failure and her pressor requirement increased, and she was placed on five different agents. She was deemed not a candidate for mechanical circulatory support given her multiple organ failure and underlying oxygen-dependent chronic lung disease. She was transitioned to comfort care and expired. DISCUSSION: This is the first reported case of Takotsubo cardiomyopathy associated with exposure to tranexamic acid. Our patient rapidly deteriorated clinically with the first dose of tranexamic acid. Li et al. proposed a protocol to diagnose suspected adverse reactions to tranexamic acid that includes measuring serum tryptase level after the suspected reaction, skin prick test, and intradermal test. (3) CONCLUSIONS: Clinicians should keep the adverse reaction in their minds while prescribing tranexamic acid to patients. REFERENCE #1: 1)Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379-1384. doi: 10.1016/j.chest.2018.09.026 REFERENCE #2: 2) Plaster S, Holy F, Antony AK. Anaphylactic Reaction to Tranexamic Acid During Posterior Spinal Fusion: A Case Report. JBJS Case Connect. 2020;10(3): e2000130. doi:10.2106/JBJS.CC.20.00130 REFERENCE #3: 3) Li PH, Trigg C, Rutkowski R, Rutkowski K. Anaphylaxis to tranexamic acid—a rare reaction to a common drug. J Allergy Clin Immunol Pract. 2017;5(3):839-41. DISCLOSURES: No relevant relationships by Junaid mir, source=Web Response No relevant relationships by Krystle Shafer, source=Web Response