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Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia.

Jeffrey L Carson1, Maria Mori Brooks1, Paul C Hébert1

  • 1From the Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C., W.J.K., H.N., S.K.); the Departments of Epidemiology and Biostatistics, School of Public Health, University of Pittsburgh (M.M.B., M.B., S.F.K.), and the Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh School of Medicine (D.J.T.) - both in Pittsburgh; the Bruyere Research Institute, University of Ottawa (P.C.H.), and the Clinical Epidemiology Program, Ottawa Hospital Research Institute (D.A.F.), Ottawa, St. Michael's Hospital, University of Toronto, Toronto (S.G.G.), Canadian VIGOUR Centre, University of Alberta (S.G.G.), and the Department of Medicine, Grey Nuns Hospital (M.S.), Edmonton, CHUM Research Centre (B.J.P.), the Departments of Anesthesiology and Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Innovation and Evaluation Hub, Centre de Recherche du CHUM (F.M.C., P.C.H.), and the Department of Anesthesiology and Pain Medicine, Université de Montréal (F.M.C.), Montreal, the Department of Medicine, McMaster University, Hamilton, ON (J.D.N.), the Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital and University of British Columbia, Vancouver (C.B.F.), and Centre Hospitalier Universitaire (CHU) de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC (B.D.) - all in Canada; the National Heart, Lung, and Blood Institute, Bethesda, MD (S.A.G.); St. Louis University School of Medicine, St. Louis (B.R.C.); FACT (French Alliance for Cardiovascular Trials) (T.S., G.D., P.G.S.), Service de Pharmacologie, Plateforme de Recherche Clinique de l'Est Parisien, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint Antoine, Sorbonne Université (T.S.), Université Paris-Cité, INSERM Unité 1148 and AP-HP, Hôpital Bichat (G.D., P.G.S.), Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Hôpital Pitié-Salpêtrière AP-HP (J.S.), and AP-HP, Hôpital Européen Georges Pompidou, Department of Cardiology, Université de Paris (E.P.), Paris, Hôpital Pasteur, Service de Cardiologie, CHU Nice, Nice (E.F.), University Hospital of Poitiers, Clinical Investigation Center (INSERM 1204), Cardiology Department, Poitiers (C.B.), and Nimes University Hospital, Montpelier University, ACTION Group, Nimes (B.L.) - all in France; Duke Clinical Research Institute, Duke University, Durham (R.D.L., J.H.A.), and the Department of Medicine, WakeMed Health and Hospitals, Winston-Salem (F.O.W.) - both in North Carolina; Brazilian Clinical Research Institute, Sao Paulo (R.D.L., P.G.M.B.S.); the Department of Medicine, Baystate Medical Center, Springfield (A.M.G.), and the Department of Pathology (L.U.) and Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (J.B.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston - both in Massachusetts; the University of Nebraska Medical Center, Omaha (A.M.G.); the Department of Medicine, Vanderbilt University Medical Center, Nashville (A.P.D.); Lifespan Cardiovascular Institute and the Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, Providence, RI (J.D.A.); the Department of Medicine, NYU Langone Health System (S.V.R.), and the Department of Medicine, Montefiore Medical Center (M.A.M.), New York, and the Department of Cardiology, Westchester Medical Center, Valhalla (H.A.C.) - all in New York; the Department of Medicine, University of Louisville, Louiville, KY (S.G.); UChicago AdventHealth Heart and Vascular (M.T.) and the Department of Medicine, University of Chicago Medicine (T.S.P.) - both in Chicago; and Green Lane Coordinating Center, Auckland, New Zealand (C.A., H.D.W.).

The New England Journal of Medicine
|November 12, 2023
PubMed
Summary
This summary is machine-generated.

A liberal red blood cell transfusion strategy did not significantly reduce myocardial infarction or death in anemic patients. However, restrictive transfusion strategies may carry potential harms, warranting careful consideration in clinical practice.

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Area of Science:

  • Cardiology
  • Hematology
  • Critical Care Medicine

Background:

  • The standard practice of red blood cell transfusion for anemia is typically initiated when hemoglobin levels drop below 7-8 g/dL.
  • Patients experiencing acute myocardial infarction (AMI) may potentially benefit from higher hemoglobin levels.
  • The optimal hemoglobin threshold for transfusion in AMI patients remains an area of clinical investigation.

Purpose of the Study:

  • To compare the efficacy and safety of restrictive versus liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia.
  • To determine the impact of transfusion thresholds on the incidence of recurrent myocardial infarction or death within 30 days post-event.

Main Methods:

  • A Phase 3, randomized, interventional trial involving 3504 patients with myocardial infarction and hemoglobin <10 g/dL.
  • Patients were assigned to either a restrictive transfusion strategy (hemoglobin cutoff 7-8 g/dL) or a liberal transfusion strategy (hemoglobin cutoff <10 g/dL).
  • The primary endpoint was a composite of myocardial infarction or all-cause mortality at 30 days.

Main Results:

  • The liberal transfusion strategy group received significantly more red blood cell units (2.5±2.3) compared to the restrictive group (0.7±1.6).
  • No statistically significant difference was observed in the primary outcome event rate between the groups (16.9% restrictive vs. 14.5% liberal; risk ratio 1.15, 95% CI 0.99-1.34).
  • Individual components of the primary outcome, including death and myocardial infarction, also did not differ significantly between the two strategies.

Conclusions:

  • In patients with AMI and anemia, a liberal transfusion strategy did not significantly decrease the risk of recurrent myocardial infarction or death at 30 days.
  • The study suggests that while a liberal approach may not offer significant benefits, the potential harms associated with a restrictive strategy cannot be ruled out.
  • Further research may be needed to establish the precise transfusion thresholds that optimize outcomes for this patient population.