Canadian Cardiovascular Society and National Advisory Committee on Blood and Blood Products Joint Statement on Blood Utilization and Transfusion for Patients With Acute Coronary Syndromes

Although the evidence base broadly recommends a restrictive red blood cell (RBC) transfusion strategy for anemic patients, its appropriateness for patients with anemia and acute coronary syndromes is not definitive. The publication of the MINT trial has challenged the value of a restrictive transfusion strategy; our panel sought to provide an overview of the evidence and a data-informed expert opinion on the best practices for these patients. Four primary trials, including REALITY and MINT, individually showed no significant differences in their primary outcomes. However, published meta-analyses suggest liberal transfusion strategies might benefit patients. Our expert opinion in the joint statement is to consider patient clinical characteristics and systems factors when choosing an RBC transfusion threshold for patients with acute coronary syndromes and anemia. It is reasonable to consider a liberal RBC transfusion strategy, acknowledging uncertainty across patients, where a target hemoglobin of > 90 g/L might be considered appropriate. Our expert opinion is that it is not possible to suggest a differential transfusion strategy on the basis of patients with type 1 or 2 myocardial infarction alone, although patient and system factors should be strongly considered for type 2 myocardial infarction before considering a liberal transfusion strategy. Transfusion-associated circulatory overload is more common using a liberal transfusion target; mitigation strategies should be used if risk factors are present. Minimizing iatrogenic anemia and treating iron deficiency reduces the need for blood transfusion and could improve patient outcomes. In this joint statement we aim to provide practical guidance in the absence of definitive evidence.