Liberal or Restrictive Postoperative Transfusion in Patients at High Cardiac Risk: The TOP Randomized Clinical Trial.

Area of Science:

• Cardiology
• Transfusion Medicine
• Critical Care Medicine

Background:

• Current red blood cell transfusion guidelines suggest transfusing patients with hemoglobin levels below 7 g/dL.
• The safety of liberal transfusion strategies in high-risk cardiac patients undergoing major surgery is not well-established.

Purpose of the Study:

• To compare the risks of death or major ischemic events within 90 days between liberal and restrictive transfusion strategies.
• To evaluate outcomes in patients at high cardiac risk who underwent major surgery and developed postoperative anemia.

Main Methods:

• A randomized clinical superiority trial involving 1428 high-risk cardiac patients undergoing major vascular or general surgery.
• Participants with postoperative hemoglobin <10 g/dL were randomized to either a liberal (transfusion trigger <10 g/dL) or restrictive (transfusion trigger <7 g/dL) strategy.

Main Results:

• The primary outcome (composite of death, myocardial infarction, coronary revascularization, acute kidney failure, or ischemic stroke) occurred in 9.1% of the liberal group vs. 10.1% of the restrictive group (RR, 0.90; 95% CI, 0.65-1.24).
• A secondary outcome (cardiac complications excluding myocardial infarction) occurred in 5.9% of the liberal group vs. 9.9% of the restrictive group (RR, 0.59; 99% CI, 0.36-0.98).

Conclusions:

• In patients at high cardiac risk undergoing major surgery, a liberal transfusion strategy did not decrease 90-day death or major ischemic event rates compared to a restrictive strategy.
• The liberal transfusion strategy was associated with a reduction in non-myocardial infarction cardiac complications.