Variations in the Use of Blood Transfusion in Patients with Coronary Artery Disease

Login or register to view PDF.
Abstract

Blood transfusions are frequently given to patients to treat low hemoglobin levels in the setting of non-ST-segment elevation acute coronary syndromes, percutaneous coronary intervention, and coronary artery bypass grafting. Evidence suggests that blood transfusion therapy in the setting of ischemic heart disease is associated with an increased risk for morbidity and mortality; however, there are no randomized clinical trials concerning transfusion strategies in ischemic heart disease. The evidence to date is observational and subject to confounding influences. This lack of definitive data has led to wide variations in transfusion practice in both the US and the international medical community. The purpose of this article is to examine the current literature concerning the transfusion practice of whole or packed red blood cells in the US and internationally in patients with ischemic heart disease. We propose that a prospective, randomized, controlled trial of transfusion strategies in ischemic heart disease is needed to determine the role of transfusion in this patient population.

Disclosure
Antonio Gutierrez, MD, has no conflicts of interest to declare. Sunil V Rao, MD, FACC, FSCAI, is a consultant for sanofi-aventis, Bristol Myers Squibb, and The Medicines Company, and receives research funding from Cordis Corporation, Momenta Pharmaceuticals, and Portola Pharmaceuticals.
Correspondence
Antonio Gutierrez, MD, Box 31022/DUMC, Durham, NC 27710. E: antonio.gutierrez@duke.edu
Received date
08 September 2008
Accepted date
18 November 2008
Citation
US Cardiology - Volume 6 Issue 1;2009:6(1):89-91
Correspondence
Antonio Gutierrez, MD, Box 31022/DUMC, Durham, NC 27710. E: antonio.gutierrez@duke.edu

Pages

Current evidence-based therapies for ischemic heart disease include antithrombotic and antiplatelet medications that reduce the risk for ischemic outcomes such as myocardial infarction and stroke.1 Given their mechanism of action, bleeding is a risk with these agents, especially when combined with invasive procedures.2 In addition to overt bleeding, clinical trials of antithrombotic strategies suggest that these patients also are subject to acute anemia (manifested as decreases in hemoglobin values during hospitalization) and blood transfusion. Several studies have shown a powerful association between anemia and adverse outcomes among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS).3 A common strategy to deal with both bleeding and anemia in the ACS population is blood transfusion. Ostensibly given to increase hemoglobin levels and improve oxygen delivery to ischemic myocardial tissue, clinical and laboratory evidence suggests that blood transfusion not only does not improve oxygenation but also is associated with worse clinical outcomes. It is important to note that these data analyses are observational, retrospective, and subject to confounding influences.4 Indeed, there has never been a randomized trial of transfusion strategies in ischemic heart disease. This lack of definitive data has resulted in wide variation in transfusion practice. The purpose of this article is to summarize the current literature on the association between blood transfusion and outcomes and to review variations in transfusion practice in patients with ischemic heart disease.

Association Between Blood Transfusion and Outcomes

Recent retrospective studies have investigated the association between blood transfusion and outcomes in patients with NSTE ACS, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Rao et al.5 examined 24,000 patients with NSTE ACS and found an association between blood transfusion and increased 30-day mortality (adjusted hazard ratio 3.94, 95% confidence interval [CI] 3.26–4.75). Similarly, Wu et al.6 found an association between transfusion and increased mortality among elderly Medicare beneficiaries with acute MI when transfusion was given for an admission hematocrit level above 33%. Mortality was lower with transfusion among patients with an admission hematocrit level <30%. Yang et al.7 examined the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative registry of ACS patients and found an association between transfusion and increased in-hospital mortality (adjusted odds ratio 1.67, 95% CI 1.48–1.88).

Pages

References
  1. Fox KA, Steg PG, Eagle KA, et al., GRACE Investigators. Decline in rates of death and heart failure in acute coronary syndromes, 1999–2006, JAMA, 2007;297(17): 1892–1900.
  2. Rao SV, Eikelboom JA, Granger CB, et al., Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes, Eur Heart J, 2007;28(10):1193–1204.
  3. Sabatine MS, Morrow DA, Giugliano RP, et al., Association of hemoglobin levels with clinical outcomes in acute coronary syndromes, Circulation, 2005;111:2042–9.
  4. Hérbert PC, Fergusson DA, Do transfusions get to the heart of the matter?, JAMA, 2004;292(13):1610–12.
  5. Rao SV, Jollis JG, Harrington RA, et al., Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes, JAMA, 2004;292:1555–62.
  6. Wu WC, Rathore SS, Wang Y,et al., Blood transfusion in elderly patients with acute myocardial infarction, N Engl J Med, 2001;345:1230–36.
  7. Yang X, Alexander KP, Chen AY, et al., CRUSADE Investigators: The implications of blood transfusions for patients with non-ST-segment elevation acute coronary syndromes: Results from the CRUSADE National Quality Improvement Initiative, J Am Coll Cardiol, 2005;46:1490–95.
  8. Jani SM, Smith DE, Share D,et al., Blood Transfusion and In-hospital Outcomes in Anemic Patients with Myocardial Infarction Undergoing Percutaneous Coronary Intervention, Clin Cardiol, 2007;30(Suppl. 2):II–56.
  9. Kinnaird TD, Stabile E, Mintz GS,et al., Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions, Am J Cardiol, 2003;92(8):930–35.
  10. Murphy GJ, Reeves BC, Rogers CA, et al., Increased Mortality, Postoperative Morbidity, and Cost After Red Blood Cell Transfusion in Patients Having Cardiac Surgery, Circulation, 2007;116;2544–52.
  11. Koch CG, Li L, Sessler DI, et al., Duration of red-cell storage and complications after cardiac surgery, N Engl J Med, 2008;358(12):1229–39.
  12. Herbert PC, Wells G, Martin C, et al., A Canadian survey of transfusion practices in critically ill patients. Transfusion Requirements in Critical Care Investigators and the Canadian Critical Care Trials Group, Crit Care Med, 1998:26:482–7.
  13. Moscucci M, Ricciardi M, Eagle KA, et al., Frequency, Predictors, and Appropriateness of Blood Transfusion After Percutaneous Coronary Intervention, Am J Cardiol, 1998;81.
  14. American College of Physicians. Practice strategies for elective red blood cell transfusion, Ann Intern Med, 1992;116:403–6.
  15. Moscucci M, Fox KA, Cannon CP, et al., Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE), Eur Heart J, 2003;24: 1815–23.
  16. Berkowitz SD, Stinnett S, Cohen M, et al., Prospective comparison of hemorrhagic complications after treatment with enoxaparin versus unfractionated heparin for unstable angina pectoris or non-ST-segment elevation acute myocardial infarction, Am J Cardiol, 2001;88:1230–34.
  17. Collet JP, Montalescot G, Agnelli G, et al., GRACE Investigators. Non-ST-segment elevation acute coronary syndrome in patients with renal dysfunction: benefit of low-molecular-weight heparin alone or with glycoprotein IIb/IIIa inhibitors on outcomes. The Global Registry of Acute Coronary Events, Eur Heart J, 2005;26:2285–93.
  18. Alexander KP, Chen AY, Roe MT, et al., CRUSADE Investigators. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes, JAMA, 2005;294:3108–16.
  19. Gilchrist IC, Berkowitz SD, Thompson TD, et al., Heparin dosing and outcome in acute coronary syndromes: the GUSTO-IIb experience. Global use of strategies to open occluded coronary arteries, Am Heart J, 2002;144:73–80.
  20. Eikelboom JW, Mehta SR, Anand SS, et al., Adverse impact of bleeding on prognosis in patients with acute coronary syndromes, Circulation, 2006;114:774–82.
  21. Anderson JL, Adams CD, Antman EM, et al., American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction); American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic Emergency Medicine. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non STElevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine, Circulation, 2007;116(7):e148–304.