Impact of red blood cell transfusion on acute coronary syndrome: a meta-analysis

Timing of Blood Transfusions and 30-Day Patient Outcomes After Coronary Artery Bypass Graft Surgery

OBJECTIVE

Packed red blood cell transfusion during coronary artery bypass graft surgery is known to be associated with adverse outcomes. However, the association of the timing between transfusions in relation to discharge and 30-day postoperative outcomes has not been studied. The study authors investigated the impact of transfusion timing on 30-day surgical outcomes.

DESIGN

A retrospective review.

SETTING

At a single tertiary-care academic hospital.

PARTICIPANTS

A total of 2,481 adult patients underwent primary coronary artery bypass graft surgery between January 2014 and December 2020.

MEASUREMENTS AND MAIN RESULTS

The relationship between the timing of packed red blood cell transfusion (intraoperative, postoperative, or both) and 30-day postoperative outcome variables was calculated as an odds ratio. The influence of timing of transfusion on adjusted probability of postoperative complications was plotted against the lowest intraoperative hematocrit. The median age of the population was 67 years (60.0-74.0), body mass index was 28.5 (25.6-32.3) kg/m², and 497 (20.0%) were female. A total of 1,588 (36%) patients received packed red blood cell transfusions; 182 (7.3%) received intraoperative transfusions, 489 (19.7%) received postoperative transfusions, and 222 (9.0%) received both (intraoperative and postoperative transfusions). Postoperative transfusion was associated with significantly higher odds of readmission (1.83 [1.32-2.54], p = 0.002) and heart failure (1.64 [1.2-2.23], p = 0.008) compared to patients with no transfusions; whereas intraoperative transfusions were not.

CONCLUSION

The authors' data suggested that the postoperative timing of transfusion in patients undergoing coronary artery bypass graft surgery may be associated with an increased incidence of 30-day heart failure and readmission. Prospective research is needed to conclusively confirm these findings.

The role of anemia on admission in acute coronary syndrome - An umbrella review of systematic reviews and meta-analyses

INTRODUCTION

The role of erythrocytes in the acute coronary syndrome (ACS) is complex. The aim of this review in terms of PICO (P: patients; I: intervention; C: comparison; O: outcome) was to summarize systematic reviews in patients (P) with acute coronary syndrome, evaluating the effects of (I) 1) iron deficiency, 2) administration of an erythropoiesis-stimulating agent (ESA), 3) anemia on admission, 4) red blood cell transfusion, 5) a restrictive transfusion strategy in comparison (C) to 1) no iron deficiency, 2) no ESA 3) no anemia on admission, 4) no red blood cell transfusion, 5) a liberal transfusion strategy on mortality (O).

METHODS

We used AMSTAR2 to assess the methodological quality of systematic reviews and grade the available research. The primary endpoint was all-cause mortality.

RESULTS

Using the data from 2,787,005 patients, the following conditions were associated with worse outcome in patients with ACS: anemia on admission (RR 2.08 95%CI 1.70-2.55) and transfusion (1.93 95%CI 1.12-3.34) of red blood cells. A liberal transfusion (RR 0.86 95%CI 0.70-1-05), administration of ESA (RR 0.55 95%CI 0.22-1.33) and iron deficiency (OR 1.24 95%CI 0.12-13.13) were not associated with altered all-cause mortality.

CONCLUSION

Patients suffering from ACS and anemia on admission are at particular risk for adverse outcome. There is evidence of associations between adverse outcomes and receiving red blood cell transfusions.

Mid-Term Mortality in Older Anemic Patients with Type 2 Myocardial Infarction: Does Blood Transfusion sImprove Prognosis?

(1) Anemia often predisposes older patients to type 2 myocardial infarction (T2MI). However, the management of this frequent association remains uncertain. We aimed to evaluate the impact of red blood cell transfusion during the acute phase of T2MI in older anemic inpatients. (2) Methods and results: We performed a retrospective study using a French regional database. One hundred and seventy-eight patients aged 65 years or older, presenting with a T2MI and anemia, were selected. Patients were split into two groups: one that received a red blood cell transfusion (≥1 red blood cell unit) and one that did not. A propensity score was built to adjust for potential confounders, and the association between transfusion and 30-day mortality was evaluated with an inverse propensity score weighted Cox model. Transfusion was not associated with 30-day all-cause mortality (propensity score weighted hazard ratio (HR) 1.59 (0.55-4.56), p = 0.38). However, 1-year all-cause mortality was significantly higher in the transfusion group (propensity score weighted HR 2.47 (1.22-4.97), p = 0.011). (3) Conclusion: Our findings in older adults with anemia suggest that blood transfusion in the acute phase of T2MI could not be associated with improved short-term prognosis. Prospective studies are urgently needed to assess the impact of transfusion on longer-term prognosis.

Red blood cell transfusion practice in a single institution in Poland in 2018-2019 - Is there room for improvement?

INTRODUCTION

Red blood cell (RBC) transfusion (RBCT) is one of the most frequently performed procedures in inpatients within modern hospital systems. However transfusion practices may vary by an institution or even by a prescribing physician. In order to assess the current RBCT practice in our institution, we performed a detailed analysis of RBCTs.

MATERIAL AND METHODS

We performed a retrospective analysis of all RBCTs in our institution between January 2018 and December 2019. The data collected included: age, sex, type of RBC, number of single and multiple unit RBCTs in bleeding and nonbleeding patients, number of multiple unit RBCTs in non-bleeding patients with and without hemoglobin (Hb) concentration determination after each RBC, primary indication for RBCT, pre-post RBCT Hb concentration in non-bleeding patients, lactate concentration pre-post RBCT in non-bleeding patients.

RESULTS

The indications for RBCT were anemia (2244, 56.2 % RBC) and bleeding (1463, 36.6 % RBC). The most frequently used types of RBCs were RBCs without buffy coat (75.1 %) and leucodepleted RBCs (20.9 %). In non-bleeding patients 45.7 % were multiple unit RBCTs, only 3% were performed with Hb determination following the first unit of RBC, 508 (20.2 %) RBCT were performed with pre-post RBCT lactate concentration determination.

CONCLUSIONS

Analysis of the local RBCT practice showed significant room for improvement. Areas of concern were type of RBC ordered, multiple unit transfusions in non-bleeding patients, lack of laboratory control of oxygenation pre-post transfusion or not taking it into account in RBCT decision making. Deficiencies are planned to be addressed by a comprehensive blood utilization review programme.

Red blood cell transfusion threshold and mortality in cardiac intensive care unit patients

BACKGROUND

The benefit of red blood cell (RBC) transfusion in anemic critically-ill patients with cardiovascular disease is uncertain, as is the optimal threshold at which RBC transfusion should be considered. We sought to examine the association between RBC transfusion and mortality stratified by nadir Hgb level and admission diagnosis among cardiac intensive care unit (CICU) patients.

METHODS

Retrospective single-center cohort of 11,754 CICU patients admitted between 2007 and 2018. The association between RBC transfusion and hospital mortality at each nadir Hgb (<8 g/dL, 8-9.9 g/dL, ≥10 g/dL) was assessed using multivariable logistic regression adjusted for the propensity to receive RBC transfusion.

RESULTS

The study population had a mean age of 68±15 years, including 38% females; 1,134 (11.4%) received RBC transfusion. Admission diagnoses included: acute coronary syndrome , 42%; heart failure, 50%; cardiac arrest , 12%; and cardiogenic shock , 12%. Patients who received RBC transfusion had higher crude hospital mortality (19% vs. 8%, P<.001). RBC transfusion was associated with lower adjusted hospital mortality in patients with nadir Hgb <8 g/dL after propensity adjustment, including subgroups with acute coronary syndrome, cardiac arrest, or cardiogenic shock (all P <.01). RBC transfusion was not associated with lower adjusted hospital mortality in any subgroup of patients with nadir Hgb ≥8 g/dL.

CONCLUSIONS

These observational data suggest the use of a Hgb threshold <8 g/dL for RBC transfusion in most CICU patients, although we could not exclude a potential benefit of RBC transfusion at a nadir Hgb of 8 to 9.9 g/dL; we did not observe any benefit from RBC transfusion at a nadir Hgb ≥10 g/dL.

Perioperative Nadir Hemoglobin Concentration and Outcome in Off-Pump Coronary Artery Bypass Surgery - A Retrospective Review

BACKGROUND

Emerging evidence advocates the use of restrictive transfusion strategies at hemoglobin (Hb) levels of approximately 7-8 g/dL in cardiac surgeries using cardiopulmonary bypass. Yet, it is unclear whether the same thresholds can be applied to off-pump coronary bypass (OPCAB) that accompanies cardiac displacement and warm regional ischemia-reperfusion injury without the aid of a bypass machine. The aim of this study is to investigate the relationship between perioperative nadir Hb level and outcome following OPCAB.Methods and Results:Medical records of 1,360 patients were reviewed. Hb levels were serially assessed during and after surgery. The incidence of composite endpoints was 35%, which included myocardial infarction, stroke, acute kidney injury, sternal infection, reoperation, prolonged mechanical ventilation, and in-hospital mortality. The nadir Hb level was significantly lower in the morbidity group than in the non-morbidity group (8.1 [7.4-9.1] vs. 8.8 [7.9-9.8] g/dL, P<0.001). Multivariable logistic regression analysis revealed nadir Hb as an independent risk factor of adverse outcome (odds ratio: 0.878, 95% confidence intervals: 0.776-0.994, P=0.04), whereas preoperative anemia and perioperative transfusion were not. The critical value of Hb for predicting detrimental outcome was 8.05 g/dL.

CONCLUSIONS

A significant association is found between perioperative nadir Hb and adverse outcome after OPCAB. Although preoperative anemia was not associated with poor prognosisper se, it was the only modifiable risk factor that was closely linked to nadir Hb.

Management and prevention of anemia (acute bleeding excluded) in adult critical care patients

OBJECTIVE

Anemia is very common in critical care patients, on admission (affecting about two thirds of patients), but also during and after their stay, due to repeated blood loss, the effects of inflammation on erythropoiesis, a decreased red blood cell life span, and haemodilution. Anemia is associated with severity of illness and length of stay.

METHODS

A committee composed of 16 experts from four scientific societies, SFAR, SRLF, SFTS and SFVTT, evaluated three fields: (1) anaemia prevention, (2) transfusion strategies and (3) non-transfusion treatment of anaemia. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SFAR-SRLF guideline panel provided ten statements concerning the management of anemia in adult critical care patients. Acute haemorrhage and chronic anemia were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for ten recommendations. Three of these recommendations had a high level of evidence (GRADE 1±) and four had a low level of evidence (GRADE 2±). No GRADE recommendation could be provided for two questions in the absence of strong consensus.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal patient management. The experts recommended phlebotomy reduction strategies, restrictive red blood cell transfusion and a single-unit transfusion policy, the use of red blood cells regardless of storage time, treatment of anemic patients with erythropoietin, especially after trauma, in the absence of contraindications and avoidance of iron therapy (except in the context of erythropoietin therapy).

Management and prevention of anemia (acute bleeding excluded) in adult critical care patients

Objective

Anemia is very common in critical care patients, on admission (affecting about two-thirds of patients), but also during and after their stay, due to repeated blood loss, the effects of inflammation on erythropoiesis, a decreased red blood cell life span, and haemodilution. Anemia is associated with severity of illness and length of stay.

Methods

A committee composed of 16 experts from four scientific societies, SFAR, SRLF, SFTS and SFVTT, evaluated three fields: (1) anemia prevention, (2) transfusion strategies and (3) non-transfusion treatment of anemia. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE^® methodology.

Results

The SFAR–SRLF guideline panel provided ten statements concerning the management of anemia in adult critical care patients. Acute haemorrhage and chronic anemia were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for ten recommendations. Three of these recommendations had a high level of evidence (GRADE 1±) and four had a low level of evidence (GRADE 2±). No GRADE recommendation could be provided for two questions in the absence of strong consensus.

Conclusions

The experts reached a substantial consensus for several strong recommendations for optimal patient management. The experts recommended phlebotomy reduction strategies, restrictive red blood cell transfusion and a single-unit transfusion policy, the use of red blood cells regardless of storage time, treatment of anaemic patients with erythropoietin, especially after trauma, in the absence of contraindications and avoidance of iron therapy (except in the context of erythropoietin therapy).

Blood transfusion and ischaemic outcomes according to anemia and bleeding in patients with non-ST-segment elevation acute coronary syndromes: Insights from the TAO randomized clinical trial

BACKGROUND

The benefits and risks of blood transfusion in patients with acute myocardial infarction who are anemic or who experience bleeding are debated. We sought to study the association between blood transfusion and ischemic outcomes according to haemoglobin nadir and bleeding status in patients with NST-elevation myocardial infarction (NSTEMI).

METHODS

The TAO trial randomized patients with NSTEMI and coronary angiogram scheduled within 72h to heparin plus eptifibatide versus otamixaban. After exclusion of patients who underwent coronary artery bypass surgery, patients were categorized according to transfusion status considering transfusion as a time-varying covariate. The primary ischemic outcome was the composite of all-cause death or MI within 180 days of randomization. Subgroup analyses were performed according to pre-transfusion hemoglobin nadir and bleeding status.

RESULTS

12,547 patients were enrolled. Among these, blood transfusion was used in 489 (3.9%) patients. Patients who received transfusion had a higher rate of death or MI (29.9% vs. 8.1%, p<0.01). This excess risk persisted after adjustment on GRACE score and nadir of hemoglobin (HR 3.36 95%CI 2.63-4.29 p<0.01). Subgroup analyses showed that blood transfusion was associated with a higher risk in patients without overt bleeding (adjusted HR 6.25 vs. 2.85; p-interaction 0.001) as well as in those with hemoglobin nadir > 9.0 g/dl (HR 4.01; p-interaction<0.0001).

CONCLUSION

In patients with NSTEMI, blood transfusion was associated with an overall increased risk of ischaemic events. However, this was mainly driven by patients without overt bleeding and those hemoglobin nadir > 9.0g/dl. This suggests possible harm of transfusion in those groups.

Patient Blood Management

Patient blood management is a highly successful and cost-effective concept that improves patient outcome by correction of anemia with hematinic medication and reduction of blood loss perioperatively by meticulous surgical techniques and individualized coagulation management.

Blood, blood components, plasma, and plasma products

This review of 2018 publications identifies side effects of blood, blood components, and plasma products. In addition, albumin, blood transfusion (erythrocytes, granulocytes, and platelets), blood substitutes (hemoglobin-based oxygen carriers), plasma products (alpha1-antitrypsin, C1 esterase inhibitor concentrate, cryoprecipitate, and fresh frozen plasma), plasma substitutes (etherified starches, and gelatin), globulins (intravenous immunoglobulin, subcutaneous immunoglobulin, and anti-D immunoglobulin), coagulation proteins (factor I, factor II, factor VIIa, factor VIII, factor IX, prothrombin complex concentrate, antithrombin III, and von Willebrand factor/factor VIII concentrates), erythropoietin and derivatives, thrombopoietin and receptor agonists, transmission of infectious agents through blood donation, and stem cells are reviewed. This chapter informs the reader about newly recognized and published data in the blood product domain.