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Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, Lemesle G, Cachanado M, Durand-Zaleski I, Arnaiz JA, Martínez-Sellés M, Silvain J, Ariza-Solé A, Ferrari E, Calvo G, Danchin N, Avendaño-Solá C, Frenkiel J, Rousseau A, Vicaut E, Simon T, Steg PG. Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial. JAMA 2021; 325:552-560. [PMID: 33560322 PMCID: PMC7873781 DOI: 10.1001/jama.2021.0135] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE The optimal transfusion strategy in patients with acute myocardial infarction and anemia is unclear. OBJECTIVE To determine whether a restrictive transfusion strategy would be clinically noninferior to a liberal strategy. DESIGN, SETTING, AND PARTICIPANTS Open-label, noninferiority, randomized trial conducted in 35 hospitals in France and Spain including 668 patients with myocardial infarction and hemoglobin level between 7 and 10 g/dL. Enrollment could be considered at any time during the index admission for myocardial infarction. The first participant was enrolled in March 2016 and the last was enrolled in September 2019. The final 30-day follow-up was accrued in November 2019. INTERVENTIONS Patients were randomly assigned to undergo a restrictive (transfusion triggered by hemoglobin ≤8; n = 342) or a liberal (transfusion triggered by hemoglobin ≤10 g/dL; n = 324) transfusion strategy. MAIN OUTCOMES AND MEASURES The primary clinical outcome was major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days. Noninferiority required that the upper bound of the 1-sided 97.5% CI for the relative risk of the primary outcome be less than 1.25. The secondary outcomes included the individual components of the primary outcome. RESULTS Among 668 patients who were randomized, 666 patients (median [interquartile range] age, 77 [69-84] years; 281 [42.2%] women) completed the 30-day follow-up, including 342 in the restrictive transfusion group (122 [35.7%] received transfusion; 342 total units of packed red blood cells transfused) and 324 in the liberal transfusion group (323 [99.7%] received transfusion; 758 total units transfused). At 30 days, MACE occurred in 36 patients (11.0% [95% CI, 7.5%-14.6%]) in the restrictive group and in 45 patients (14.0% [95% CI, 10.0%-17.9%]) in the liberal group (difference, -3.0% [95% CI, -8.4% to 2.4%]). The relative risk of the primary outcome was 0.79 (1-sided 97.5% CI, 0.00-1.19), meeting the prespecified noninferiority criterion. In the restrictive vs liberal group, all-cause death occurred in 5.6% vs 7.7% of patients, recurrent myocardial infarction occurred in 2.1% vs 3.1%, emergency revascularization prompted by ischemia occurred in 1.5% vs 1.9%, and nonfatal ischemic stroke occurred in 0.6% of patients in both groups. CONCLUSIONS AND RELEVANCE Among patients with acute myocardial infarction and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of MACE after 30 days. However, the CI included what may be a clinically important harm. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02648113.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Jose R. Gonzalez-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Etienne Puymirat
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, Lille, France
- French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine, Paris, France
| | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Manuel Martínez-Sellés
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), INSERM UMRS 1166, Paris, France
| | - Albert Ariza-Solé
- University Hospital Bellvitge, Heart Disease Institute, Barcelona, Spain
| | - Emile Ferrari
- Université Côte d’Azur, CHU de Nice, Hôpital Pasteur 1, Service de Cardiologie, Nice, France
| | - Gonzalo Calvo
- Àrea del Medicament, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Nicolas Danchin
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Cristina Avendaño-Solá
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Jerome Frenkiel
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine, Paris, France
| | - Eric Vicaut
- AP-HP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine, Paris, France
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
- Royal Brompton Hospital, Imperial College, London, United Kingdom
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Ducrocq G, Calvo G, González-Juanatey JR, Durand-Zaleski I, Avendano-Sola C, Puymirat E, Lemesle G, Arnaiz JA, Martínez-Sellés M, Rousseau A, Cachanado M, Vicaut E, Silvain J, Karam C, Danchin N, Simon T, Steg PG. Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial. Clin Cardiol 2021; 44:143-150. [PMID: 33405291 PMCID: PMC7852166 DOI: 10.1002/clc.23453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 01/28/2023] Open
Abstract
Background Anemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear. Hypothesis We hypothesized that a “restrictive” transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a “liberal” transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly. Methods REALITY is an international, randomized, multicenter, open‐label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost‐effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all‐cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year. Results The trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost‐effectiveness of the restrictive strategy at a threshold of €50 000 per quality‐adjusted life year. Conclusions REALITY will provide important guidance on the management of patients with AMI and anemia.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Gonzalo Calvo
- Àrea del Medicament Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - José Ramón González-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Cristina Avendano-Sola
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Etienne Puymirat
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV; Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Alexandra Rousseau
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Marine Cachanado
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Eric Vicaut
- AP-HP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, AP-HP, INSERM UMRS 1166, Paris, France
| | - Carma Karam
- Cardiology Department, Ambroise Paré Hospital, AP-HP, Boulogne, University of Versailles-Saint Quentin en Yvelines, Boulogne-Billancourt, France
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.,Royal Brompton Hospital, Imperial College, London, UK
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Nielsen AE, Nielsen ND. Assessing productive efficiency and operating scale of community blood centers. Transfusion 2016; 56:1267-73. [PMID: 26830252 DOI: 10.1111/trf.13493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND In recent years demand for blood products has decreased, and as a result, the blood product marketplace has become much more competitive. Reducing inefficiency in the procurement and processing of blood products at blood centers can reduce costs while assuring that demand for blood products is met. STUDY DESIGN AND METHODS This study uses data envelopment analysis to compare the productive efficiency of 65 community blood centers to determine to what extent efficiency can be improved, what cost savings and increases in platelet (PLT) production may be obtained by eliminating inefficiency, and what scales of operation are the most efficient from a budgetary and staffing standpoint. Data were collected from the 2012 to 2013 AABB Directory of Community Blood Centers and Hospital Blood Banks. RESULTS The study found that 27 of 65 blood centers are efficient. The remaining 38 blood centers can reduce budget and staff levels and may be able to expand output. If inefficient centers were to eliminate all inefficiency, the total savings would be $671 million, approximately 20% of the aggregated budget ($3.45 billion) of all centers in the study. In addition, the centers would also see a 36% increase in PLT production. Inefficiency of some large blood centers stems from operating at too large a scale, while inefficiency of most small blood centers is scale independent. CONCLUSION The results suggest that reducing inefficiency in blood procurement may be a good strategy to maximize competitiveness in the blood product marketplace. These findings further suggest that the trend of blood center consolidation may be ill advised from a cost containment perspective.
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Affiliation(s)
| | - Nathan D Nielsen
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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Chan AW, de Gara CJ. An evidence-based approach to red blood cell transfusions in asymptomatically anaemic patients. Ann R Coll Surg Engl 2015; 97:556-62. [PMID: 26492900 PMCID: PMC5096603 DOI: 10.1308/rcsann.2015.0047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Surgeons and physicians encounter blood transfusions on a daily basis but a robust evidence-based strategy on indications and timing of transfusion in asymptomatic anaemic patients is yet to be determined. For judicious use of blood products, the risks inherent to packed red blood cells, the patient's co-morbidities and haemoglobin (Hb)/haematocrit levels should be considered. This review critiques and summarises the latest available evidence on the indications for transfusions in healthy and cardiac disease patients as well as the timing of transfusions relative to surgery. METHODS An electronic literature search of the MEDLINE(®), Google Scholar™ and Trip databases was conducted for articles published in English between January 2006 and January 2015. Studies discussing timing and indications of transfusion in medical and surgical patients were retrieved. Bibliographies of studies were checked for other pertinent articles that were missed by the initial search. FINDINGS Six level 1 studies (randomised controlled trials or systematic reviews) and six professional society guidelines were included in this review. In healthy patients without cardiac disease, a restrictive transfusion trigger of Hb 70-80g/l is safe and appropriate whereas in cardiac patients, the trigger is Hb 80-100g/l. The literature on timing of transfusions relative to surgery is limited. For the studies available, preoperative transfusions were associated with a decreased incidence of subsequent transfusions and timing of transfusions did not affect the rates of colorectal cancer recurrence.
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