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Jeon J, Kang D, Park H, Lee K, Lee JE, Huh W, Cho J, Jang HR. Impact of anemia requiring transfusion or erythropoiesis-stimulating agents on new-onset cardiovascular events and mortality after continuous renal replacement therapy. Sci Rep 2024; 14:6556. [PMID: 38503801 PMCID: PMC10951301 DOI: 10.1038/s41598-024-56772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
Anemia is common in critically ill patients undergoing continuous renal replacement therapy (CRRT). We investigated the impact of anemia requiring red blood cell (RBC) transfusion or erythropoiesis-stimulating agents (ESAs) on patient outcomes after hospital discharge in critically ill patients with acute kidney injury (AKI) requiring CRRT. In this retrospective cohort study using the Health Insurance Review and Assessment database of South Korea, 10,923 adult patients who received CRRT for 3 days or more between 2010 and 2019 and discharged alive were included. Anemia was defined as the need for RBC transfusion or ESAs. Outcomes included cardiovascular events (CVEs) and all-cause mortality after discharge. The anemia group showed a tendency to be older with more females and had more comorbidities compared to the control group. Anemia was not associated with an increased risk of CVEs (adjusted hazard ratio [aHR]: 1.05; 95% confidence interval [CI]: 0.85-1.29), but was associated with an increased risk of all-cause mortality (aHR: 1.41; 95% CI 1.30-1.53). For critically ill patients with AKI requiring CRRT, anemia, defined as requirement for RBC transfusion or ESAs, may increase the long-term risk of all-cause mortality.
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Affiliation(s)
- Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Kyungho Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea.
| | - Hye Ryoun Jang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06531, Republic of Korea.
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Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis. Gen Thorac Cardiovasc Surg 2023; 71:323-330. [PMID: 36884106 DOI: 10.1007/s11748-023-01923-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Cardiac surgical procedures are associated with a high incidence of periprocedural blood loss and blood transfusion. Although both may be associated with a range of postoperative complications there is disagreement on the impact of blood transfusion on long-term mortality. This study aims to provide a comprehensive review of the published outcomes of perioperative blood transfusion, examined as a whole and by index procedure. METHODS A systematic review of perioperative blood transfusion cardiac surgical patients was conducted. Outcomes related to blood transfusion were analysed in a meta-analysis and aggregate survival data were derived to examine long-term survival. RESULTS Thirty-nine studies with 180,074 patients were identified, the majority (61.2%) undergoing coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR 3.87, p < 0.001). After a median of 6.4 years (range 1-15), mortality remained significantly higher for those who received a perioperative transfusion (OR 2.01, p < 0.001). Pooled hazard ratio for long-term mortality similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies. CONCLUSIONS Perioperative red blood transfusion appears to be associated with a significant reduction in long-term survival for patients after cardiac surgery. Strategies such as preoperative optimisation, intraoperative blood conservation, judicious use of postoperative transfusions, and professional development into minimally invasive techniques should be utilised where appropriate to minimise the need for perioperative transfusions.
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Hu RT, Royse AG, Royse C, Scott DA, Bowyer A, Boggett S, Summers P, Mazer CD. Health-related quality of life after restrictive versus liberal RBC transfusion for cardiac surgery: Sub-study from a randomized clinical trial. Transfusion 2022; 62:1973-1983. [PMID: 36066319 DOI: 10.1111/trf.17084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transfusion Requirements in Cardiac Surgery III (TRICS III), a multi-center randomized controlled trial, demonstrated clinical non-inferiority for restrictive versus liberal RBC transfusion for patients undergoing cardiac surgery. However, it is uncertain if transfusion strategy affects long-term health-related quality of life (HRQOL). STUDY DESIGN AND METHODS In this planned sub-study of Australian patients in TRICS III, we sought to determine the non-inferiority of restrictive versus liberal transfusion strategy on long-term HRQOL and to describe clinical outcomes 24 months postoperatively. The restrictive strategy involved transfusing RBCs when hemoglobin was <7.5 g/dl; the transfusion triggers in the liberal group were: <9.5 g/L intraoperatively, <9.5 g/L in intensive care, or <8.5 g/dl on the ward. HRQOL assessments were performed using the 36-item short form survey version 2 (SF-36v2). Primary outcome was non-inferiority of summary measures of SF-36v2 at 12 months, (non-inferiority margin: -0.25 effect size; restrictive minus liberal scores). Secondary outcomes included non-inferiority of HRQOL at 18 and 24 months. RESULTS Six hundred seventeen Australian patients received allocated randomization; HRQOL data were available for 208/311 in restrictive and 217/306 in liberal group. After multiple imputation, non-inferiority of restrictive transfusion at 12 months was not demonstrated for HRQOL, and the estimates were directionally in favor of liberal transfusion. Non-inferiority also could not be concluded at 18 and 24 months. Sensitivity analyses supported these results. There were no differences in quality-adjusted life years or composite clinical outcomes up to 24 months after surgery. DISCUSSION The non-inferiority of a restrictive compared to a liberal transfusion strategy was not established for long-term HRQOL in this dataset.
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Affiliation(s)
- Raymond T Hu
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Alistair G Royse
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Colin Royse
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Outcomes Research Consortium, The Cleveland Clinic, Cleveland, Ohio, USA
| | - David A Scott
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Andrea Bowyer
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Stuart Boggett
- Department of Surgery, University of Melbourne, Parkville, Victoria, Australia
| | - Peter Summers
- Statistical Consulting Centre, University of Melbourne, Parkville, Victoria, Australia.,Melbourne Disability Institute, University of Melbourne, Parkville, Victoria, Australia.,Centre for Health Analytics, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Cyril David Mazer
- Department of Anaesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Transfusion strategies in patients with acute coronary syndrome and anemia: a meta-analysis. Egypt Heart J 2022; 74:17. [PMID: 35312886 PMCID: PMC8938537 DOI: 10.1186/s43044-022-00252-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Anemia is a known risk factor for ischemic heart disease and serves as an independent predictor of major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). This meta-analysis pools data from randomized controlled trials (RCTs) to better define hemoglobin (Hb) thresholds for transfusion in this setting. Results MEDLINE, EMBASE, and Cochrane databases were searched using the terms “Acute Coronary Syndrome” AND “Blood Transfusion” including their synonyms. A total of three randomized controlled trials were included. Restrictive transfusion strategy (RTS) was defined as transfusing for Hb ≤ 8 g/dl with a post-transfusion goal of 8 to 10 g/dl. Liberal transfusion strategy (LTS) was defined as Hb ≤ 10 g/dl and post-transfusion goal of at least 11 g/dl. The primary end point was 30-day mortality. Secondary outcomes included recurrent ACS events, new or worsening CHF within 30 days, and major adverse cardiac events (MACE). The primary analytic method used was random effects model. Out of 821 patients, 400 were randomized to LTS, and 421 to RTS. Mean age was 70.3 years in RTS versus 76.4 in LTS. There was no statistically significant difference for 30-day mortality in LTS compared to RTS [odds ratio (OR) 1.69; 95% CI 0.35 to 8.05]. Similarly, there was no difference in MACE (OR 0.74; 95% CI 0.21 to 2.63), CHF (OR 0.82; 95% CI 0.18 to 3.76), or the incidence of recurrent ACS (OR 1.21; 95% CI 0.49 to 2.95). Conclusions In the setting of ACS, there is no difference between LTS and RTS for the outcomes of mortality, MACE, recurrent ACS, or CHF at 30 days. Further evidence in the form of high-quality RCTs are needed to compare RTS and LTS. Supplementary Information The online version contains supplementary material available at 10.1186/s43044-022-00252-2.
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Das D, Savu A, Bainey KR, Welsh RC, Kaul P. Temporal Trends in in-Hospital Bleeding and Transfusion in a Contemporary Canadian ST-Elevation Myocardial Infarction Patient Population. CJC Open 2021; 3:479-487. [PMID: 34027351 PMCID: PMC8129449 DOI: 10.1016/j.cjco.2020.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Background Although ST-elevation myocardial infarction (STEMI) management has evolved substantially over the past decade, its effect on bleeding and transfusion rates are largely unknown in a contemporary population. Methods Our study cohort included patients 20 years of age or older who were hospitalized for STEMI between 2007 and 2016 across all Canadian provinces, except Quebec. Unadjusted rates of bleeding and of transfusion during STEMI episodes were calculated overall and for each province according to fiscal year. Patients were stratified into 4 groups according to their bleeding/transfusion. Characteristics, treatment, and outcomes were compared between groups. Multivariate logistic regression modelling was used to assess the association between bleeding and transfusion on in-hospital mortality. Results Using 108,832 STEMI episodes, rates of in-hospital bleeding and transfusion declined between 2007 and 2016 from 3.9% to 2.8% (P < 0.0001) and 4.7% to 3.8% (P < 0.0001), respectively. However, variation in bleeding and transfusion rates were observed across Canadian provinces. Patients with bleeding or transfusion, were older, female, and had more comorbidities. Compared with patients who did not bleed or receive a transfusion, individuals who bled, were transfused, or bled and were transfused, had higher in-hospital mortality (18.6%, 30.3%, and 30.4%, respectively [P < 0.0001]). The association remained after adjustment: bleeding (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.4), transfusion (OR, 4.4; 95% CI, 3.9-4.9), and bleeding and transfusion (OR, 3.8; 95% CI, 3.2-4.6). Conclusions The proportion of Canadian STEMI patients who experienced in-hospital bleeding and transfusion has decreased over the past 9 years. However, patients with bleed or transfusion remain at higher risk of adverse outcomes.
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Affiliation(s)
- Debraj Das
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C Welsh
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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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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7
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Nguyen FT, van den Akker T, Lally K, Lam H, Lenskaya V, Liu STH, Bouvier NM, Aberg JA, Rodriguez D, Krammer F, Strauss D, Shaz BH, Rudon L, Galdon P, Jhang JS, Arinsburg SA, Baine I. Transfusion reactions associated with COVID-19 convalescent plasma therapy for SARS-CoV-2. Transfusion 2020; 61:78-93. [PMID: 33125158 DOI: 10.1111/trf.16177] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Convalescent plasma (CP) for treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has shown preliminary signs of effectiveness in moderate to severely ill patients in reducing mortality. While studies have demonstrated a low risk of serious adverse events, the comprehensive incidence and nature of the spectrum of transfusion reactions to CP is unknown. We retrospectively examined 427 adult inpatient CP transfusions to determine incidence and types of reactions, as well as clinical parameters and risk factors associated with transfusion reactions. STUDY DESIGN AND METHODS Retrospective analysis was performed for 427 transfusions to 215 adult patients with coronavirus 2019 (COVID-19) within the Mount Sinai Health System, through the US Food and Drug Administration emergency investigational new drug and the Mayo Clinic Expanded Access Protocol to Convalescent Plasma approval pathways. Transfusions were blindly evaluated by two reviewers and adjudicated by a third reviewer in discordant cases. Patient demographics and clinical and laboratory parameters were compared and analyzed. RESULTS Fifty-five reactions from 427 transfusions were identified (12.9% incidence), and 13 were attributed to transfusion (3.1% incidence). Reactions were classified as underlying COVID-19 (76%), febrile nonhemolytic (10.9%), transfusion-associated circulatory overload (9.1%), and allergic (1.8%) and hypotensive (1.8%) reactions. Statistical analysis identified increased transfusion reaction risk for ABO blood group B or Sequential Organ Failure Assessment scores of 12 to 13, and decreased risk within the age group of 80 to 89 years. CONCLUSION Our findings support the use of CP as a safe, therapeutic option from a transfusion reaction perspective, in the setting of COVID-19. Further studies are needed to confirm the clinical significance of ABO group B, age, and predisposing disease severity in the incidence of transfusion reaction events.
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Affiliation(s)
- Freddy T Nguyen
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Tayler van den Akker
- Department of Pathology, Icahn School of Medicine at Mount Sinai West, New York, New York, USA
| | - Kimberly Lally
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hansen Lam
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Volha Lenskaya
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean T H Liu
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole M Bouvier
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith A Aberg
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Denise Rodriguez
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Donna Strauss
- New York Blood Center Enterprises, New York, New York, USA
| | - Beth H Shaz
- New York Blood Center Enterprises, New York, New York, USA
| | - Louella Rudon
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patricia Galdon
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey S Jhang
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Suzanne A Arinsburg
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Baine
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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El-Qushayri AE, Ghozy S, Morsy S, Ali F, Islam SMS. Blood Transfusion and the Risk of Cancer in the US Population: Is There an Association? Clin Epidemiol 2020; 12:1121-1127. [PMID: 33116905 PMCID: PMC7573206 DOI: 10.2147/clep.s271275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/08/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose We aimed to test if blood transfusion is a risk factor for the prevalence of cancer. Patients and Methods We conducted secondary analyses using the NHANES database from 1999 to 2016. We included all individuals who received a blood transfusion with known cancer comorbidity (diseased or not). We used univariate logistic regression to identify any possible association between history of blood transfusion and the prevalence of cancer with adjustment for different co-founders was done. Regression results were expressed as odds ratios (ORs) and 95% confidence interval (95% CI) for both adjusted and unadjusted models. Results A total of 48,796 individuals were included in the final analysis: 6333 of them received a blood transfusion, while the other 42,463 individuals did not. In individuals who received a blood transfusion, the most prevalent cancer was breast cancer (3.4%), followed by prostate (3.0%), non-melanoma skin (2.4%) cancers, while non-melanoma skin (1.2%), prostate (1.1%) and breast (1.1%) cancers were the most prevalent in the no transfusion individuals. There was a significant association between the reported history of blood transfusion and the overall prevalence of cancer in both the unadjusted (OR= 3.47; 95% CI= 3.23–0.72; P-value< 0.001) and adjusted model (OR= 1.86; 95% CI= 1.72–0.2.01; P-value< 0.001). On the level of individual cancers, a significant reduction in cancer prevalence was found in patients with breast, cervix, larynx, Hodgkin’s lymphoma, melanoma, prostate, skin (non-melanoma), skin (unspecified), soft tissue, testicular, thyroid, and uterine cancers. Conclusion Results did not imply any concrete association between cancer risk and history of blood transfusion. These findings would help in debunking the myth of increased cancer risk following blood transfusion.
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Affiliation(s)
| | - Sherief Ghozy
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Sara Morsy
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Faria Ali
- Department of Internal Medicine, Henry Ford Allegiance Health, Jackson, MI 49201, USA
| | - Sheikh Mohammed Shariful Islam
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia
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Moady G, Atar S. Author’s reply. J Cardiol 2020; 75:116. [DOI: 10.1016/j.jjcc.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 11/17/2022]
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10
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Cho BC, DeMario VM, Grant MC, Hensley NB, Brown CH, Hebbar S, Mandal K, Whitman GJ, Frank SM. Discharge Hemoglobin Level and 30-Day Readmission Rates After Coronary Artery Bypass Surgery. Anesth Analg 2019; 128:342-348. [PMID: 30059402 DOI: 10.1213/ane.0000000000003671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels on discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG). METHODS We retrospectively evaluated 1552 patients undergoing isolated CABG at our institution from January 2013 to May 2016. We evaluated 2 Hb cohorts: "high" (above) and "low" (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (<8 g/dL) discharge Hb levels on 30-day readmission rates by dividing the patients into 4 anemia cohorts based on discharge Hb levels: "no anemia" (>12 g/dL), "mild anemia" (10-11.9 g/dL), "moderate anemia" (8-9.9 g/dL), and "severe anemia" (<8 g/dL). Risk adjustment accounted for age, sex, Charlson comorbidity index, preoperative comorbidities, revision sternotomy, and patient blood management program implementation. RESULTS The "high" and "low" groups had similar patient characteristics except for Hb levels (mean discharge Hb was 10.4 ± 0.9 vs 8.5 ± 0.6 g/dL, respectively). Notably, no evidence for a difference in 30-day readmission rates was noted between the "high" (76/746; 10.2%) and "low" (97/806; 12.0%) (P = .25) Hb cohorts. The 4 anemia cohorts had differences in age, revision sternotomy incidence, Hb levels, certain patient comorbidities, and time to readmission. On multivariable analysis, the risk-adjusted odds of readmission in the "low" Hb cohort (odds ratio, 1.16; 95% confidence interval, 0.84-1.61; P = .36) was not significant compared to the "high" Hb cohort. Compared to patients with discharge Hb ≥8 g/dL, patients with Hb <8 g/dL had a higher incidence of readmission (22/129; 17.1% vs 151/1423; 10.6%; P = .036). On multivariable analysis, Hb <8 g/dL on discharge was predictive of readmission (odds ratio, 1.77; 95% confidence interval, 1.05-2.88; P = .03). The most common reason for readmission was volume overload, followed by infection and arrhythmias. CONCLUSIONS A discharge Hb level below the institution mean for CABG patients does not provide evidence for an association with an increased 30-day readmission rate. In the small number of patients discharged with Hb <8 g/dL, there is a suggestion of increased risk for readmission and larger more controlled studies are needed to verify or refute this finding.
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Affiliation(s)
- Brian C Cho
- From the Department of Anesthesiology/Critical Care Medicine
| | | | - Michael C Grant
- From the Department of Anesthesiology/Critical Care Medicine
| | - Nadia B Hensley
- From the Department of Anesthesiology/Critical Care Medicine
| | - Charles H Brown
- From the Department of Anesthesiology/Critical Care Medicine
| | | | - Kaushik Mandal
- Department of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Glenn J Whitman
- Department of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, Faculty, Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery. Anesthesiology 2019; 129:1082-1091. [PMID: 30124488 DOI: 10.1097/aln.0000000000002397] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes. METHODS After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index. RESULTS After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016). CONCLUSIONS In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.
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Nakahashi T, Tada H, Sakata K, Yakuta Y, Tanaka Y, Gamou T, Nomura A, Terai H, Horita Y, Ikeda M, Namura M, Takamura M, Hayashi K, Yamagishi M, Kawashiri MA. Impact of decreased ankle-brachial index on 30-day bleeding complications and long-term mortality in patients with acute coronary syndrome after percutaneous coronary intervention. J Cardiol 2019; 74:116-122. [DOI: 10.1016/j.jjcc.2019.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/07/2019] [Accepted: 01/15/2019] [Indexed: 01/28/2023]
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Mincu RI, Rassaf T, Totzeck M. Red blood cell transfusion in patients with ST-elevation myocardial infarction-a meta-analysis of more than 21,000 patients. Neth Heart J 2018; 26:454-460. [PMID: 30039381 PMCID: PMC6115305 DOI: 10.1007/s12471-018-1137-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Red blood cell transfusion remains controversial in patients with acute coronary syndromes and particularly in patients with ST-elevation myocardial infarction (STEMI). METHODS We systematically searched PubMed, Cochrane, EMBASE, and Web of Science for studies published until January 2017 describing the outcomes in patients with STEMI who received red blood cell transfusion, compared with patients who did not. RESULTS A total of 21,770 patients with STEMI from 5 cohort studies were included in the meta-analysis, 984 (4.5%) received red blood cell transfusion and 20,786 (95.4%) did not. Red blood cell transfusion was associated with a higher risk of in-hospital and long-term mortality, emergency repeated percutaneous coronary intervention (PCI), reinfarction rate, stroke rate, and heart failure. The group with red blood cell transfusion had a slightly higher incidence of diabetes mellitus and hypertension, but a lower incidence of smoking. The two groups had the same incidence of prior myocardial infarction, prior coronary artery bypass graft surgery and malignancy. Prior heart failure, prior stroke and prior PCI were more frequent in the group that had received red blood cell transfusion. The mean nadir haemoglobin was 8.5 ± 0.1 g/dl in the group with red blood cell transfusion and 12.5 ± 0.4 g/dl in the control group, p < 0.001. CONCLUSIONS Red blood cell transfusion increases the morbidity and mortality in patients with STEMI. This difference could not be explained by the higher morbidity in the red blood cell transfusion group alone. Further randomised controlled trials are required to provide a reliable haemoglobin threshold for these patients.
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Affiliation(s)
- R I Mincu
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany.,University and Emergency Hospital, Cardiac Research Unit, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - T Rassaf
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany
| | - M Totzeck
- Medical Faculty, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany.
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Allonen J, Nieminen MS, Hiippala S, Sinisalo J. Relation of Use of Red Blood Cell Transfusion After Acute Coronary Syndrome to Long-Term Mortality. Am J Cardiol 2018; 121:1496-1504. [PMID: 29631802 DOI: 10.1016/j.amjcard.2018.02.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/17/2018] [Accepted: 02/26/2018] [Indexed: 01/28/2023]
Abstract
Registry studies have associated red blood cell (RBC) transfusion with increased in-hospital mortality in patients with acute coronary syndrome (ACS). The impact on long-term mortality after 1-year follow-up remains unknown. Consecutive patients with ACS (n = 2,009) of a prospective Genetic Predisposition of Coronary Artery Disease cohort were followed for a median of 8.6 years (95% confidence interval [CI] 8.59 to 8.69). After discharge, 1,937 (96%) patients survived for over 30 days. Of those survivors, a subgroup of previously transfusion-naïve patients 85/1,937 (4.4%) who had received at least 1 RBC transfusion during hospitalization were compared with 1,278/1,937 patients (66.0%) who had not received any transfusion either during the hospitalization or the entire follow-up. Unadjusted long-term mortality was significantly higher in the patients transfused with RBC compared with their counterparts not transfused with RBC (58.8% vs 20.3%, p <0.001). The results remained significant for hazard ratio (HR) 1.91, 95% CI 1.39 to 2.63, p <0.001, after multivariate Cox proportional hazards model analysis and were similar after 1-year landmark analysis (HR 1.90, 95% CI 1.34 to 2.70, p <0.001). The higher all-cause mortality was largely explained by cancer mortality (15.3% vs 4.1%, p <0.001) and cardiovascular mortality (34.1% vs 12.1%, p <0.001). After 1:1 propensity score matching (n = 65 vs 65), the association of RBC transfusion with worse survival remained significant (HR 2.70, 95% CI 1.48 to 4.95, p = 0.001). Inverse probability weighted Cox analyses turned out similar results (HR 2.07, 95% CI 1.38 to 3.11, p <0.001). In conclusion, the strong association of need for RBC transfusion with increased mortality continued for patients with ACS even after a 1-year follow-up.
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Putot A, Zeller M, Perrin S, Beer JC, Ravisy J, Guenancia C, Robert R, Manckoundia P, Cottin Y. Blood Transfusion in Elderly Patients with Acute Myocardial Infarction: Data from the RICO Survey. Am J Med 2018; 131:422-429.e4. [PMID: 29030059 DOI: 10.1016/j.amjmed.2017.09.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Red blood cell transfusion benefit during acute myocardial infarction remains unclear in the elderly. We aimed to assess the transfusion impact on 1-year mortality in acute myocardial infarction patients aged ≥65 years, according to their age and hemoglobin nadir. METHODS We included 3316 consecutive patients with acute myocardial infarction aged ≥65 years from the "obseRvatoire des Infarctus de Côte d'Or" (RICO) survey. They were categorized according to their hemoglobin nadir (≤8, >8 to ≤10, and >10 g/dL) and age (<80 or ≥80 years). RESULTS A total of 1906 patients (57%) were 65-79 years old, and 1410 (43%) were aged ≥80 years, of whom 103 (5%) and 145 (10%) patients received red blood cell transfusion, respectively (P < .001). In Cox regression analysis, transfusion was associated with increased 1-year mortality for hemoglobin nadir >10 g/dL but no significant effect for hemoglobin nadir between 8 and 10 g/dL. When hemoglobin nadir was ≤8 g/dL, transfusion did not influence 1-year mortality for younger patients (65-79 years). However, for older patients (≥80 years), transfusion was associated with lower mortality (hazard ratio 0.43 [95% confidence interval, 0.22-0.86], P = .016). CONCLUSION Among older patients with acute myocardial infarction, the effect of transfusion was largely dependent on hemoglobin threshold and age. Transfusion was associated with increased 1-year mortality when hemoglobin nadir was >10 g/dL. However, in patients aged ≥80 years with hemoglobin nadir <8 g/dL, transfusion was associated with a 50% reduction in 1-year mortality.
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Affiliation(s)
- Alain Putot
- Médecine interne gériatrie, Pôle Personnes Âgées, Centre Hospitalier Universitaire, Dijon, France
| | - Marianne Zeller
- Laboratoire Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne Franche-Comté, Dijon, France.
| | - Sophie Perrin
- Médecine interne gériatrie, Pôle Personnes Âgées, Centre Hospitalier Universitaire, Dijon, France
| | - Jean-Claude Beer
- Service de Cardiologie, Centre Hospitalier Universitaire, Dijon, France
| | - Jack Ravisy
- Service de Cardiologie, Clinique de Fontaine, Fontaine les Dijon, France
| | - Charles Guenancia
- Service de Cardiologie, Centre Hospitalier Universitaire, Dijon, France
| | - Raphaël Robert
- Service de Cardiologie, Centre Hospitalier Universitaire, Dijon, France
| | - Patrick Manckoundia
- Médecine interne gériatrie, Pôle Personnes Âgées, Centre Hospitalier Universitaire, Dijon, France; Institut National de la Santé et de la Recherche Médicale U1093 Cognition Action Plasticité, Université de Bourgogne Franche-Comté, Dijon, France
| | - Yves Cottin
- Laboratoire Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne Franche-Comté, Dijon, France; Service de Cardiologie, Centre Hospitalier Universitaire, Dijon, France
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Kao I, Xiong Y, Steffen A, Smuda K, Zhao L, Georgieva R, Pruss A, Bäumler H. Preclinical In Vitro Safety Investigations of Submicron Sized Hemoglobin Based Oxygen Carrier HbMP-700. Artif Organs 2018; 42:549-559. [DOI: 10.1111/aor.13071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 09/05/2017] [Accepted: 10/02/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Ijad Kao
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
| | - Yu Xiong
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
- CC-Ery GmbH; Berlin Germany
| | - Axel Steffen
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
- CC-Ery GmbH; Berlin Germany
| | - Kathrin Smuda
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
| | - Lian Zhao
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
- Institute of Transfusion Medicine, Academy of Military Medical Sciences; Beijing China
| | - Radostina Georgieva
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
| | - Axel Pruss
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
| | - Hans Bäumler
- Charité-Universitätsmedizin Berlin, Institute of Transfusion Medicine; Berlin Germany
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Wang Y, Shi X, Du R, Chen Y, Zhang Q. Impact of red blood cell transfusion on acute coronary syndrome: a meta-analysis. Intern Emerg Med 2018; 13:231-241. [PMID: 28039615 DOI: 10.1007/s11739-016-1594-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/20/2016] [Indexed: 02/05/2023]
Abstract
The impact of red blood cell transfusion on outcomes in patients with acute coronary syndrome is controversial. Pubmed, EMBASE, and Cochrane Library were searched for studies of red blood cell transfusion and acute coronary syndrome that were published in any language, from January 1, 1966, to April 1, 2016. We analyzed 17 observational studies, of 2,525,550 subjects. We conducted a systematic review with meta-analysis of studies assessing the association between blood transfusion and the risk for all-cause mortality and reinfarction. The search yielded 17 observational studies, of 2,525,550 subjects, during a study follow-up period, ranging from 30 days to 5 years. Red blood cell transfusion compared with no blood transfusion is associated with higher short- and long-term all-cause mortality as well as reinfarction rates (adjusted RR 2.23; 95% CI 1.47-3.39; HR 1.93; 95% CI 1.12-3.34; RR 2.61; 95% CI 2.17-3.14, respectively). In hemoglobin-stratified analyses, a graded association between red blood cell transfusion and mortality was observed, transfusion and risk of all-cause mortality was borderline significant at hemoglobin levels below 8.0 g/dL (RR 0.52; 95% CI 0.25-1.06), and was associated with an increased risk of mortality at a hemoglobin above 10 g/dL (RR 3.34; 95% CI 2.25-4.97). Red blood cell transfusion was associated with an increased risk of short- and long-term mortality as well as myocardial reinfarction. However, transfusion appeared to have beneficial or neutral effects on mortality at hemoglobin levels below 8.0 g/dL, and harmful effects above 10 g/dL. A large definitive randomized controlled trial addressing this issue is urgently required.
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Affiliation(s)
- Yushu Wang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Sichuan, China
| | - Xiuli Shi
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Sichuan, China
| | - Rongsheng Du
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Sichuan, China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Sichuan, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, Sichuan, China.
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19
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Napolitano LM. Anemia and Red Blood Cell Transfusion: Advances in Critical Care. Crit Care Clin 2017; 33:345-364. [PMID: 28284299 DOI: 10.1016/j.ccc.2016.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Anemia is common in the intensive care unit (ICU), resulting in frequent administration of red blood cell (RBC) transfusions. Significant advances have been made in understanding the pathophysiology of anemia in the ICU, which is anemia of inflammation. This anemia is related to high hepcidin concentrations resulting in iron-restricted erythropoiesis, and decreased erythropoietin concentrations. A new hormone (erythroferrone) has been identified, which mediates hepcidin suppression to allow increased iron absorption and mobilization from iron stores. RBC transfusions are most commonly administered to ICU patients for treatment of anemia. All strategies to reduce anemia in the ICU should be implemented.
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Affiliation(s)
- Lena M Napolitano
- Division of Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery], Department of Surgery, University of Michigan Health System, University Hospital, Room 1C340-UH, 1500 East Medical Drive, SPC 5033, Ann Arbor, MI 48109-5033, USA.
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Czarny MJ, Hwang CW, Naiman DQ, Lemmon CC, Hasan RK, Wang T, Aversano T. Heparin versus bivalirudin for non-primary percutaneous coronary intervention: A post-Hoc analysis of the CPORT-E trial. Catheter Cardiovasc Interv 2017; 90:366-377. [PMID: 28160375 DOI: 10.1002/ccd.26953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/23/2016] [Accepted: 12/30/2016] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To compare bivalirudin to heparin during non-primary percutaneous coronary intervention (PCI). BACKGROUND The optimal anticoagulant to support PCI remains uncertain. METHODS We performed a propensity score-based analysis comparing clinical outcomes of patients receiving heparin to those receiving bivalirudin during non-primary PCI. RESULTS Of 18,867 patients in the Cardiovascular Patient Outcomes Research Team Non-Primary PCI (CPORT-E) trial, we selected 7,913 patients undergoing non-staged PCI of whom 57.3% received heparin and 42.7% received bivalirudin. In-hospital myocardial infarction occurred in 4.4% of patients receiving bivalirudin and 3.0% of patients receiving heparin (relative risk [RR] 1.5, 95% confidence interval [CI] 1.1-2.1, P = 0.022); this difference persisted at 6 weeks (5.0% vs. 3.6%, RR 1.4, 95% CI 1.0-1.8, P = 0.041). There was no difference in all-cause mortality either in-hospital (0.2% vs. 0.1% for heparin vs. bivalirudin, P = 0.887) or at 6 weeks (0.5% vs. 0.7%, P = 0.567). In-hospital bleeding requiring transfusion occurred in 0.9% of patients receiving bivalirudin and 1.9% of patients receiving heparin (RR 0.4, 95% CI 0.3-0.7, P <0.001), but there was no difference at 6 weeks (2.7% for heparin vs. 1.9% for bivalirudin, RR 0.7, 95% CI 0.5-1.0, P = 0.062). CONCLUSIONS In patients undergoing non-primary PCI at hospitals without on-site cardiac surgery, bivalirudin was associated with a decreased risk of in-hospital bleeding requiring transfusion and an increased risk of in-hospital MI compared to heparin. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew J Czarny
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Chao-Wei Hwang
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Q Naiman
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia C Lemmon
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rani K Hasan
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas Wang
- Center for Cardiac and Vascular Research, Washington Adventist Hospital, Takoma Park, Maryland
| | - Thomas Aversano
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Yin Z, Yu B, Liu W, Lan K. Blood transfusion and mortality in myocardial infarction: an updated meta-analysis. Oncotarget 2017; 8:102254-102262. [PMID: 29254241 PMCID: PMC5731951 DOI: 10.18632/oncotarget.19208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/29/2017] [Indexed: 12/19/2022] Open
Abstract
Background Several observational and preclinical studies have shown that blood transfusion may modify the mortality of patients with myocardial infarction (MI). The aim of this meta-analysis is to evaluate the recent evidence on the effectiveness of blood transfusion for all-cause mortality in patients with MI. Materials and Methods PUBMED, EMBASE and the Cochrane central register of controlled trials were searched up to June 2016 by two independent investigators. Studies were considered eligible if they recruited adult MI patients and reported hazard ratio (HR) for all-cause mortality comparing those who received blood transfusion with those who did not receive blood transfusion. We abstracted and calculated pooled HRs using a random-effects model. Results From 4277 unique reports, we identified 17 studies including 260811 patients with 11 studies examining short-term (in hospital/30-day) all-cause mortality and 9 studies examining long-term (more than 30 days) all-cause mortality. Meta-analysis demonstrated that patients treated with blood transfusion had increased short-term all-cause mortality (HR, 2.39, 95% CI 1.81 to 3.15) compared with those without blood transfusion treatment. Similar findings were observed by subgroup analyses. We also find significant association between blood transfusion and long-term all-cause mortality (HR 1.90, 95% CI 1.40 to 2.58) for MI patients. Conclusions In patients with MI, blood transfusion treatment is associated with patient short-term and long-term all-cause mortality. However, further large-scale prospective studies are needed to establish its validity of this association.
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Affiliation(s)
- Zuomin Yin
- Department of Chest Pain Center, The Affiliated Central Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Botao Yu
- Department of Chest Pain Center, The Affiliated Central Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Weisheng Liu
- Department of Chest Pain Center, The Affiliated Central Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ketao Lan
- Department of Chest Pain Center, The Affiliated Central Hospital of Qingdao University, Qingdao, Shandong Province, China
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Wang Y, Shi X, Wen M, Chen Y, Zhang Q. Restrictive versus liberal blood transfusion in patients with coronary artery disease: a meta-analysis. Curr Med Res Opin 2017; 33:761-768. [PMID: 28067544 DOI: 10.1080/03007995.2017.1280010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare clinical outcomes between restrictive versus liberal blood transfusion strategies in patients with coronary artery disease (CAD). RESEARCH DESIGN AND METHODS A literature search from January 1966 to May 2016 was performed in PubMed, EMBASE and Cochrane Library to find trials evaluating a restrictive hemoglobin transfusion trigger of ≤8 g/dL, compared with a more liberal trigger. Two study authors independently extracted data from the trials. The primary outcome was mortality and the secondary outcome was subsequent myocardial infarction. Relative risks (RRs) with their 95% confidence intervals (CIs) were assessed. RESULTS Six trials involving 133,058 participants were included in this study. Pooled results revealed no difference in mortality between the liberal transfusion and restrictive transfusions (RR = 1.17, 95% CI = 0.91-1.52, P = .22). Subgroup analysis revealed that a restrictive transfusion strategy was associated with a higher risk of in-hospital mortality (RR = 1.38, 95% CI = 1.15-1.67, P < .001) and 30 day mortality (RR = 1.21, 95% CI = 1.01-1.45, P = .03), compared with the liberal strategy. No significant difference was found between the liberal transfusion strategy and restrictive transfusion strategy in risk for subsequent myocardial infarction (RR = 1.09, 95% CI = 0.57-2.06, P = .80). LIMITATIONS Limitations include (1) limited number of trials, especially those evaluating myocardial infarction, (2) observed heterogeneity, (3) confounding by indication and other inherent bias may exist. CONCLUSION The findings suggest that restrictive blood transfusion was associated with higher in-hospital and 30 day mortality than liberal blood transfusion in CAD patients. The conclusions are mainly based on retrospective studies and should not be considered as recommendation before they are supported by randomized controlled trials.
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Affiliation(s)
- Yushu Wang
- a Department of Cardiology , West China Hospital, Sichuan University , Chengdu , Sichuan , China
| | - Xiuli Shi
- a Department of Cardiology , West China Hospital, Sichuan University , Chengdu , Sichuan , China
| | - Meiqin Wen
- a Department of Cardiology , West China Hospital, Sichuan University , Chengdu , Sichuan , China
| | - Yucheng Chen
- a Department of Cardiology , West China Hospital, Sichuan University , Chengdu , Sichuan , China
| | - Qing Zhang
- a Department of Cardiology , West China Hospital, Sichuan University , Chengdu , Sichuan , China
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Impact of blood transfusion on in-hospital myocardial infarctions according to patterns of acute coronary syndrome: Insights from the BleeMACS registry. Int J Cardiol 2016; 221:364-70. [DOI: 10.1016/j.ijcard.2016.07.075] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 07/04/2016] [Indexed: 01/28/2023]
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Hemoglobin Level and Hospital Mortality Among ICU Patients With Cardiac Disease Who Received Transfusions. J Am Coll Cardiol 2016; 66:2510-8. [PMID: 26653625 DOI: 10.1016/j.jacc.2015.09.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/10/2015] [Accepted: 09/15/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a paucity of randomized clinical trial data on the use of red blood cell (RBC) transfusion in critically ill patients, specifically in the setting of cardiac disease. OBJECTIVES This study examined how hemoglobin (Hgb) level and cardiac disease modify the relationship of RBC transfusion with hospital mortality. The aim was to estimate the Hgb level threshold below which transfusion would be associated with reduced hospital mortality. METHODS We performed secondary data analyses of Veterans Affairs intensive care unit (ICU) episodes across 5 years. Logistic regression quantified the effect of transfusion on hospital mortality while adjusting for nadir Hgb level, demographic characteristics, admission information, comorbid conditions, and ICU admission diagnoses. RESULTS Among 258,826 ICU episodes, 12.4% involved transfusions. Hospital death occurred in 11.6%. Without comorbid heart disease, transfusion was associated with decreased adjusted hospital mortality when Hgb was approximately <7.7 g/dl, but transfusion increased mortality above this Hgb level. Corresponding Hgb level thresholds were approximately 8.7 g/dl when comorbid heart disease was present and approximately 10 g/dl when the ICU admission diagnosis was acute myocardial infarction (AMI). Sensitivity analysis using additional adjustment for selected blood tests in a subgroup of 182,792 ICU episodes lowered these thresholds by approximately 1 g/dl. CONCLUSIONS Transfusion of critically ill patients was associated with reduced hospital mortality when Hgb level was <8 to 9 g/dl in the presence of comorbid heart disease. This Hgb level threshold for transfusion was 9 to 10 g/dl when AMI was the ICU admission diagnosis.
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Hellhammer K, Zeus T, Verde PE, Veulemanns V, Kahlstadt L, Wolff G, Erkens R, Westenfeld R, Navarese EP, Merx MW, Rassaf T, Kelm M. Red cell distribution width in anemic patients undergoing transcatheter aortic valve implantation. World J Cardiol 2016; 8:220-230. [PMID: 26981217 PMCID: PMC4766272 DOI: 10.4330/wjc.v8.i2.220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/03/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the impact of red blood cell distribution width on outcome in anemic patients undergoing transcatheter aortic valve implantation (TAVI).
METHODS: In a retrospective single center cohort study we determined the impact of baseline red cell distribution width (RDW) and anemia on outcome in 376 patients with aortic stenosis undergoing TAVI. All patients were discussed in the institutional heart team and declined for surgical aortic valve replacement due to high operative risk. Collected data included patient characteristics, imaging findings, periprocedural in hospital data, laboratory results and follow up data. Blood samples for hematology and biochemistry analysis were taken from every patient before and at fixed intervals up to 72 h after TAVI including blood count and creatinine. Descriptive statistics were used for patient’s characteristics. Kaplan-Meier survival curves were used for time to event outcomes. A recursive partitioning regression and classification was used to investigate the association between potential risk factors and outcome variables.
RESULTS: Mean age in our study population was 81 ± 6.1 years. Anemia was prevalent in 63.6% (n = 239) of our patients. Age and creatinine were identified as risk factors for anemia. In our study population, anemia per se did influence 30-d mortality but did not predict longterm mortality. In contrast, a RDW > 14% showed to be highly predictable for a reduced short- and longterm survival in patients with aortic valve disease after TAVI procedure.
CONCLUSION: Age and kidney function determine the degree of anemia. The anisocytosis of red blood cells in anemic patients supplements prognostic information in addition to that derived from the WHO-based definition of anemia.
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Barbarova I, Klempfner R, Rapoport A, Wasserstrum Y, Goren I, Kats A, Segal G. Avoidance of Blood Transfusion to Patients Suffering From Myocardial Injury and Severe Anemia Is Associated With Increased Long-Term Mortality: A Retrospective Cohort Analysis. Medicine (Baltimore) 2015; 94:e1635. [PMID: 26402836 PMCID: PMC4635776 DOI: 10.1097/md.0000000000001635] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Myocardial injury and anemia are common among patients in internal medicine departments. Nevertheless, the level of anemia in which blood should be given to these patients is ill defined. We conducted a retrospective, cohort analysis. A total of 209 patients hospitalized to internal medicine, with myocardial injury (troponin I > 0.2 mcg/L, not diagnosed as ACS, acute coronary syndrome) and anemia (Hb < 10 g/dL, without overt bleeding) were included. The overall in-hospital mortality rate was 20.7%. A total of 37 patients (17.8%) had severe anemia (Hb < 8 g/dL). A total of 73 patients (34.9%) were transfused. Severe anemia was not associated with increased long-term mortality in the whole cohort while survival of patients with severe anemia that were not transfused was significantly reduced compared to transfused patients (44% vs 80%; P = 0.03). Mortality rates were similar for all patients with Hb ≥ 8 g/dL, regardless of transfusion (54% vs 49%; P = 0.60). Consistently, lack of blood transfusion in patients with severe anemia was independently associated with a 2.27 (1.08-4.81) greater adjusted risk of all-cause mortality (P-value for interaction = 0.04), whereas it did not significantly increase in patients with Hb ≥ 8 g/dL. Avoidance of blood transfusion is associated with unfavorable outcomes among patients with myocardial injury and severe anemia.
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Affiliation(s)
- Irina Barbarova
- From the Department of Internal Medicine "T" (BI, RA, GI, KA, SG); Leviev Heart Institute, Chaim Sheba Medical Center, Ramat Gan (KR); and Sackler Faculty of Medicine, Tel-Aviv University, Israel (WY, KR)
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Cem A, Serpil UOZ, Fevzi T, Murat O, Umit G, Esin E, Pinar U, Sahin S, Hasan K, Cem A. Efficacy of near-infrared spectrometry for monitoring the cerebral effects of severe dilutional anemia. Heart Surg Forum 2015; 17:E154-9. [PMID: 25002392 DOI: 10.1532/hsf98.2013293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Clear guidelines for red cell transfusion during cardiac surgery have not yet been established. The current focus on blood conservation during cardiac surgery has increased the urgency to determine the minimum safe hematocrit for these patients. The aim of this study was to determine whether monitoring of cerebral regional oxygen saturation (rSO2) via near-infrared spectrometry (NIRS) is effective for assessing the cerebral effects of severe dilutional anemia during elective coronary arterial bypass graft surgery (CABG). METHODS The prospective observational study involved patients who underwent cerebral rSO2 monitoring by NIRS during elective isolated first-time CABG: an anemic group (N=15) (minimum Hemoglobin (Hb) <7 g/dL at any period during cardiopulmonary bypass (CPB) and a control group (N=15) (Hb >8 g/dL during CPB). Mean arterial pressure (MAP), pump blood flow, blood lactate level, pCO2, pO2 at five time points and cross-clamp time, extracorporeal circulation time were recorded for each patient. Group results statistically were compared. RESULTS The anemic group had significantly lower mean preoperative Hb than the control group (10.3 mg/dL versus 14.2 mg/dL; P = .001). The lowest Hb levels were observed in the hypothermic period of CPB in the anemic group. None of the controls exhibited a >20% decrease in cerebral rSO2. Eleven (73.3%) of the anemic patients required an increase in pump blood flow to raise their cerebral rSO2. CONCLUSIONS In this study, the changes in cerebral rSO2 in the patients with low Hb were within acceptable limits, and this was in concordance with the blood lactate levels and blood-gas analysis. It can be suggested that NIRS monitoring of cerebral rSO2 can assist in decision making related to blood transfusion and dilutional anemia during CPB.
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Affiliation(s)
- Arıtürk Cem
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Ustalar Ozgen Zehra Serpil
- Department of Anesthesiology and Reanimation, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Toraman Fevzi
- Department of Anesthesiology and Reanimation, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Okten Murat
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Güllü Umit
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Erkek Esin
- Department of Cardiovascular Surgery, Acıbadem Healthcare Group, Acıbadem Kadikoy Hospital, Kadikoy, Istanbul, Turkey
| | - Uysal Pinar
- Department of Cardiovascular Surgery, Acıbadem Healthcare Group, Acıbadem Kadikoy Hospital, Kadikoy, Istanbul, Turkey
| | - Sensy Sahin
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Karabulut Hasan
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
| | - Alhan Cem
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Atasehir, Istanbul, Turkey
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Carson JL, Sieber F, Cook DR, Hoover DR, Noveck H, Chaitman BR, Fleisher L, Beaupre L, Macaulay W, Rhoads GG, Paris B, Zagorin A, Sanders DW, Zakriya KJ, Magaziner J. Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet 2015; 385:1183-9. [PMID: 25499165 PMCID: PMC4498804 DOI: 10.1016/s0140-6736(14)62286-8] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy. METHODS In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with ClinicalTrials.gov, number NCT00071032. FINDINGS Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4-4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 [95% CI 0·95-1·25]; p=0·21). INTERPRETATION Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20-25% or cause of death. FUNDING National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Donald Richard Cook
- Division of General Internal Medicine, University of Calgary, Calgary, AB, Canada
| | - Donald R Hoover
- Department of Statistics, Rutgers University, New Brunswick, NJ, USA
| | - Helaine Noveck
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Lee Fleisher
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Beaupre
- Departments of Physical Therapy and Surgery, Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada
| | - William Macaulay
- Department of Orthopedic Surgery, New York-Presbyterian Hospital at Columbia University, New York, NY, USA
| | | | - Barbara Paris
- Division of Geriatrics, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - Aleksandra Zagorin
- Division of Geriatrics, Maimonides Medical Center, Brooklyn, New York, NY, USA
| | - David W Sanders
- Department of Orthopaedic Surgery, University of Western Ontario, London, ON, Canada
| | - Khwaja J Zakriya
- Department of Anesthesia, Surgeons Surgery Center, Cumberland, MD, USA
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Yeh RW, Wimmer NJ. Blood transfusion in myocardial infarction: opening old wounds for comparative-effectiveness research. J Am Coll Cardiol 2014; 64:820-2. [PMID: 25145527 DOI: 10.1016/j.jacc.2014.05.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 05/12/2014] [Indexed: 01/28/2023]
Affiliation(s)
- Robert W Yeh
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Neil J Wimmer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Salisbury AC, Reid KJ, Marso SP, Amin AP, Alexander KP, Wang TY, Spertus JA, Kosiborod M. Blood Transfusion During Acute Myocardial Infarction. J Am Coll Cardiol 2014; 64:811-9. [DOI: 10.1016/j.jacc.2014.05.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/10/2014] [Accepted: 05/01/2014] [Indexed: 01/20/2023]
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Simoni J, Simoni G, Moeller JF, Feola M, Wesson DE. Artificial oxygen carrier with pharmacologic actions of adenosine-5'-triphosphate, adenosine, and reduced glutathione formulated to treat an array of medical conditions. Artif Organs 2014; 38:684-90. [PMID: 24980041 DOI: 10.1111/aor.12337] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Effective artificial oxygen carriers may offer a solution to tackling current transfusion medicine challenges such as blood shortages, red blood cell storage lesions, and transmission of emerging pathogens. These products, could provide additional therapeutic benefits besides oxygen delivery for an array of medical conditions. To meet these needs, we developed a hemoglobin (Hb)-based oxygen carrier, HemoTech, which utilizes the concept of pharmacologic cross-linking. It consists of purified bovine Hb cross-linked intramolecularly with open ring adenosine-5'-triphosphate (ATP) and intermolecularly with open ring adenosine, and conjugated with reduced glutathione (GSH). In this composition, ATP prevents Hb dimerization, and adenosine promotes formation of Hb polymers as well as counteracts the vasoconstrictive and pro-inflammatory properties of Hb via stimulation of adenosine receptors. ATP also serves as a regulator of vascular tone through activation of purinergic receptors. GSH blocks Hb's extravasation and glomerular filtration by lowering the isoelectric point, as well as shields heme from nitric oxide and reactive oxygen species. HemoTech and its manufacturing technology have been broadly tested, including viral and prion clearance validation studies and various nonclinical pharmacology, toxicology, genotoxicity, and efficacy tests. The clinical proof-of-concept was carried out in sickle cell anemia subjects. The preclinical and clinical studies indicate that HemoTech works as a physiologic oxygen carrier and has efficacy in treating: (i) acute blood loss anemia by providing a temporary oxygen bridge while stimulating an endogenous erythropoietic response; (ii) sickle cell disease by counteracting vaso-occlusive/inflammatory episodes and anemia; and (iii) ischemic vascular diseases particularly thrombotic and restenotic events. The pharmacologic cross-linking of Hb with ATP, adenosine, and GSH showed usefulness in designing an artificial oxygen carrier for multiple therapeutic indications.
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Affiliation(s)
- Jan Simoni
- Division of Artificial Oxygen Carriers, Texas HemoBioTherapeutics & BioInnovation Center (THBBC), Lubbock, TX, USA; School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Du Pont-Thibodeau G, Harrington K, Lacroix J. Anemia and red blood cell transfusion in critically ill cardiac patients. Ann Intensive Care 2014; 4:16. [PMID: 25024880 PMCID: PMC4085735 DOI: 10.1186/2110-5820-4-16] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 05/07/2014] [Indexed: 12/19/2022] Open
Abstract
Anemia and red blood cell (RBC) transfusion occur frequently in hospitalized patients with cardiac disease. In this narrative review, we report the epidemiology of anemia and RBC transfusion in hospitalized adults and children (excluding premature neonates) with cardiac disease, and on the outcome of anemic and transfused cardiac patients. Both anemia and RBC transfusion are common in cardiac patients, and both are associated with mortality. RBC transfusion is the only way to rapidly treat severe anemia, but is not completely safe. In addition to hemoglobin (Hb) concentration, the determinant(s) that should drive a practitioner to prescribe a RBC transfusion to cardiac patients are currently unclear. In stable acyanotic cardiac patients, Hb level above 70 g/L in children and above 70 to 80 g/L in adults appears safe. In cyanotic children, Hb level above 90 g/L appears safe. The appropriate threshold Hb level for unstable cardiac patients and for children younger than 28 days is unknown. The optimal transfusion strategy in cardiac patients is not well characterized. The threshold at which the risk of anemia outweighs the risk of transfusion is not known. More studies are needed to determine when RBC transfusion is indicated in hospitalized patients with cardiac disease.
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Affiliation(s)
| | - Karen Harrington
- Sainte-Justine Hospital, Room 3431, 3175 Côte Sainte-Catherine, Montreal, QC H3T 1C5, Canada
| | - Jacques Lacroix
- Sainte-Justine Hospital, Room 3431, 3175 Côte Sainte-Catherine, Montreal, QC H3T 1C5, Canada
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Gurm HS, Kooiman J, LaLonde T, Grines C, Share D, Seth M. A random forest based risk model for reliable and accurate prediction of receipt of transfusion in patients undergoing percutaneous coronary intervention. PLoS One 2014; 9:e96385. [PMID: 24816645 PMCID: PMC4015942 DOI: 10.1371/journal.pone.0096385] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/08/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Transfusion is a common complication of Percutaneous Coronary Intervention (PCI) and is associated with adverse short and long term outcomes. There is no risk model for identifying patients most likely to receive transfusion after PCI. The objective of our study was to develop and validate a tool for predicting receipt of blood transfusion in patients undergoing contemporary PCI. METHODS Random forest models were developed utilizing 45 pre-procedural clinical and laboratory variables to estimate the receipt of transfusion in patients undergoing PCI. The most influential variables were selected for inclusion in an abbreviated model. Model performance estimating transfusion was evaluated in an independent validation dataset using area under the ROC curve (AUC), with net reclassification improvement (NRI) used to compare full and reduced model prediction after grouping in low, intermediate, and high risk categories. The impact of procedural anticoagulation on observed versus predicted transfusion rates were assessed for the different risk categories. RESULTS Our study cohort was comprised of 103,294 PCI procedures performed at 46 hospitals between July 2009 through December 2012 in Michigan of which 72,328 (70%) were randomly selected for training the models, and 30,966 (30%) for validation. The models demonstrated excellent calibration and discrimination (AUC: full model = 0.888 (95% CI 0.877-0.899), reduced model AUC = 0.880 (95% CI, 0.868-0.892), p for difference 0.003, NRI = 2.77%, p = 0.007). Procedural anticoagulation and radial access significantly influenced transfusion rates in the intermediate and high risk patients but no clinically relevant impact was noted in low risk patients, who made up 70% of the total cohort. CONCLUSIONS The risk of transfusion among patients undergoing PCI can be reliably calculated using a novel easy to use computational tool (https://bmc2.org/calculators/transfusion). This risk prediction algorithm may prove useful for both bed side clinical decision making and risk adjustment for assessment of quality.
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Affiliation(s)
- Hitinder S. Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Judith Kooiman
- Department of Thrombosis and Hemostasis and Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas LaLonde
- Department of Internal Medicine, St John Providence Health System, Detroit, Michigan, United States of America
| | - Cindy Grines
- Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan, United States of America
| | - David Share
- Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
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Sherwood MW, Wang Y, Curtis JP, Peterson ED, Rao SV. Patterns and outcomes of red blood cell transfusion in patients undergoing percutaneous coronary intervention. JAMA 2014; 311:836-43. [PMID: 24570247 PMCID: PMC4276400 DOI: 10.1001/jama.2014.980] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Studies have shown variation in the use of red blood cell transfusion among patients with acute coronary syndromes. There are no definitive data for the efficacy of transfusion in improving outcomes, and concerning data exist about possible association with harm. Current transfusion practices in patients undergoing percutaneous coronary intervention (PCI) are not well understood. OBJECTIVE To determine the current patterns of blood transfusion among patients undergoing PCI and the association of transfusion with adverse cardiac outcomes across hospitals in the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of all patient visits from the CathPCI Registry from July 2009 to March 2013 that included PCI, excluding those with missing data on bleeding complications or who underwent in-hospital coronary artery bypass graft surgery (N = 2,258,711 visits). MAIN OUTCOMES AND MEASURES Transfusion rates in the overall population and by hospital (N = 1431) were the primary outcomes. The association of transfusion with myocardial infarction, stroke, and death after accounting for a patient's propensity for transfusion was also measured. RESULTS The overall rate of transfusion was 2.14% (95% CI, 2.13%-2.16%) and quarterly transfusion rates slightly declined from July 2009 to March 2013 (from 2.11% [95% CI, 2.03%-2.19%] to 2.04% [95% CI, 1.97%-2.12%]; P < .001). Patients who were more likely to receive transfusion were older (mean, 70.5 vs 64.6 years), were women (56.3% vs 32.5%), and had hypertension (86.4% vs 82.0%), diabetes (44.8% vs 34.6%), advanced renal dysfunction (8.7% vs 2.3%), prior myocardial infarction (33.0% vs 30.2%), or prior heart failure (27.0% vs 11.8%). Overall, 96.3% of sites gave a transfusion to less than 5% of patients and 3.7% of sites gave a transfusion to 5% of patients or more. Variation in hospital risk-standardized rates of transfusion persisted after adjustment, and hospitals showed variability in their transfusion thresholds. Receipt of transfusion was associated with myocardial infarction (42,803 events; 4.5% vs 1.8%; odds ratio [OR], 2.60; 95% CI, 2.57-2.63), stroke (5011 events; 2.0% vs 0.2%; OR, 7.72; 95% CI, 7.47-7.98), and in-hospital death (31,885 events; 12.5% vs 1.2%; OR, 4.63; 95% CI, 4.57-4.69), irrespective of bleeding complications. CONCLUSIONS AND RELEVANCE Among patients undergoing PCI at US hospitals, there was considerable variation in blood transfusion practices, and receipt of transfusion was associated with increased risk of in-hospital adverse cardiac events. These observational findings may warrant a randomized trial of transfusion strategies for patients undergoing PCI.
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Affiliation(s)
| | - Yongfei Wang
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeptha P Curtis
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina
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Effective reduction of blood product use in a community teaching hospital: when less is more. Am J Med 2013; 126:894-902. [PMID: 24054957 DOI: 10.1016/j.amjmed.2013.06.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 05/10/2013] [Accepted: 06/03/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND The increased morbidity and mortality associated with liberal blood product usage have been convincingly demonstrated. The clinical problems they pose have prompted development of more restrictive evidence-based transfusion criteria. Education alone has a limited impact on the adoption of these criteria into practice. New York Methodist Hospital undertook a proactive approach to reduce unnecessary transfusions. METHOD In November 2008, an interventional monitoring program to ensure adherence to transfusion criteria for packed red blood cells (PRBC), platelets, fresh frozen plasma (FFP), and cryoprecipitate transfusions was started. Blood bank technologists routinely monitored transfusion requests against a list of established criteria and experienced clinicians reviewed and adjudicated transfusion requests when the blood bank technologist's action was appealed. RESULTS Transfusion usage decreased sharply in Year 1 (November 2008-October 2009) and continued to decrease in Year 2 (November 2009-October 2010). PRBC use decreased by 30.1% and 37.7%, with a 47.6% decrease in multi-unit transfusions; platelet use decreased by 24.3% and 41.2%; fresh frozen plasma use decreased by 41.8% and 31.1%; and cryoprecipitate use decreased by 38.7% and 56.1% during monitoring Years 1 and 2, respectively. Decreases occurred despite a 4.0% increase in hospital admissions during the monitoring years. The decreased blood product usage was accompanied by 28.6% reduction in complications. A 26.1% decrease in blood product requests from Year 1 to Year 2 suggested a practice change by the ordering physicians themselves. The total cost of blood products decreased by $2,235,676. CONCLUSION We established a successful method to reduce transfusions of all blood products using strict adherence to evidence-based criteria and continuous monitoring. Our model translates into improved patient safety by decreasing the number of unnecessary transfusions. This also led to a significant reduction in hospital expenses.
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Doktorova M, Motovska Z. Clinical review: bleeding - a notable complication of treatment in patients with acute coronary syndromes: incidence, predictors, classification, impact on prognosis, and management. Crit Care 2013; 17:239. [PMID: 24093465 PMCID: PMC4056027 DOI: 10.1186/cc12764] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article focuses on the incidence, predictors, classification, impact on prognosis, and management of bleeding associated with the treatment of acute coronary syndrome. The issue of bleeding complications is related to the continual improvement of ischemic heart disease treatment, which involves mainly (a) the widespread use of coronary angiography, (b) developments in percutaneous coronary interventions, and (c) the introduction of new antithrombotics. Bleeding has become an important health and economic problem and has an incidence of 2.0% to 17%. Bleeding significantly influences both the short- and long-term prognoses. If a group of patients at higher risk of bleeding complications can be identified according to known risk factors and a risk scoring system can be developed, we may focus more on preventive measures that should help us to reduce the incidence of bleeding.
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Fujii T, Masuda N, Ijichi T, Kamiyama Y, Tanaka S, Nakazawa G, Shinozaki N, Matsukage T, Ogata N, Ikari Y. Transradial intervention for patients with ST elevation myocardial infarction with or without cardiogenic shock. Catheter Cardiovasc Interv 2013; 83:E1-7. [DOI: 10.1002/ccd.24896] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/06/2013] [Accepted: 02/18/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Toshiharu Fujii
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Naoki Masuda
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Takeshi Ijichi
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Yoshinari Kamiyama
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Shigemitsu Tanaka
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Gaku Nakazawa
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Norihiko Shinozaki
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Takashi Matsukage
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Nobuhiko Ogata
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
| | - Yuji Ikari
- Division of Cardiology; Tokai University School of Medicine; Isehara Japan
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Pospíšil J, Hromádka M, Bernat I, Rokyta R. STEMI - The importance of balance between antithrombotic treatment and bleeding risk. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2013.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Garfinkle M, Lawler PR, Filion KB, Eisenberg MJ. Red blood cell transfusion and mortality among patients hospitalized for acute coronary syndromes: A systematic review. Int J Cardiol 2013; 164:151-7. [DOI: 10.1016/j.ijcard.2011.12.118] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 12/23/2011] [Accepted: 12/31/2011] [Indexed: 11/16/2022]
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Kougias P, Orcutt S, Pak T, Pisimisis G, Barshes NR, Lin PH, Bechara CF. Impact of postoperative nadir hemoglobin and blood transfusion on outcomes after operations for atherosclerotic vascular disease. J Vasc Surg 2013; 57:1331-7; discussion. [PMID: 23384496 DOI: 10.1016/j.jvs.2012.10.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 10/10/2012] [Accepted: 10/17/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Controversy surrounds the topic of transfusion policy after noncardiac operations. This study assessed the combined impact of postoperative nadir hemoglobin (nHb) levels and blood transfusion on adverse events after open surgical intervention in patients who undergo operative intervention for atherosclerotic vascular disease. METHODS Consecutive patients who underwent peripheral arterial disease (PAD)-related operations were balanced on baseline characteristics by inverse weighting on propensity score calculated as their probability to have nHb greater than 10 gm/dL on the basis of operation type, demographics, and comorbidities, including the revised cardiac risk index. A multivariate generalized estimating equation analysis was performed to investigate associations between nHb, transfusion, and a composite outcome of perioperative death and myocardial infarction. Logistic and Cox proportional hazards regressions were used to assess the impact of nHb and transfusion on respiratory and wound complications; and a composite end point (CE) of death, myocardial infarction during a 2-year follow-up. Level of statistical significance was set at alpha of 0.0125 to adjust for the increased probability of type I error attributable to multiple comparisons. RESULTS The analysis cohort included 880 patients (1074 operations). After adjusting for nHb level, the number of units transfused was not associated with the perioperative occurrence of the CE (odds ratio [OR], 1.13; P = .025). Adjusted for the number of units transfused, nHb had no impact on the perioperative CE (OR, 0.62; P = .22). An interaction term between transfusion and nHb level remained nonsignificant (P = .312), indicating that the impact of blood transfusion was the same regardless of the nHb level. Perioperative respiratory complications were more likely in patients receiving transfusions (OR, 1.22; P = .009), and perioperative wound infections were less common in patients with nHb >10 gm/dL (OR, 0.65; P = .01). During an average follow-up of 24 months, transfused patients were more likely to develop the CE (hazard ratio [HR], 1.15, P = .009), whereas nHb level did not impact the long-term adverse event rate (HR, 0.78; P = .373). The above associations persisted even after adjusting the Cox regression model for the occurrence of perioperative cardiac events. CONCLUSIONS Although nHb less than 10 gm/dL is not associated with death or ACS after PAD-related operations, maintaining nHb greater than 10 gm/dL appears to decrease the risk of wound infection. Blood transfusion is associated with increased risk of perioperative respiratory complications. Until a randomized trial settles this issue definitively, a restrictive transfusion strategy is justified in patients undergoing operations for atherosclerotic vascular disease.
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Affiliation(s)
- Panos Kougias
- Michael E DeBakey VA Medical Center, Houston, Tex 77030, USA.
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Valente S, Lazzeri C, Chiostri M, Giglioli C, Attanà P, Picariello C, Dini CS, Gensini GF. The impact of blood transfusion on short and long term prognosis in STEMI patients treated with primary percutaneous coronary intervention. Int J Cardiol 2012; 157:281-3. [DOI: 10.1016/j.ijcard.2012.03.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 03/05/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
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Simoni J. Artificial Oxygen Carriers: Renewed Commercial Interest and Scientific/Technological Advances. Artif Organs 2012; 36:123-6. [DOI: 10.1111/j.1525-1594.2011.01430.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Zacharski LR, Shamayeva G, Chow BK. Effect of controlled reduction of body iron stores on clinical outcomes in peripheral arterial disease. Am Heart J 2011; 162:949-957.e1. [PMID: 22093213 DOI: 10.1016/j.ahj.2011.08.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 08/19/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Published results from a controlled clinical trial in patients with peripheral arterial disease found improved outcomes with iron (ferritin) reduction among middle-aged subjects but not the entire cohort. The mechanism of the age-specific effect was explored. METHODS Randomization to iron reduction (phlebotomy, n = 636) or control (n = 641) stratified by prognostic variables permitted analysis of effects of age and ferritin on primary (all-cause mortality) and secondary (death, nonfatal myocardial infarction, and stroke) outcomes. RESULTS Iron reduction improved outcomes in youngest age quartile patients (primary outcome hazard ratio [HR] 0.44, 95% CI 0.21-0.92, P = .028; secondary outcome HR 0.34, 95% CI 0.19-0.61, P < .001). Mean follow-up ferritin levels (MFFL) declined with increasing entry age in controls. Older age (P = .035) and higher ferritin (P < .001) at entry predicted poorer compliance with phlebotomy and rising MFFL in iron-reduction patients. Intervention produced greater ferritin reduction in younger patients. Improved outcomes with lower MFFL were found in iron-reduction patients (primary outcome HR 1.11, 95% CI 1.01-1.23, P = .028; secondary outcome HR 1.10, 95% CI 1.0-1.20, P = .044) and the entire cohort (primary outcome HR 1.11, 95% CI 1.01-1.23, P = .037). Improved outcomes occurred with MFFL below versus above the median of the entire cohort means (primary outcome HR 1.48, 95% CI 1.14-1.92, P = .003; secondary outcome HR 1.22, 95% CI 0.99-1.50, P = .067). CONCLUSIONS Lower iron burden predicted improved outcomes overall and was enhanced by phlebotomy. Controlling iron burden may improve survival and prevent or delay nonfatal myocardial infarction and stroke.
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Safety of same day discharge following percutaneous coronary intervention. Heart Lung Circ 2011; 20:353-6. [PMID: 21429794 DOI: 10.1016/j.hlc.2011.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is a body of literature reporting the safety of discharging patients the same day as percutaneous coronary revascularisation. Nevertheless, overnight stay continues to be the general standard of care. METHODS Over a single calendar year, 130 patients having elective, percutaneous coronary revascularisation were discharged home the day of the procedure with the majority of procedures using radial access. Patients were observed post procedure for six hours and if no problems occurred, discharge was undertaken. The purpose of the study was to assess complications in the 24 hours following discharge. RESULTS Within the following 24 hours post discharge, there were no complications reported including bleeding, recurrent ischaemia, or hospitalisation. CONCLUSION Same day discharge following elective percutaneous revascularisation appears both efficacious and safe with a low risk of post discharge complications.
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Leon MB, Piazza N, Nikolsky E, Blackstone EH, Cutlip DE, Kappetein AP, Krucoff MW, Mack M, Mehran R, Miller C, Morel MA, Petersen J, Popma JJ, Takkenberg JJM, Vahanian A, van Es GA, Vranckx P, Webb JG, Windecker S, Serruys PW. Standardized endpoint definitions for transcatheter aortic valve implantation clinical trials: a consensus report from the Valve Academic Research Consortium. Eur Heart J 2011; 32:205-17. [PMID: 21216739 PMCID: PMC3021388 DOI: 10.1093/eurheartj/ehq406] [Citation(s) in RCA: 504] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To propose standardized consensus definitions for important clinical endpoints in transcatheter aortic valve implantation (TAVI), investigations in an effort to improve the quality of clinical research and to enable meaningful comparisons between clinical trials. To make these consensus definitions accessible to all stakeholders in TAVI clinical research through a peer reviewed publication, on behalf of the public health. BACKGROUND Transcatheter aortic valve implantation may provide a worthwhile less invasive treatment in many patients with severe aortic stenosis and since its introduction to the medical community in 2002, there has been an explosive growth in procedures. The integration of TAVI into daily clinical practice should be guided by academic activities, which requires a harmonized and structured process for data collection, interpretation, and reporting during well-conducted clinical trials. METHODS AND RESULTS The Valve Academic Research Consortium established an independent collaboration between Academic Research organizations and specialty societies (cardiology and cardiac surgery) in the USA and Europe. Two meetings, in San Francisco, California (September 2009) and in Amsterdam, the Netherlands (December 2009), including key physician experts, and representatives from the US Food and Drug Administration (FDA) and device manufacturers, were focused on creating consistent endpoint definitions and consensus recommendations for implementation in TAVI clinical research programs. Important considerations in developing endpoint definitions included (i) respect for the historical legacy of surgical valve guidelines; (ii) identification of pathophysiological mechanisms associated with clinical events; (iii) emphasis on clinical relevance. Consensus criteria were developed for the following endpoints: mortality, myocardial infarction, stroke, bleeding, acute kidney injury, vascular complications, and prosthetic valve performance. Composite endpoints for TAVI safety and effectiveness were also recommended. CONCLUSION Although consensus criteria will invariably include certain arbitrary features, an organized multidisciplinary process to develop specific definitions for TAVI clinical research should provide consistency across studies that can facilitate the evaluation of this new important catheter-based therapy. The broadly based consensus endpoint definitions described in this document may be useful for regulatory and clinical trial purposes.
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Affiliation(s)
- Martin B Leon
- Columbia University Medical Center, Center for Interventional Vascular Therapy, 173 Fort Washington Avenue, Heart Center, New York, NY 10032, USA.
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Mehta RH, Stebbins A, Lopes RD, Rao SV, Bates ER, Pieper KS, Armstrong PW, Van de Werf F, White HD, Califf RM, Alexander JH, Granger CB. Race, Bleeding, and Outcomes in STEMI Patients Treated with Fibrinolytic Therapy. Am J Med 2011; 124:48-57. [PMID: 21187185 DOI: 10.1016/j.amjmed.2010.07.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 07/29/2010] [Accepted: 07/29/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND studies have shown higher bleeding and mortality rates among African Americans who receive fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) compared with whites; however, the relationship of bleeding risk to mortality has not been evaluated. METHODS we studied data from 32,260 STEMI patients receiving fibrinolysis enrolled in the US in 5 clinical trials. Bleeding was defined according to criteria from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries study. Main outcome measure was adjusted 1-year mortality. RESULTS despite younger age (median: 57 years vs 61 years) and fewer comorbidities, moderate or severe bleeding occurred more frequently among African-Americans than whites (16.3% vs 14.1%; P=.0147, adjusted OR 1.36; 95% confidence interval [CI], 1.14-1.62; P=.0006) as did 1-year mortality (11.5% vs 9.4%). African-American race and moderate or severe bleeding were independently related to 1-year mortality (χ(2) 9.02, P=.0003 and 148.58, P<.0001, respectively). Mortality was highest among African Americans with bleeding (hazard ratio [HR] 2.83; 95% CI, 2.08-3.86) followed by whites with bleeding (HR 1.99; 95% CI, 1.78-2.22) and African Americans without bleeding (HR 1.33; 95% CI, 1.02-1.73) (referent whites without bleeding). CONCLUSIONS in STEMI patients receiving fibrinolysis, moderate or severe bleeding and mortality were significantly higher in African Americans compared with whites. Bleeding was associated with similarly increased mortality risk in both groups.
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Affiliation(s)
- Rajendra H Mehta
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
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Standardized Endpoint Definitions for Transcatheter Aortic Valve Implantation Clinical Trials. J Am Coll Cardiol 2011; 57:253-69. [DOI: 10.1016/j.jacc.2010.12.005] [Citation(s) in RCA: 666] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 09/30/2010] [Accepted: 10/06/2010] [Indexed: 12/15/2022]
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