DESCRIPTION: Optimal transfusion strategies for patients with acute myocardial infarction (AMI) are uncertain. The aim of this guideline is to provide recommendations for red blood cell transfusion in patients with AMI.
METHODS: These guidelines are based on evidence from randomized controlled trials of patients presenting with AMI and assigned to 2 different transfusion strategies (restrictive or liberal) based on hemoglobin concentrations or hematocrit levels before receipt of a transfusion. A meta-analysis of eligible trials was performed using Cochrane methods. The international panel followed GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods to summarize evidence and formulate recommendations. This guideline's primary perspective is that of the patient, including medical, financial, and psychological effects, with secondary consideration of health care system issues, particularly conservation of the limited and costly blood supply.
RECOMMENDATION: For hospitalized patients with AMI, the panel suggests a liberal red cell transfusion strategy when the hemoglobin concentration is less than 10 g/dL (conditional recommendation, low-certainty evidence). A restrictive strategy of 7 to 8 g/dL may result in increased mortality in patients with AMI. The direction of the recommendation for the liberal strategy was based on the great importance of mortality for patients. The conditional recommendation was based on the low certainty of evidence and the competing consideration of blood supply conservation. Clinicians should adopt mitigation strategies to reduce potential adverse events associated with a liberal transfusion strategy, and all transfusion decisions should incorporate the clinical context rather than solely the hemoglobin concentration.
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Hospital Doctor/Hospitalists |  |
| Internal Medicine | |
| Hematology | |
| Cardiology | |
Patients with myocardial infarction (MI) often present with anemia (up to 40% in the elderly). This guideline is based on a meta-analysis of 4 RCTs of these patients assigned to 2 different transfusion strategies: 1. hemoglobin <7 (restrictive); or 2. <10 (liberal). At 30 days, the liberal group had 1.2% lower mortality and 0.9% lower MI rate, although neither difference was statistically significant. Even with this and the fact that 3.5 times more transfusions were given in the liberal strategy, the authors recommend it.
As an Internist treating patients with AMI and anemia, I found this article very useful for everyday clinical practice.
I think it is a good idea to mention and discuss patient blood management (PBM) in the article mainly in the introduction and the discussion. The link to PBM will improve the understanding of the guidelines more and make them more relevant to clinical practice.
Although the level of evidence remains weak, this article defines the standard of care in the US. An important article to be aware of for any hospitalist taking care of cardiac patients.
As someone who designed and taught a two-hour lecture on best practices for Emergency transfusions, this finding is consistent with best practices.
