Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.
BACKGROUND
It is unclear if blood transfusion in anemic patients with acute coronary syndromes is associated with improved survival.


OBJECTIVE
To determine the association between blood transfusion and mortality among patients with acute coronary syndromes who develop bleeding, anemia, or both during their hospital course.


METHODS
We analyzed 24,112 enrollees in 3 large international trials of patients with acute coronary syndromes (the GUSTO IIb, PURSUIT, and PARAGON B trials). Patients were grouped according to whether they received a blood transfusion during the hospitalization. The association between transfusion and outcome was assessed using Cox proportional hazards modeling that incorporated transfusion as a time-dependent covariate and the propensity to receive blood, and a landmark analysis.


METHODS
Thirty-day mortality.


RESULTS
Of the patients included, 2401 (10.0%) underwent at least 1 blood transfusion during their hospitalization. Patients who underwent transfusion were older and had more comorbid illness at presentation and also had a significantly higher unadjusted rate of 30-day death (8.00% vs 3.08%; P<.001), myocardial infarction (MI) (25.16% vs 8.16%; P<.001), and death/MI (29.24% vs 10.02%; P<.001) compared with patients who did not undergo transfusion. Using Cox proportional hazards modeling that incorporated transfusion as a time-dependent covariate, transfusion was associated with an increased hazard for 30-day death (adjusted hazard ratio [HR], 3.94; 95% confidence interval [CI], 3.26-4.75) and 30-day death/MI (HR, 2.92; 95% CI, 2.55-3.35). In the landmark analysis that included procedures and bleeding events, transfusion was associated with a trend toward increased mortality. The predicted probability of 30-day death was higher with transfusion at nadir hematocrit values above 25%.


CONCLUSIONS
Blood transfusion in the setting of acute coronary syndromes is associated with higher mortality, and this relationship persists after adjustment for other predictive factors and timing of events. Given the limitations of post hoc analysis of clinical trials data, a randomized trial of transfusion strategies is warranted to resolve the disparity in results between our study and other observational studies. We suggest caution regarding the routine use of blood transfusion to maintain arbitrary hematocrit levels in stable patients with ischemic heart disease.
Duke Clinical Research Institute, Durham, NC 27715, USA. sunil.rao@duke.edu
Sunil V
SV
Rao
James G
JG
Jollis
Robert A
RA
Harrington
Christopher B
CB
Granger
L Kristin
LK
Newby
Paul W
PW
Armstrong
David J
DJ
Moliterno
Lauren
L
Lindblad
Karen
K
Pieper
Eric J
EJ
Topol
Jonathan S
JS
Stamler
Robert M
RM
Califf
D000368:Aged; D000740:Anemia / Q000150:complications* / Q000628:therapy*; D001803:Blood Transfusion; D005260:Female; D006470:Hemorrhage / Q000150:complications / Q000628:therapy; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications* / Q000401:mortality*; D016016:Proportional Hazards Models; D016019:Survival Analysis