Ischaemic heart disease

Restrictive blood transfusion strategy supported for MI patients with anaemia

Restricting blood transfusion in anaemic heart attack patients to those with very low haemoglobin levels saves blood with no negative impact on clinical outcomes, a European study has shown.

The REALITY trial compared a restrictive vs liberal transfusion policy in 668 patients during hospital admission with acute MI and anaemia (haemoglobin 100 g/L or below, but above 70 g/L).

In the restrictive strategy, transfusion was withheld unless haemoglobin dropped to 80 g/L. In the liberal strategy, transfusion was given as soon as haemoglobin was 100 g/L or below.

Results presented at the European Society of Cardiology virtual meeting (ESC 2020) showed that the restrictive transfusion strategy was non-inferior to the liberal strategy in the primary endpoint of preventing major adverse cardiac events (MACE) at 30 days.

The primary clinical outcome occurred in 36 patients (11.0%) allocated to the restrictive strategy and 45 patients (14.0%) patients allocated to the liberal strategy (difference -3.0%; 95% confidence interval [CI] -8.4% to 2.4%).

The relative risk of 30-day MACE with the restrictive versus liberal strategy was 0.79.

Cost effectiveness analysis indicated that the restrictive strategy had an 84% probability of being cost-saving while improving clinical outcomes, i.e. “dominant” from a medico-economic standpoint.

Regarding safety, compared to patients receiving the liberal strategy, those allocated to the restrictive strategy were significantly less likely to develop an infection (restrictive 0.0% vs. liberal 1.5%; p=0.03) or acute lung injury (restrictive 0.3% vs. liberal 2.2%; p=0.03).

The study investigators said the findings should help resolve clinical uncertainty over the benefits of blood transfusion for anaemia, which affects 5–10% of patients with myocardial infarction and is an independent predictor of cardiac events and increased mortality.

Principal investigator Professor Philippe Gabriel Steg of Hospital Bichat, Paris, said: “Blood is a precious resource, and transfusion is costly, logistically cumbersome, and has side effects. The REALITY trial supports the use of a restrictive strategy for blood transfusion in myocardial infarction patients with anaemia.

“The restrictive strategy saves blood, is safe, and is at least as effective in preventing 30-day cardiac events compared to a liberal strategy, while saving money.”

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