Transfusion Thresholds for Acute Coronary Syndromes—Insights From the TRICS‐III Randomized Controlled Trial, Systematic Review, and Meta‐Analysis

Mistry, Nikhil; Hare, Gregory M. T.; Shehata, Nadine; Belley‐Côté, Emilie P.; Papa, Fábio de Vasconcelos; Kramer, Robert S.; Saha, Tarit; Wijeysundera, Duminda N.; Ko, Dennis T.; Verma, Subodh; Mazer, C. David

doi:10.1161/jaha.122.028497

Cited by 10 publications

(4 citation statements)

References 7 publications

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“…Therefore, the recommended hemoglobin transfusion threshold is 7 g/dl for stable critically ill patients (including patients with moderate ischemic heart disease), with a target value of 7–9 g/dl. In patients with acute coronary syndrome, higher threshold values of 8.5–9.5 g/dl may be appropriate improving long‐term cardiovascular outcomes (Hébert et al 1999 ; Mistry et al 2023 ).…”

Section: Discussionmentioning

confidence: 99%

Hemolysis during open heart surgery in patients with hereditary spherocytosis — systematic review of the literature and case study

Mendrala,

Czober,

Darocha

et al. 2024

Perioper Med

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Background Due to the distinctive nature of cardiac surgery, patients suffering from hereditary spherocytosis (HS) are potentially at a high risk of perioperative complications resulting from hemolysis. Despite being the most prevalent cause of hereditary chronic hemolysis, the standards of surgical management are based solely on expert opinion. Objective We analyze the risk of hemolysis in HS patients after cardiac surgery based on a systematic review of the literature. We also describe a case of a patient with hereditary spherocytosis who underwent aortic valve repair. Methods This systematic review was registered in the PROSPERO international prospective register of systematic reviews (CRD42023417666) and included records from Embase, MEDLINE, Web of Science, and Google Scholar databases. The case study investigates a 38-year-old patient who underwent surgery for an aortic valve defect in mid-2022. Results Of the 787 search results, 21 studies describing 23 cases of HS undergoing cardiac surgery were included in the final analysis. Hemolysis was diagnosed in five patients (one coronary artery bypass graft surgery, two aortic valve bioprosthesis, one ventricular septal defect closure, and one mitral valve plasty). None of the patients died in the perioperative period. Also, no significant clinical hemolysis was observed in our patient during the perioperative period. Conclusions The literature data show that hemolysis is not common in patients with HS undergoing various cardiac surgery techniques. The typical management of a patient with mild/moderate HS does not appear to increase the risk of significant clinical hemolysis. Commonly accepted beliefs about factors inducing hemolysis during cardiac surgery may not be fully justified and require further investigation.

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Section: Discussionmentioning

confidence: 99%

Hemolysis during open heart surgery in patients with hereditary spherocytosis — systematic review of the literature and case study

Mendrala,

Czober,

Darocha

et al. 2024

Perioper Med

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“…A posthoc analysis of these data suggested clinical equipoise between the transfusion strategies within 5 months of randomization (HR), and a favoring of the liberal strategy after 5 months. This observation was supported by a systematic review and meta-analysis of long-term major adverse cardiac events, which incorporated the results of an acute myocardial infarction sub study of the Transfusion Requirements in Cardiac Surgery III (TRICS-III) trial [11 ▪ ]. The follow-up time for 96% of the participants included this analysis was ≥6 months.…”

Section: Text Of Reviewmentioning

confidence: 91%

“…The observations suggesting a clinical benefit with a liberal strategy are underpowered, and further evidence is needed before conclusive statements can be made regarding the effect of transfusion strategy on long-term MACE in acute coronary syndromes [11 ▪ ]. The mechanism(s) contributing to this association have not been investigated; however, evidence from clinical studies support the biological plausibility for this relationship.…”

Section: Text Of Reviewmentioning

confidence: 99%

Transfusion thresholds in acute coronary syndromes

Mistry,

Jiang,

Chin

et al. 2023

Current Opinion in Cardiology

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Purpose of review Anemia is prevalent in patients with acute coronary syndromes. In this setting, there is uncertainty and controversy surrounding the optimal transfusion strategy for managing anemia. The goal of this review is to summarize the current clinical evidence, guidelines, and future directions for managing transfusion in acute coronary syndromes. Recent findings There is limited evidence from randomized trials evaluating restrictive versus liberal transfusion in patients hospitalized with and/or for acute coronary syndromes. The results from these studies suggest clinical equipoise between transfusion strategies for short term outcomes, and a trend toward favoring a liberal strategy for long term major adverse cardiac events. There is inconsistency across clinical practice guidelines with respect to the optimal strategy for managing anemia and transfusion in acute coronary syndromes due to insufficient evidence. Summary More evidence is urgently needed to conclusively establish the optimal strategy for transfusion management in the setting of acute coronary syndromes. These data will directly inform harmonization of clinical practice guidelines. Future investigations should explore alternative strategies to hemoglobin for quantifying the degree of anemic stress for personalizing transfusion therapy, the effects on functional outcomes, and managing anemia following hospital discharge.

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“…A recent meta-analysis from 2023, 9 which encompassed RCTs 10 , 11 , 12 enrolling patients with acute coronary syndrome, did not reveal a statistically significant difference between the liberal and restrictive strategies concerning outcomes such as mortality, acute myocardial infarction, revascularization, and the composite outcome of these events.…”

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confidence: 99%

Anemia and outcomes in cardiac surgery

Costa,

Papa,

Hare

et al. 2024

Brazilian Journal of Anesthesiology (English Edition)

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Transfusion Thresholds for Acute Coronary Syndromes—Insights From the TRICS‐III Randomized Controlled Trial, Systematic Review, and Meta‐Analysis

Cited by 10 publications

References 7 publications

Hemolysis during open heart surgery in patients with hereditary spherocytosis — systematic review of the literature and case study

Hemolysis during open heart surgery in patients with hereditary spherocytosis — systematic review of the literature and case study

Transfusion thresholds in acute coronary syndromes

Anemia and outcomes in cardiac surgery

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