Guidelines call for restricting transfusions in heart disease patients

As part of its guidelines for treating anemia and iron deficiency in adults with heart disease, the American College of Physicians (ACP) recommended limiting red blood cell (RBC) transfusions to patients with a hemoglobin less than 7 g/dL and avoiding erythropoiesis-stimulating agents (ESAs) in patients who are mildly to moderately anemic with congestive heart failure or coronary heart disease.

The ACP released their guidelines in the Dec. 2 issue of Annals of Internal Medicine.

The ACP used its guideline grading system to make recommendations based on the quality of the available evidence. The Clinical Guidelines Committee, led by Amir Qaseem, MD, PhD, searched databases for studies focusing on anemia and iron deficiency, initially between 1947 and 2012, and then with additional studies included through April 2013.

As outcomes, the committee looked at mortality, hospitalization, exercise tolerance, quality of life as well as cardiovascular events and harms that included high blood pressure, venous thromboemboli and ischemic cerebrovascular events.

They sought to determine the health benefits and harms of treating anemic patients with RBC transfusions, ESAs and the benefits and harms of treating iron deficiency anemia with iron.

“Transfusion may benefit patients with lower hemoglobin levels, less than 7–8 g/dL, but the evidence suggests that red blood cell transfusion for milder anemia in patients with heart disease does not improve mortality,” ACP President Molly Cooke, MD, said in a release.

The evidence found few harms and no difference in adverse effects between more limited use of transfusions and more liberal use of transfusions.

The committee also found that the “harms outweigh the benefits for treating patients with mild to moderate anemia using ESAs.” ESAs were associated with an increased risk of thromboembolic events and possibly an increased rate of strokes.

The ACP also addressed the need for high-value care, which is why the committee did not recommend liberal use of blood transfusions in patients with asymptomatic anemia or ESAs in patients with mild to moderate anemia, based on the evidence suggesting that harms outweigh benefits.