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Sunil V. Rao, MD; James G. Jollis, MD; Robert A. Harrington, MD; Christopher B. Granger, MD; L. Kristin Newby, MD; Paul W. Armstrong, MD; David J. Moliterno, MD; Lauren Lindblad, MS; Karen Pieper, MS; Eric J. Topol, MD; Jonathan S. Stamler, MD; Robert M. Califf, MD

JAMA. 2004;292:1555-1562.

Context  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.

Design, Setting, and Patients  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.

Main Outcome Measure  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.

Author Affiliations: Duke Clinical Research Institute (Drs Rao, Jollis, Harrington, Granger, Newby, and Califf and Mss Lindblad and Pieper) and Department of Medicine and the Howard Hughes Medical Institute, Duke University Medical Center (Dr Stamler), Durham, NC; Department of Cardiology, University of Alberta, Edmonton (Dr Armstrong); Division of Cardiology, University of Kentucky, Lexington (Dr Moliterno); and Cleveland Clinic Foundation, Cleveland, Ohio (Dr Topol).

Corresponding Author: Sunil V. Rao, MD, Duke Clinical Research Institute, PO Box 17969, 2400 Pratt St, Durham, NC 27715 (sunil.rao{at}duke.edu).

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RELATED LETTERS

Blood Transfusion in Patients With Acute Coronary Syndrome
Saif S. Rathore, Martha J. Radford, and Harlan M. Krumholz
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