ACP recommends conservative use of transfusions and erythropoiesis-stimulating agents in patients with heart disease

Red blood cell transfusions should be restricted to cases of severe anemia in patients with heart disease, the American College of Physicians recommended in a clinical practice guideline published in Annals of Internal Medicine.

ACP also recommends against using erythropoiesis-stimulating agents (ESAs) in patients with mild to moderate anemia and congestive heart failure (CHF) or coronary heart disease (CHD) because the harms, including increased risks of thromboembolic events and stroke, outweigh the benefits.

To develop the guideline, ACP conducted a systemic review to answer 3 questions related to the treatment of anemia in patients with CHF or CHD:

• What are the health benefits and harms of treating anemia with red blood cell transfusions?
• What are the health benefits and harms of treating anemia with ESAs?
• What are the health benefits and harms of using iron to treat iron deficiency with or without anemia?

Among a combined review of medical and surgical patients, low-quality evidence from 6 studies showed no mortality benefit for liberal red blood cell transfusion (hemoglobin level >10 g/dL) compared with restrictive red blood cell transfusion (hemoglobin level <10 g/dL) (relative risk [RR], 0.94; 95% CI, 0.61 to 1.42; I²=16.8%).

Low-quality evidence showed that liberal red blood cell transfusions were associated with fewer cardiovascular events (RR, 0.64; 95% CI, 0.38 to 1.09; I²=0.0%), although the data were not statistically significant.

There was not enough evidence to determine the effect of red blood cell transfusions on exercise tolerance and duration or the effect of red blood cell transfusions on quality of life. There were only sparse reports of harms for red blood cell transfusions for anemic patients with heart disease.

Among a group of only nonsurgical patients, low-quality evidence from 3 trials showed no mortality benefit with a higher red blood cell transfusion threshold in nonsurgical patients with acute myocardial infarction (MI) or known ischemic heart disease. Evidence was insufficient to determine the effect of red blood cell transfusions on exercise tolerance and duration or on quality of life.

Among a group of only surgical patients, low-quality evidence from 3 studies assessed short-term mortality in hip fracture and vascular surgery patients treated with liberal red blood cell transfusion (hemoglobin trigger, 10 g/dL) compared with restrictive transfusion (hemoglobin trigger, 8 to 9 g/dL). There was no difference in outcomes (RR, 1.35; 95% CI, 0.80 to 2.25; I²=0.0%). Observational studies did not find a mortality benefit with aggressive transfusion.

Subgroup analysis in 1 study in vascular surgery patients found an increase in MI in patients transfused at a hemoglobin level of 9 g/dL or more compared with those transfused at hemoglobin levels ranging from 7 to 9 g/dL. Low-quality evidence from 2 studies did not find a statistically significant difference between liberal and restrictive red blood cell transfusion protocols in cardiovascular complications of MI (RR, 0.60; 95% CI, 0.34 to 1.03; I²=0.0%). There was not enough evidence to determine the effect of red blood cell transfusions on exercise tolerance and duration or on quality of life.

High-quality evidence showed that ESA treatment did not improve mortality in anemic patients with stable CHF. Pooled data from 11 studies of patients with CHF or CHD (hemoglobin target levels, 12 to 15 g/dL) suggested an increased risk for mortality (RR, 1.07; 95% CI, 0.98 to 1.16; I²=0.0%) for patients receiving ESA treatment compared with control patients.

High-quality evidence showed that ESAs do not affect cardiovascular events in patients with stable CHF. Pooled data from 7 studies showed no difference in the risk for cardiovascular events when comparing ESA treatment with control (RR, 0.94; 95% CI, 0.82 to 1.08; I²=41.5%). Hemoglobin target levels ranged from 9.0 to 15.0 g/dL in the studies.

Moderate-quality evidence showed that ESA treatment had no effect on exercise tolerance and duration in patients with stable CHF. Pooled data from 9 studies showed that treatment with ESAs in patients with CHF (hemoglobin target levels, 12.0 to 15.0 g/dL) resulted in improved New York Heart Association functional class scores compared with control patients (mean difference, −0.77; 95% CI, −1.12 to −0.32; I²=96%). However, the results were generally inconsistent and the studies were highly heterogeneous.

The guideline was released in conjunction with ACP's efforts to encourage high-value care. In related news, the American Society of Hematology released its Choosing Wisely^® list of 5 tests and treatments that physicians and patients should question.

The 5 items are as follows:

• Avoid liberal red blood cell transfusion.
• Avoid thrombophilia testing in adults in the setting of transient major thrombosis risk factors.
• Avoid inferior vena cava filters except in specified circumstances.
• Avoid plasma or prothrombin complex concentrate in the nonemergent reversal of vitamin K antagonists.
• Limit routine CT surveillance following curative-intent treatment of non-Hodgkin lymphoma.

The list appeared online first Dec. 4 in the society's journal, Blood. The Choosing Wisely^® campaign is led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the U.S., including the American College of Physicians.