Etiology
Red blood cell transfusion after PCI was associated with increased mortality, MI, and stroke
Sherwood MW, Wang Y, Curtis JP, Peterson ED, Rao SV. Patterns and outcomes of red blood cell transfusion in patients undergoing percutaneous coronary intervention. JAMA. 2014;311:836-43.
Clinical impact ratings: h ★★★★★✩✩ C ★★★★★✩✩ Question Is red blood cell transfusion after percutaneous coronary intervention (PCI) associated with in-hospital adverse events?
Methods Design: Retrospective cohort study using data from the CathPCI registry. Setting: 1431 hospitals in the USA. Patients: 2 258 711 patient visits (1 967 218 patients) that involved a first PCI or cardiac catheterization during each hospital stay from July 2009 to March 2013. During 48 430 patient visits (mean age 71 y, 56% women), patients received a red blood cell transfusion after PCI. 2 210 281 control patient visits (mean age 65 y, 67% men) did not include a transfusion. Exclusion criteria were coronary artery bypass graft surgery during the same hospital stay or missing data on bleeding events, complications, or discharge status. Risk factors: Red blood cell transfusion (receipt of packed red blood cells or whole blood) during hospital stay. Outcomes: Outcomes included in-hospital mortality, myocardial infarction (MI), and stroke.
Main results The overall transfusion rate was 2.14% (95% CI 2.13 to 2.16) and varied from 0% to 13% across hospital sites. Red blood cell transfusion after PCI was associated with increased in-hospital mortality, MI, and stroke (Table).
Conclusion Red blood cell transfusion after percutaneous coronary intervention was associated with increased in-hospital mortality, MI, and stroke. Association between red blood cell transfusion after percutaneous coronary intervention (PCI) and in-hospital adverse events* Outcomes
Event rates Transfusion
Adjusted odds ratio (95% CI)†
No transfusion
Composite of mortality, myocardial infarction, or stroke
17%
3.1%
3.62 (3.59 to 3.66)
In-hospital mortality
13%
1.2%
4.63 (4.57 to 4.69)
Myocardial infarction
4.5%
1.8%
2.60 (2.57 to 2.63)
Stroke
2.0%
0.2%
7.72 (7.47 to 7.98)
*CI defined in Glossary. †Adjusted for age, sex, race, body mass index, prior MI, prior coronary artery bypass graft or valvular surgery, cardiogenic shock, cardiac arrest, use of intraaortic balloon pump, prior congestive heart failure, peripheral vascular disease, cerebrovascular disease, tobacco use, chronic lung disease, diabetes, hyperlipidemia, family history, dialysis, glomerular filtration rate, New York Heart Association class IV congestive heart failure, location of lesion, PCI indication, PCI status, and hospital characteristics.
JC12
© 2014 American College of Physicians
Source of funding: American College of Cardiology Foundation’s National Cardiovascular Data Registry. For correspondence: Dr. M.W. Sherwood, Duke Clinical Research Institute, Durham, NC, USA. E-mail matthew.sherwood@ dm.duke.edu. ■
Commentary The study by Sherwood and colleagues describes broad variation in transfusion practice after PCI across different hospitals. Patients who received transfusions had a higher incidence of death or major adverse events. The causal versus casual nature of this association is unclear because patients receiving transfusions are generally sicker than those who do not. Blood products are usually given to patients who are bleeding or have symptomatic anemia, conditions that are also associated with worse outcome after PCI (1). Although the results of the study by Sherwood and colleagues are probably confounded by indication for transfusion, biological plausibility supports the adverse events described in this study (especially the increased risk for thrombosis) (2), and these findings cannot be dismissed. The marked variation in transfusion rates across institutions suggests that prescribing rates could be reduced without affecting clinical outcomes. In different clinical settings, restrictive blood transfusion improved outcomes (e.g., patients with gastrointestinal bleeding) (3) or did not differ from liberal transfusion (e.g., hip surgery) (4). Clinicians should recognize the downside of transfusion, and blood products should only be ordered when absolutely necessary. The appropriate threshold for transfusion in patients having PCI is unknown. A large pragmatic clinical trial is needed to guide practice. Hitinder S. Gurm, MD Kim Eagle, MD University of Michigan Ann Arbor, Michigan, USA References 1. Doyle BJ, Rihal CS, Gastineau DA, Holmes DR Jr. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol. 2009;53:2019-27. 2. Silvain J, Abtan J, Kerneis M, et al. Impact of red blood cell transfusion on platelet aggregation and inflammatory response in anemic coronary and noncoronary patients: The TRANSFUSION-2 Study (impact of transfusion of red blood cell on platelet activation and aggregation studied with flow cytometry use and light transmission aggregometry). J Am Coll Cardiol. 2014;63:1289-96. 3. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21. 4. Carson JL, Terrin ML, Noveck H, et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365:2453-62.
17 June 2014 | ACP Journal Club | Volume 160 • Number 12
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930364/ by a University of California San Diego User on 06/09/2017
Red blood cell transfusion after PCI was associated with increased mortality, MI, and stroke
Sherwood MW, Wang Y, Curtis JP, Peterson ED, Rao SV. Patterns and outcomes of red blood cell transfusion in patients undergoing percutaneous coronary intervention. JAMA. 2014;311:836-43.
Clinical impact ratings: h ★★★★★✩✩ C ★★★★★✩✩ Question Is red blood cell transfusion after percutaneous coronary intervention (PCI) associated with in-hospital adverse events?
Methods Design: Retrospective cohort study using data from the CathPCI registry. Setting: 1431 hospitals in the USA. Patients: 2 258 711 patient visits (1 967 218 patients) that involved a first PCI or cardiac catheterization during each hospital stay from July 2009 to March 2013. During 48 430 patient visits (mean age 71 y, 56% women), patients received a red blood cell transfusion after PCI. 2 210 281 control patient visits (mean age 65 y, 67% men) did not include a transfusion. Exclusion criteria were coronary artery bypass graft surgery during the same hospital stay or missing data on bleeding events, complications, or discharge status. Risk factors: Red blood cell transfusion (receipt of packed red blood cells or whole blood) during hospital stay. Outcomes: Outcomes included in-hospital mortality, myocardial infarction (MI), and stroke.
Main results The overall transfusion rate was 2.14% (95% CI 2.13 to 2.16) and varied from 0% to 13% across hospital sites. Red blood cell transfusion after PCI was associated with increased in-hospital mortality, MI, and stroke (Table).
Conclusion Red blood cell transfusion after percutaneous coronary intervention was associated with increased in-hospital mortality, MI, and stroke. Association between red blood cell transfusion after percutaneous coronary intervention (PCI) and in-hospital adverse events* Outcomes
Event rates Transfusion
Adjusted odds ratio (95% CI)†
No transfusion
Composite of mortality, myocardial infarction, or stroke
17%
3.1%
3.62 (3.59 to 3.66)
In-hospital mortality
13%
1.2%
4.63 (4.57 to 4.69)
Myocardial infarction
4.5%
1.8%
2.60 (2.57 to 2.63)
Stroke
2.0%
0.2%
7.72 (7.47 to 7.98)
*CI defined in Glossary. †Adjusted for age, sex, race, body mass index, prior MI, prior coronary artery bypass graft or valvular surgery, cardiogenic shock, cardiac arrest, use of intraaortic balloon pump, prior congestive heart failure, peripheral vascular disease, cerebrovascular disease, tobacco use, chronic lung disease, diabetes, hyperlipidemia, family history, dialysis, glomerular filtration rate, New York Heart Association class IV congestive heart failure, location of lesion, PCI indication, PCI status, and hospital characteristics.
JC12
© 2014 American College of Physicians
Source of funding: American College of Cardiology Foundation’s National Cardiovascular Data Registry. For correspondence: Dr. M.W. Sherwood, Duke Clinical Research Institute, Durham, NC, USA. E-mail matthew.sherwood@ dm.duke.edu. ■
Commentary The study by Sherwood and colleagues describes broad variation in transfusion practice after PCI across different hospitals. Patients who received transfusions had a higher incidence of death or major adverse events. The causal versus casual nature of this association is unclear because patients receiving transfusions are generally sicker than those who do not. Blood products are usually given to patients who are bleeding or have symptomatic anemia, conditions that are also associated with worse outcome after PCI (1). Although the results of the study by Sherwood and colleagues are probably confounded by indication for transfusion, biological plausibility supports the adverse events described in this study (especially the increased risk for thrombosis) (2), and these findings cannot be dismissed. The marked variation in transfusion rates across institutions suggests that prescribing rates could be reduced without affecting clinical outcomes. In different clinical settings, restrictive blood transfusion improved outcomes (e.g., patients with gastrointestinal bleeding) (3) or did not differ from liberal transfusion (e.g., hip surgery) (4). Clinicians should recognize the downside of transfusion, and blood products should only be ordered when absolutely necessary. The appropriate threshold for transfusion in patients having PCI is unknown. A large pragmatic clinical trial is needed to guide practice. Hitinder S. Gurm, MD Kim Eagle, MD University of Michigan Ann Arbor, Michigan, USA References 1. Doyle BJ, Rihal CS, Gastineau DA, Holmes DR Jr. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol. 2009;53:2019-27. 2. Silvain J, Abtan J, Kerneis M, et al. Impact of red blood cell transfusion on platelet aggregation and inflammatory response in anemic coronary and noncoronary patients: The TRANSFUSION-2 Study (impact of transfusion of red blood cell on platelet activation and aggregation studied with flow cytometry use and light transmission aggregometry). J Am Coll Cardiol. 2014;63:1289-96. 3. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11-21. 4. Carson JL, Terrin ML, Noveck H, et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365:2453-62.
17 June 2014 | ACP Journal Club | Volume 160 • Number 12
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930364/ by a University of California San Diego User on 06/09/2017
