Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis

Annemarie B. Docherty*, Rob O'Donnell, Susan Brunskill, Marialena Trivella, Carolyn Doree, Lars Holst, Martyn Parker, Merete Gregersen, Juliano Pinheiro de Almeida, Timothy S. Walsh, Simon J. Stanworth

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

OBJECTIVE

To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Randomised controlled trials involving a threshold for red blood cell transfusion in hospital. We searched (to 2 November 2015) CENTRAL, Medline, Embase, CINAHL, PubMed, LILACS, NHSBT Transfusion Evidence Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ISRCTN Register, and EU Clinical Trials Register. Authors were contacted for data whenever possible.

TRIAL SELECTION

Published and unpublished randomised controlled trials comparing a restrictive with liberal transfusion threshold and that included patients with cardiovascular disease.

DATA EXTRACTION AND SYNTHESIS

Data extraction was completed in duplicate. Risk of bias was assessed using Cochrane methods. Relative risk ratios with 95% confidence intervals were presented in all meta-analyses. Mantel-Haenszel random effects models were used to pool risk ratios.

MAIN OUTCOME MEASURES

30 day mortality, and cardiovascular events.

RESULTS

41 trials were identified; of these, seven included data on patients with cardiovascular disease. Data from a further four trials enrolling patients with cardiovascular disease were obtained from the authors. In total, 11 trials enrolling patients with cardiovascular disease (n= 3033) were included for meta-analysis (restrictive transfusion, n= 1514 patients; liberal transfusion, n= 1519). The pooled risk ratio for the association between transfusion thresholds and 30 day mortality was 1.15 (95% confidence interval 0.88 to 1.50, P= 0.50), with little heterogeneity (I-2= 14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio 1.78, 95% confidence interval 1.18 to 2.70, P= 0.01, I-2= 0%).

CONCLUSIONS

The results show that it may not be safe to use a restrictive transfusion threshold of less than 80 g/L in patients with ongoing acute coronary syndrome or chronic cardiovascular disease. Effects on mortality and other outcomes are uncertain. These data support the use of a more liberal transfusion threshold (> 80 g/L) for patients with both acute and chronic cardiovascular disease until adequately powered high quality randomised trials have been undertaken in patients with cardiovascular disease.

Original languageEnglish
Article numberi1351
Number of pages11
JournalBritish Medical Journal (BMJ)
Volume352
DOIs
Publication statusPublished - 29 Mar 2016

Keywords

  • RANDOMIZED-CONTROLLED-TRIAL
  • BLOOD-CELL TRANSFUSION
  • CRITICALLY-ILL PATIENTS
  • TRAUMATIC BRAIN-INJURY
  • HIP FRACTURE SURGERY
  • MYOCARDIAL-INFARCTION
  • ELDERLY-PATIENTS
  • CARDIAC-SURGERY
  • CLINICAL-TRIAL
  • ACUTE-LEUKEMIA

Cite this