Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia
Gerard Portela, Jeffrey L. Carson, Sonja A. Swanson, John H. Alexander, Paul C. Hébert, Shaun G. Goodman, Philippe Gabríel Steg, Marnie Bertolet, Jordan B. Strom, Dean Fergusson, Tabassome Simon, Harvey D. White, Howard A. Cooper, J. Dawn Abbott, Sunil V. Rao, Bernard Chaitman, Christopher B. Fordyce, Renato D. Lópes, Benoit Daneault, Maria M. Brooks, MINT Investigators, Adam C. Salisbury, Adam Gershon, Adedayo Adeboye, Adriana Carbonaro, Adriano Caixeta, A. Garvey Rene, Agnes Lee, Ahmad Mizyed, Ahmed Hassanin, A. Kone, A. Cherian, Akshay Bagai, Alana Gulliver, Aleisha Easton, Alexandra Rousseau, Alexandre Gautier, Alexandre Schaan de Quadros, Alexia Dantigny, Alexia Ep, Ali Ghamraoui, Alice Jacobs, Aline Giacomo, Allison Schley, Amanda Barnett, Amanda Bollino, Amanda Logan, Amanda Salvatore, Amanda Tice, Amandine Grelier, Amandine Ruissel, Ameen Patel, Ami Patel, Amina Zamiti-Smondel, Amy McMeans, Andrea Sarafolean, Andrew Baker, Andrew M. Goldsweig, Andrew P. DeFilippis, Andrew Starovoytov, Angeline Camilo, Angélique Andrieu, Angie Adler, Anh-Phuong Pham, Anna Helena Felipe Pereira Centurione, Anna Koulova, Anna S. Law, Anna Tran, Anne Druart, Antoine Fayol, Antoine Léquipar, Anuritha Tirumani, Anushka Jayasekara, Araceli Boan, Arav Jhand, Ariel Diaz, Arlete Matos, Arnaud Ferrante, Arthur Bracey, Arthur Darmon, Arthur Ramonatxo, Asha Aravind, Asha Mellor, Ashley Armstrong, A. Adam, Ata ur Rehman Quraishi, Attílio Galhardo, Audrey Cailliau, Aurélie Gutehrle, Axelle Fuentes, Barbara Gallagher, Barbara A. Konkle, Barbara Shannon, Barbara Shimada-Krouwer, Barinder Hansra, Barry H. Kaplan, Barry F. Uretsky, Basile Verdier, Batric Popovic, Baya Mahtout
Abstract
BACKGROUND: The optimal hemoglobin threshold to guide red blood cell (RBC) transfusion for patients with acute myocardial infarction (MI) and anemia is uncertain. OBJECTIVE: To estimate the efficacy of 4 individual hemoglobin thresholds (<10 g/dL [<100 g/L], <9 g/dL [<90 g/L], <8 g/dL [<80 g/L], and <7 g/dL [<70 g/L]) to guide transfusion in patients with acute MI and anemia. DESIGN: Prespecified secondary analysis of the MINT (Myocardial Ischemia and Transfusion) trial using target trial emulation methods. (ClinicalTrials.gov: NCT02981407). SETTING: 144 clinical sites in 6 countries. PARTICIPANTS: 3492 MINT trial participants with acute MI and a hemoglobin level below 10 g/dL. INTERVENTION: Four transfusion strategies to maintain patients' hemoglobin concentrations at or above thresholds of 10, 9, 8, or 7 g/dL. Protocol exceptions were permitted for specified adverse clinical events. MEASUREMENTS: Data from the MINT trial were leveraged to emulate 4 transfusion strategies and estimate per protocol effects on the composite outcome of 30-day death or recurrent MI (death/MI) and 30-day death using inverse probability weighting. RESULTS: The 30-day risk for death/MI was 14.8% (95% CI, 11.8% to 18.4%) for a <10-g/dL strategy, 15.1% (CI, 11.7% to 18.2%) for a <9-g/dL strategy, 15.9% (CI, 12.4% to 19.0%) for a <8-g/dL strategy, and 18.3% (CI, 14.6% to 22.0%) for a <7-g/dL strategy. Absolute risk differences and risk ratios relative to the <10-g/dL strategy for 30-day death/MI increased as thresholds decreased, although 95% CIs were wide. Findings were similar and imprecise for 30-day death. LIMITATION: Unmeasured confounding may have persisted despite adjustment. CONCLUSION: The 30-day risks for death/MI and death among patients with acute MI and anemia seem to increase progressively with lower hemoglobin concentration thresholds for transfusion. However, the imprecision around estimates from this target trial analysis precludes definitive conclusions about individual hemoglobin thresholds. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.