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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.
BMJ 2016; 352:i1351BMJ

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Published and unpublished randomised controlled trials comparing a restrictive with liberal transfusion threshold and that included patients with cardiovascular disease.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

REGISTRATION

PROSPERO CRD42014014251.

Authors+Show Affiliations

Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK Critical Care Department, Royal Infirmary Edinburgh, Edinburgh, UK annemarie.docherty@ed.ac.uk.Critical Care Department, Royal Infirmary Edinburgh, Edinburgh, UK.Systematic Review Initiative, NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.Systematic Review Initiative, NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.Centre for Statistics in Medicine, University of Oxford, Oxford, UK.Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.Department of Orthopaedics, Peterborough and Stamford Hospitals NHS Trust, Peterborough, UK.Department of Geriatrics, Aarhus University, Aarhus, Denmark.Surgical Intensive Care Unit and Department of Anesthesiology, Cancer Institute, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil.Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK Critical Care Department, Royal Infirmary Edinburgh, Edinburgh, UK.Systematic Review Initiative, NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK Department of Haematology, NHS Blood and Transplant/Oxford University Hospitals NHS Trust, Oxford, UK.

Pub Type(s)

Comparative Study
Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

27026510

Citation

Docherty, Annemarie B., et al. "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." BMJ (Clinical Research Ed.), vol. 352, 2016, p. i1351.
Docherty AB, O'Donnell R, Brunskill S, et al. 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. BMJ. 2016;352:i1351.
Docherty, A. B., O'Donnell, R., Brunskill, S., Trivella, M., Doree, C., Holst, L., ... Stanworth, S. J. (2016). 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. BMJ (Clinical Research Ed.), 352, p. i1351. doi:10.1136/bmj.i1351.
Docherty AB, et al. 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. BMJ. 2016 Mar 29;352:i1351. PubMed PMID: 27026510.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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. AU - Docherty,Annemarie B, AU - O'Donnell,Rob, AU - Brunskill,Susan, AU - Trivella,Marialena, AU - Doree,Carolyn, AU - Holst,Lars, AU - Parker,Martyn, AU - Gregersen,Merete, AU - Pinheiro de Almeida,Juliano, AU - Walsh,Timothy S, AU - Stanworth,Simon J, Y1 - 2016/03/29/ PY - 2016/3/31/entrez PY - 2016/3/31/pubmed PY - 2016/8/2/medline SP - i1351 EP - i1351 JF - BMJ (Clinical research ed.) JO - BMJ VL - 352 N2 - 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. REGISTRATION: PROSPERO CRD42014014251. SN - 1756-1833 UR - https://www.unboundmedicine.com/medline/citation/27026510/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_ L2 - http://www.bmj.com/cgi/pmidlookup?view=long&pmid=27026510 DB - PRIME DP - Unbound Medicine ER -