CardioExchange Archive

The American College of Physicians (ACP) is recommending more conservative use of transfusions and erythropoiesis-stimulating agents (ESAs) in anemia patients with heart disease. But the authors of the new clinical practice guidelines, published in the Annals of Internal Medicine, acknowledge that the evidence base is too flimsy to support firm conclusions.

“Overall,” wrote the authors, “despite the epidemiologic and biologically plausible association of anemia with poor outcomes, we did not find consistent evidence that anemia correction improves outcomes in patients with heart disease…” The poor outcomes of heart patients with anemia have prompted aggressive treatment strategies, but “it is unclear whether these strategies improve outcomes.”

Liberal use of transfusions has not been well-tested in clinical trials. Although a possible short-term benefit has been found in a small study in patients with an acute coronary syndrome, this finding has not been confirmed. “In the meantime,” say the authors, “the low-strength evidence suggesting a possible benefit needs to be weighed against the well-known potential adverse effects of blood transfusions.”

“Transfusion may benefit patients with lower hemoglobin levels, less than 7 – 8 g/dL, but the evidence suggests that red blood cell transfusion for milder anemia in patients with heart disease does not improve mortality,” said Molly Cooke, president of the ACP, in a press release.

The authors also offer no endorsement for widespread use of ESAs in this population. “The evidence evaluating the impact of ESAs in patients with heart disease did not show improved health outcomes,” they write. In fact, they write, ESAs “may be associated with serious harms” in patients with mild to moderate anemia and heart disease. More modest hemoglobin targets may possibly be safe and beneficial, “but the lack of any functional or quality-of-life benefits from more aggressive use of ESAs suggests that a potential benefit is unlikely.”

The new guideline offers some support for the use of intravenous iron in patients with heart failure and iron deficiency. Results from one large trial suggest that iron replacement may have short-term benefits, but, the authors warn, “the long-term health implications are uncertain, and harms have not been more widely assessed in this population.”