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Treating Anemia in Patients with Heart Disease

The American College of Physicians recommends that transfusions and erythropoiesis-stimulating agents be restricted to patients with more-severe anemia.

Sponsoring organization: American College of Physicians (ACP)

Target Population: Primary care physicians, cardiologists

Background and Objective

Treatments for anemia in patients with heart disease include erythropoiesis-stimulating agents (ESAs), red blood cell (RBC) transfusions, and iron replacement, but whether these treatments improve outcomes is unclear. The ACP's new guideline is based on a systematic review of evidence on benefits and harms of these treatments in patients with congestive heart failure (CHF) or coronary heart disease (CHD).

Key Points

— Treatment with RBC transfusions (low-quality evidence)

• No short-term mortality benefit was found for liberal RBC transfusion versus more restrictive transfusion (hemoglobin trigger level, >10 g/dL vs. 8–9 g/dL) in medical and surgical patients with anemia and heart disease.
• Aggressive treatment of anemia with RBC transfusions doesn't benefit and might harm patients with acute coronary syndrome or myocardial infarction or those who are undergoing percutaneous coronary interventions.

— Treatment with ESAs (moderate- to high-quality evidence)

• Among anemic patients with stable CHF, ESA use does not lower all-cause mortality or risk for adverse cardiovascular events but might be associated with harms, such as venous thromboembolism.

Recommendations

• Use a restrictive RBC transfusion strategy (trigger hemoglobin threshold, 7–8 g/dL) in hospitalized patients with anemia and CHD (grade: weak recommendation; low-quality evidence).
• Do not use ESAs in patients with mild-to-moderate anemia and CHF or CHD (grade: strong recommendation; moderate-quality evidence).

COMMENT

Patients with heart disease often have anemia, and treating them aggressively intuitively seems like the best choice. However, this clinical practice guideline emphasizes that more (e.g., red blood cells) is not always better and clarifies how and when we should intervene.

Jamaluddin Moloo, MD, MPH reviewing Qaseem A et al. Ann Intern Med 2013 Dec 3. Kansagara D et al. Ann Intern Med 2013 Dec 3.

CITATION(S):

Qaseem A et al. Treatment of anemia in patients with heart disease: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2013 Dec 3; 159:770.
[Link to free full-text Ann Intern Med article PDF | PubMed® abstract]

Kansagara D et al. Treatment of anemia in patients with heart disease: A systematic review. Ann Intern Med 2013 Dec 3; 159:746.
[Link to free full-text Ann Intern Med article PDF | PubMed® abstract]