Red blood cell (RBC) transfusions should be restricted to those individuals with severe anemia in patients with heart disease, the American College of Physicians (ACP) recommends in a new clinical practice guideline published today in Annals of Internal Medicine, ACP's flagship journal.
ACP also recommends against using erythropoiesis-stimulating agents (ESAs) in patients with mild to moderate anemia and congestive heart failure (CHF) or coronary artery disease (CHD) because the harms, including increased risks of thromboembolic events and stroke rates, outweigh the benefits.
"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, MD, FACP, president, ACP.
"The evidence evaluating the impact of ESAs in patients with heart disease did not show improved health outcomes."
ACP's guideline also includes advice to help physicians practice high value care.
Anemia is common in patients with heart disease. Anemia is present in approximately one-third of patients with CHF and 10 to 20 percent of patients with CHD. Anemia can worsen cardiac function and is associated with poor outcomes, including increased risk of hospitalization, decreased exercise capacity, and poor quality of life. It is unclear whether anemia directly and independently leads to these poor outcomes or whether it reflects a more severe underlying illness.
Because of the poor outcomes associated with anemia in patients with heart disease, a number of treatments have been tried, including RBC transfusions, ESAs, and iron replacement. Overall, it is unclear whether these strategies improve outcomes.
Emerging evidence shows short term benefit of one form of intravenous iron in patients with CHF and low ferritin (less than 100), but ACP found evidence lacking on long-term outcomes. Additionally, the effect of oral iron and how it compares to intravenous iron for treating anemic patients with heart disease is unknown.
To develop the guideline, ACP looked at the evidence to answer three questions related to the treatment of anemia in patients with CHF or CHD:
- What are the health benefits and harms of treating anemia with RBC transfusions?
- What are the health benefits and harms of treating anemia with ESAs?
- What are the health benefits and harms of using iron to treat iron deficiency with or without anemia?
Annals of Internal Medicine also published a summary for patients.
- Amir Qaseem, MD, PhD, MHA; Linda L. Humphrey, MD, MPH; Nick Fitterman, MD; Melissa Starkey, PhD; Paul Shekelle, MD, PhD,. Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, December 2013
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