07 September 2020

Restricting blood transfusion in anaemic heart attack patients to those with very low haemoglobin levels saves blood and does not lead to negative clinical outcomes, a major European conference has heard.

The findings of the REALITY trial is the largest randomised trial to compare a restrictive versus a liberal blood transfusion strategy in myocardial infarction patients with anaemia. The trial found that using a restrictive strategy for blood transfusion in myocardial infarction patients with anaemia saves blood, is safe, and is at least as effective in preventing 30-day cardiac events.

The trial was conducted in 35 hospitals in France and Spain. It involved 668 patients with acute myocardial infarction and anaemia at any time during admission.

The study, presented at the ESC Congress 2020, compared a restrictive strategy in which transfusion was withheld unless haemoglobin dropped to 8 g/dL, with a liberal strategy, which gave transfusion as soon as haemoglobin was 10 g/dL or below.

Patients were randomly allocated to the restrictive or liberal transfusion strategy and followed-up for 30 days.

The primary clinical endpoint was a composite of major adverse cardiac events (MACE) at 30 days, including all-cause death, myocardial infarction, stroke, and emergency percutaneous coronary intervention (PCI) prompted by myocardial ischaemia. The cost effectiveness endpoint was the incremental cost effectiveness ratio (ICER) at 30 days.

Principal investigator Prof Philippe Gabriel Steg of Hospital Bichat, Paris, France explained the reasons for having both a clinical and cost effectiveness outcome: “Our hypothesis was that in myocardial infarction patients with anaemia, a restrictive strategy would be non-inferior to a liberal strategy with respect to clinical outcomes at 30 days but would be less costly.”

Analysis found that the primary clinical outcome occurred in 36 patients (11.0%) allocated to the restrictive strategy and 45 patients (14.0%) allocated to the liberal strategy. The relative risk of 30-day MACE with the restrictive strategy compared with liberal strategy was 0.79.

Individuals allocated to the restrictive strategy were significantly less likely to develop an infection or acute lung injury.

Cost effectiveness analysis indicated that the restrictive strategy had an 84% probability of being cost saving while improving clinical outcomes.

Prof Steg said: “Blood is a precious resource, and transfusion is costly, logistically cumbersome, and has side effects. The REALITY trial supports the use of a restrictive strategy for blood transfusion in myocardial infarction patients with anaemia. The restrictive strategy saves blood, is safe, and is at least as effective in preventing 30-day cardiac events compared to a liberal strategy, while saving money.”

Source: European Society of Cardiology



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