Type I NSTEMI Management & Transfusion Medicine

C H E S T   P A I N 

PEARLS OF THE DAY:

1. ACS algorithm & medical management of a type I NSTEMI

2. PRBC transfusion thresholds in patients with cardiovascular disease
3. Five landmark trials on the topic of transfusion

Dr. Armstrong presented an elderly female patient with NHL, and a recent positive NM stress test. In light of the patient's active malignancy with impressive leukocytosis (WBC: 134), she was not a candidate for coronary angiogram/PCI.

Subsequently, she presented to PPMC with chest pain and was found to have a type I NSTEMI (anginal CP + positive biomarkers without ST changes on EKG).

ACS ALGORITHM:

 
Algorithm c/o Brandon Temte

Our patient fell into the type I NSTEMI category. Her TIMI score was 4. Of course, standard therapy in this patient would advise coronary cath +/- PCI. This patient was not a candidate for cath due to her NHL with profound leukocytosis and so she had to be managed medically.

To review: medical management for Type I ACS includes: Aspirin  + P2Y12 inhibitor + anticoagulation.

Ezra et. al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary. J Am Coll Cardiol. 2014 Dec, 64 (24) 2645-2687.

As a complication of the anticoagulation & anti-platelet therapy, the patient subsequently developed acute blood loss anemia and a hemothorax. The patient received PRBCs & a transfusion threshold of HGB > 9 was used in the setting of ACS 

Clinical Question:

Dr. Armstrong investigated the data regarding the transfusion threshold for patients with anemia and underlying CAD. 

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 doi: https://doi.org/10.1136/bmj.i1351 (Published 29 March 2016). https://www.bmj.com/content/352/bmj.i1351

The study reviewed and evaluated 11 trials. 

The meta analysis demonstrated a trend toward a lower rate of cardiovascular events in patients managed with more liberal transfusion thresholds. 

Of note: TRICS III came out after the above BMJ meta analysis and again found that a strict threshold is non inferior to a liberal threshold. 

TRICS III (2017): Mazer CD, et al. "Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery". The New England Journal of Medicine. 2017. 377(22):2133-44.

https://www.nejm.org/doi/full/10.1056/NEJMoa1711818

• Clinical Question: In patients undergoing cardiac surgery who have a moderate-to-high risk of death, is a restrictive transfusion strategy applied throughout the perioperative period noninferior to a liberal transfusion strategy, in terms of major morbidities and mortality?
• Bottom Line: A restrictive red-cell transfusion strategy (transfusing for hemoglobin <7.5 g/dL) resulted in fewer red-cell transfusions than a more liberal red-cell transfusion strategy (hemoglobin <9.5 g/dL) and was non-inferior for major clinical outcomes among moderate- and high-risk patients undergoing on-pump cardiac surgery.

The landmark trials regarding transfusion threshold are:

(information c/o https://www.wikijournalclub.org/wiki/WikiJournalClub:Usable_articles#Hematology)

FOCUS (2011): Carson JL, et al. "Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery". The New England Journal of Medicine. 2011. 365(26):2453-62.

• Clinical Question: Among high-risk patients undergoing hip surgery, does a liberal transfusion strategy (target hemoglobin >10 g/dL) improve survival or functional outcomes at 60 days compared to a restrictive strategy (target hemoglobin >8 g/dL)?
• Bottom Line: Among high-risk patients undergoing hip surgery, a liberal transfusion strategy targeting a hemoglobin >10 g/dL does not improve survival or functional outcomes compared to a restrictive strategy targeting a hemoglobin of >8 g/dL.

TRISS (2014): Holst L, et al. "Transfusion thresholds in Septic Shock". The New England Journal of Medicine. 2014. 371(15):1381-1391.

• Clinical Question: In patients with septic shock, how does a restrictive transfusion strategy (Hgb ≤ 7 g/dL) compare with a liberal transfusion strategy (Hgb ≤ 9 g/dL) in terms of 90-day mortalit
• Bottom Line: Patients with septic shock who underwent transfusion at a Hgb threshold of 7 g/dL had similar mortality at 90 days but used 50% fewer units of blood compared with those who underwent transfusion at a Hgb threshold of 9 g/dL.

TRICC (1999): Hebert PC, et al. "A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care". The New England Journal of Medicine. 1999. 340(6):409-417.

• Clinical Question: Among critically ill patients, how does a restrictive transfusion strategy (hemoglobin goal of 7-9 g/dL) compare with a liberal transfusion strategy (hemoglobin goal of 10-12 g/dL) in decreasing mortality?
• Bottom Line: In critically ill patients, restrictive transfusion (Hgb >7 g/dL) is associated with better survival compared to liberal strategy (Hgb >10).

Transfusion strategies for acute upper gastrointestinal bleeding (2013): Villanueva C et al. "Transfusion strategies for acute upper gastrointestinal bleeding". The New England Journal of Medicine. 2013. 368(1):11-21.

• Clinical Question: In patients with an upper GI bleed, how does a restrictive transfusion goal compare with a liberal transfusion goal in regards to mortality?
• Bottom Line: Among patients with acute upper GI bleeding, a restrictive transfusion threshold (Hgb ≥7) was associated with reduced mortality at 45 days compared to a liberal transfusion threshold (Hgb ≥10).

Thanks for reading, Emma

The information posted above is for educational use only by the trainees of a non-profit hospital residency program.