PHILADELPHIA, December 3, 2013 -- 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:
Annals of Internal Medicine also published a summary for patients.
How ACP Selects Topics for Clinical Practice Guidelines
Candidate topics come from surveys of ACP members, other clinicians, ACP's Clinical Guidelines Committee members, and other committees and governance of ACP. In selecting a topic, the Clinical Guidelines Committee considers the following criteria: effect of the condition on morbidity and mortality, prevalence of the condition, whether effective health care is available, areas of uncertainty and evidence that current performance does not meet best practices, cost of the condition, relevance to internal medicine, and the likelihood that evidence is available to develop recommendations. ACP's methodology paper has more information about the guideline process.
About the American College of Physicians
The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 137,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.
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