Abstract 10489: CVSA Early Career Investigator Award Finalist: Restrictive or Liberal Transfusion for Acute Coronary Syndromes - Insights From the TRICS-III Randomized Controlled Trial, Systematic Review, and Meta-Analysis

Abstract

Introduction: The optimal transfusion strategy for patients with ACS is unclear. Current data are inconclusive and there is a paucity of long term data; therefore, we performed a subgroup analysis of patients with AMI in the Transfusion Thresholds in Cardiac Surgery (TRICS-III) randomized controlled trial (RCT) to add evidence addressing this important clinical question, and interpret the results in the context of a systematic review and meta-analysis. Methods: The TRICS-III trial randomized patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death to restrictive transfusion (transfuse at hemoglobin <7.5g/dL) or a liberal strategy (operating room and ICU: transfuse at hemoglobin <9.5g/dL; ward: <8.5g/dL). AMI patients were those undergoing coronary artery bypass graft surgery with a recent MI and ≥1 of the following enrichment criteria: unstable angina, critical preoperative state, preoperative intra aortic balloon pump, and/or emergency surgery. The primary outcome for this analysis was MACE (all-cause death, MI, and revascularization) at 6 months. The MEDLINE and EMBASE databases were searched through April 2022 to identify RCTs evaluating restrictive versus liberal transfusion in patients with ACS. The primary outcome was MACE at the longest available timepoint. Results: In the TRICS AMI population (N=194), a restrictive transfusion strategy did not increase the risk of MACE (OR: 1.36; 95% CI: 0.57-3.27). Three additional RCTs met eligibility criteria for the systematic review yielding a total of 1015 patients. The transfusion strategies were similar across all studies. After synthesizing the data, restrictive transfusion was associated with a trend toward an increased absolute risk of MACE (4%; 95% CI, -1 to 9%) and MI (3%; 95% CI, 0 to 6%) at the longest available timepoint (Figure). Conclusion: In the setting of ACS, liberal transfusion strategies may reduce the risk of long term adverse cardiovascular events.