2025-08-20 ラトガース大学
<関連情報>
- https://www.rutgers.edu/news/how-doctors-blood-transfusion-research-changing-standards-and-saving-lives
- https://evidence.nejm.org/doi/full/10.1056/EVIDoa2400223
- https://www.nejm.org/doi/full/10.1056/NEJMoa2307983
- https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001309
- https://www.acpjournals.org/doi/10.7326/ANNALS-25-00706
心筋梗塞における制限的輸血と自由輸血の比較 — 患者レベルメタ解析 Restrictive versus Liberal Transfusion in Myocardial Infarction — A Patient-Level Meta-Analysis
Jeffrey L. Carson, M.D., Dean A. Fergusson, Ph.D., Helaine Noveck, M.P.H., Ranjeeta Mallick, Ph.D., Tabassome Simon, M.D., Ph.D., Sunil V. Rao, M.D., Howard Cooper, M.D., +15 , and P. Gabriel Steg, M.D.
NEJM Evidence Published December: 23, 2024
DOI: 10.1056/EVIDoa2400223
Abstract
Background
Clinical guidelines have concluded that there are insufficient data to provide recommendations for the hemoglobin threshold for the use of red cell transfusion in patients with acute myocardial infarction (MI) and anemia. After the recent publication of the Myocardial Infarction and Transfusion (MINT) trial, we performed an individual patient-level data meta-analysis to evaluate the effect of restrictive versus liberal blood transfusion strategies.
Methods
We conducted searches in major databases. Eligible trials randomly assigned patients with MI and anemia to either a restrictive (i.e., transfusion threshold of 7–8 g/dl) or liberal (i.e., transfusion threshold of 10 g/dl) red cell transfusion strategy. We used individual patient data from each trial. The primary outcome was a composite of 30-day mortality or MI.
Results
We included 4311 patients from four trials. The primary outcome occurred in 334 patients (15.4%) in the restrictive strategy and 296 patients (13.8%) in the liberal strategy (relative risk [RR] 1.13, 95% confidence interval [CI], 0.97 to 1.30). Death at 30 days occurred in 9.3% of patients in the restrictive strategy and in 8.1% of patients in the liberal strategy (RR 1.15, 95% CI, 0.95 to 1.39). Cardiac death at 30 days occurred in 5.5% of patients in the restrictive strategy and in 3.7% of patients in the liberal strategy (RR 1.47, 95% CI, 1.11 to 1.94). Heart failure (RR 0.89, 95% CI, 0.70 to 1.13) was similar in the transfusion strategies. All-cause mortality at 6 months occurred in 20.5% of patients in the restrictive strategy compared with 19.1% of patients in the liberal strategy (hazard ratio 1.08, 95% CI, 1.05 to 1.11).
Conclusions
Pooling individual patient data from four trials did not find a definitive difference in our primary composite outcome of MI or death at 30 days. At 6 months, a restrictive transfusion strategy was associated with increased all-cause mortality. (Partially funded by a grant from the U.S. National Heart, Lung, and Blood Institute [R01HL171977].)
心筋梗塞および貧血における制限的または寛解的輸血戦略 Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia
Jeffrey L. Carson, M.D., Maria Mori Brooks, Ph.D., Paul C. Hébert, M.D., M.H.Sc., Shaun G. Goodman, M.D., Marnie Bertolet, Ph.D., Simone A. Glynn, M.D., M.P.H., Bernard R. Chaitman, M.D., +37 , for the MINT Investigators
The New England Journal of Medicine Published: November 11, 2023
DOI: 10.1056/NEJMoa2307983
Abstract
Background
A strategy of administering a transfusion only when the hemoglobin level falls below 7 or 8 g per deciliter has been widely adopted. However, patients with acute myocardial infarction may benefit from a higher hemoglobin level.
Methods
In this phase 3, interventional trial, we randomly assigned patients with myocardial infarction and a hemoglobin level of less than 10 g per deciliter to a restrictive transfusion strategy (hemoglobin cutoff for transfusion, 7 or 8 g per deciliter) or a liberal transfusion strategy (hemoglobin cutoff, <10 g per deciliter). The primary outcome was a composite of myocardial infarction or death at 30 days.
Results
A total of 3504 patients were included in the primary analysis. The mean (±SD) number of red-cell units that were transfused was 0.7±1.6 in the restrictive-strategy group and 2.5±2.3 in the liberal-strategy group. The mean hemoglobin level was 1.3 to 1.6 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group on days 1 to 3 after randomization. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group (risk ratio modeled with multiple imputation for incomplete follow-up, 1.15; 95% confidence interval [CI], 0.99 to 1.34; P=0.07). Death occurred in 9.9% of the patients with the restrictive strategy and in 8.3% of the patients with the liberal strategy (risk ratio, 1.19; 95% CI, 0.96 to 1.47); myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively (risk ratio, 1.19; 95% CI, 0.94 to 1.49).
Conclusions
In patients with acute myocardial infarction and anemia, a liberal transfusion strategy did not significantly reduce the risk of recurrent myocardial infarction or death at 30 days. However, potential harms of a restrictive transfusion strategy cannot be excluded. (Funded by the National Heart, Lung, and Blood Institute and others; MINT ClinicalTrials.gov number, NCT02981407.)
2025 ACC/AHA/ACEP/NAEMSP/SCAI急性冠症候群患者の管理ガイドライン:米国心臓病学会/米国心臓協会臨床診療ガイドライン合同委員会報告書 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
Sunil V. Rao, MD, FACC, FSCAI, Michelle L. O’Donoghue, MD, MPH, FACC, FAHA, Marc Ruel, MD, MPH, FACC, FAHA, Tanveer Rab, MD, FACC, MSCAI, Jaqueline E. Tamis-Holland, MD, FACC, FAHA, FSCAI, John H. Alexander, MD, MHS, FACC, FAHA, Usman Baber, MD, MS, FACC, FSCAI, … , and Marlene S. Williams, MD, FACC
Circulation Published:27 February 2025
DOI:https://doi.org/10.1161/CIR.0000000000001309
Abstract
Aim:
The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” incorporates new evidence since the “2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction” and the corresponding “2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes” and the “2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction.” The “2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes” and the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization” retire and replace, respectively, the “2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease.”
Methods:
A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.
Structure:
Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
急性心筋梗塞における赤血球輸血:AABBインターナショナル臨床実践ガイドライン Red Cell Transfusion in Acute Myocardial Infarction: AABB International Clinical Practice Guidelines
Monica B. Pagano, MD, Simon J. Stanworth, MD, DPhil, Jane Dennis, PhD, Sara Bakhtary, MD, Jeannie Callum, MD, Jeffrey L. Carson, MD, Claudia S. Cohn, MD, PhD
Annals of Internal Medicine Published:19 August 2025
DOI:https://doi.org/10.7326/ANNALS-25-00706
Abstract
Description:
Optimal transfusion strategies for patients with acute myocardial infarction (AMI) are uncertain. The aim of this guideline is to provide recommendations for red blood cell transfusion in patients with AMI.
Methods:
These guidelines are based on evidence from randomized controlled trials of patients presenting with AMI and assigned to 2 different transfusion strategies (restrictive or liberal) based on hemoglobin concentrations or hematocrit levels before receipt of a transfusion. A meta-analysis of eligible trials was performed using Cochrane methods. The international panel followed GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods to summarize evidence and formulate recommendations. This guideline’s primary perspective is that of the patient, including medical, financial, and psychological effects, with secondary consideration of health care system issues, particularly conservation of the limited and costly blood supply.
Recommendation:
For hospitalized patients with AMI, the panel suggests a liberal red cell transfusion strategy when the hemoglobin concentration is less than 10 g/dL (conditional recommendation, low-certainty evidence). A restrictive strategy of 7 to 8 g/dL may result in increased mortality in patients with AMI. The direction of the recommendation for the liberal strategy was based on the great importance of mortality for patients. The conditional recommendation was based on the low certainty of evidence and the competing consideration of blood supply conservation. Clinicians should adopt mitigation strategies to reduce potential adverse events associated with a liberal transfusion strategy, and all transfusion decisions should incorporate the clinical context rather than solely the hemoglobin concentration.
