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Invited Commentary |

Optimal Transfusion Trigger in Surgical Patients With Coronary Artery Disease

Steven M. Frank, MD1; Aslam Ejaz, MD, MPH2; Timothy M. Pawlik, MD, MPH, PhD3
[+] Author Affiliations
1Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
2Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago
3Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
JAMA Surg. 2016;151(2):146. doi:10.1001/jamasurg.2015.3399.
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Among patients with known coronary artery disease (CAD), the ideal transfusion trigger based on nadir hemoglobin is still unclear. Three of the largest randomized clinical trials on transfusion triggers and perioperative outcomes were performed among cardiac patients undergoing cardiac surgery,13 a clinical scenario that is very different from cardiac patients undergoing noncardiac surgery. In fact, other than 2 very small pilot studies in patients with myocardial infarction (MI) who were randomized to higher or lower transfusion triggers—one supporting a liberal4 and the other a restrictive5 transfusion strategy—the ideal hemoglobin trigger in the setting of MI (perioperative or nonperioperative) is unknown. The best evidence to date for the ideal transfusion trigger in noncardiac surgery is from the FOCUS Trial, which showed no benefit for any of the measured outcomes when a transfusion trigger of 10 g/dL (to convert to grams per liter, multiply by 10) was compared with a trigger of 8 g/dL among a cohort of elderly patients with a high incidence of CAD undergoing orthopedic procedures.6 Furthermore, a large retrospective study reported that postoperative transfusions after noncardiac surgery were associated with increased adverse postoperative outcomes, with the exception of postoperative MI.7

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