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Original Investigation | Association of VA Surgeons

Blood Transfusion and 30-Day Mortality in Patients With Coronary Artery Disease and Anemia Following Noncardiac Surgery

Robert H. Hollis, MD1,2; Brandon A. Singletary, MPH1,2; James T. McMurtrie, BS1,2; Laura A. Graham, MPH1,2; Joshua S. Richman, MD, PhD1,2; Carla N. Holcomb, MD1,2; Kamal M. Itani, MD3; Thomas M. Maddox, MD, MSc4; Mary T. Hawn, MD, MPH1,2
[+] Author Affiliations
1Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham
2The Center for Surgical, Medical Acute Care Research, and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama
3Department of Surgery, VA Boston Health Care System, Boston University and Harvard Medical School, Boston, Massachusetts
4VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver
JAMA Surg. 2016;151(2):139-145. doi:10.1001/jamasurg.2015.3420.
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Published online

Importance  Although liberal blood transfusion thresholds have not been beneficial following noncardiac surgery, it is unclear whether higher thresholds are appropriate for patients who develop postoperative myocardial infarction (MI).

Objective  To evaluate the association between postoperative blood transfusion and mortality in patients with coronary artery disease and postoperative MI following noncardiac surgery.

Design, Setting, and Participants  Retrospective cohort study involving Veterans Affairs facilities from January 1, 2000, to December 31, 2012. A total of 7361 patients with coronary artery disease who underwent inpatient noncardiac surgery and had a nadir postoperative hematocrit between 20% and 30%. Patients with significant bleeding, including any preoperative blood transfusion or transfusion of greater than 4 units during the intraoperative or postoperative setting, were excluded. Mortality rates were compared using both logistic regression and propensity score matching. Patients were stratified by postoperative nadir hematocrit and the presence of postoperative MI.

Exposure  Initial postoperative blood transfusion.

Main Outcomes and Measures  The 30-day postoperative mortality rate.

Results  Of the 7361 patients, 2027 patients (27.5%) received at least 1 postoperative blood transfusion. Postoperative mortality occurred in 267 (3.6%), and MI occurred in 271 (3.7%). Among the 5334 patients without postoperative blood transfusion, lower nadir hematocrit was associated with an increased risk for mortality (hematocrit of 20% to <24%: 7.3%; 24% to <27%: 3.7%; and 27% to 30%: 1.6%; P < .01). In patients with postoperative MI, blood transfusion was associated with lower mortality, for those with hematocrit of 20% to 24% (odds ratio, 0.28; 95% CI, 0.13-0.64). In patients without postoperative MI, transfusion was associated with significantly higher mortality for those with hematocrit of 27% to 30% (odds ratio, 3.21; 95% CI, 1.85-5.60).

Conclusions and Relevance  These findings support a restrictive postoperative transfusion strategy in patients with stable coronary artery disease following noncardiac surgery. However, interventional studies are needed to evaluate the use of a more liberal transfusion strategy in patients who develop postoperative MI.

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Figure 1.
Mean Hematocrit Preceding Transfusion Over Time

Mean nadir hematocrit preceding blood transfusion across time. The error bars represent standard errors.

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Figure 2.
30-Day Mortality Rate by Nadir Postoperative Hematocrit in Patients With and Without Postoperative Blood Transfusion

The solid and dashed lines represent estimated rates and the shaded areas represent 95% CIs.

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Figure 3.
Multivariate Analysis of 30-Day Mortality Rates in Patients With and Without Transfusion

Results are presented from the overall cohort and stratified by occurrence of myocardial infarction (MI) in the postoperative period. HCT indicates hematocrit.

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