Patterns and outcomes of red blood cell transfusion in patients undergoing percutaneous coronary intervention

Abstract

Importance: Studies have shown variation in the use of red blood cell transfusion among patients with acute coronary syndromes. There are no definitive data for the efficacy of transfusion in improving outcomes, and concerning data exist about possible association with harm. Current transfusion practices in patients undergoing percutaneous coronary intervention (PCI) are not well understood.

Objective: To determine the current patterns of blood transfusion among patients undergoing PCI and the association of transfusion with adverse cardiac outcomes across hospitals in the United States.

Design, setting, and participants: Retrospective cohort study of all patient visits from the CathPCI Registry from July 2009 to March 2013 that included PCI, excluding those with missing data on bleeding complications or who underwent in-hospital coronary artery bypass graft surgery (N = 2,258,711 visits).

Main outcomes and measures: Transfusion rates in the overall population and by hospital (N = 1431) were the primary outcomes. The association of transfusion with myocardial infarction, stroke, and death after accounting for a patient's propensity for transfusion was also measured.

Results: The overall rate of transfusion was 2.14% (95% CI, 2.13%-2.16%) and quarterly transfusion rates slightly declined from July 2009 to March 2013 (from 2.11% [95% CI, 2.03%-2.19%] to 2.04% [95% CI, 1.97%-2.12%]; P < .001). Patients who were more likely to receive transfusion were older (mean, 70.5 vs 64.6 years), were women (56.3% vs 32.5%), and had hypertension (86.4% vs 82.0%), diabetes (44.8% vs 34.6%), advanced renal dysfunction (8.7% vs 2.3%), prior myocardial infarction (33.0% vs 30.2%), or prior heart failure (27.0% vs 11.8%). Overall, 96.3% of sites gave a transfusion to less than 5% of patients and 3.7% of sites gave a transfusion to 5% of patients or more. Variation in hospital risk-standardized rates of transfusion persisted after adjustment, and hospitals showed variability in their transfusion thresholds. Receipt of transfusion was associated with myocardial infarction (42,803 events; 4.5% vs 1.8%; odds ratio [OR], 2.60; 95% CI, 2.57-2.63), stroke (5011 events; 2.0% vs 0.2%; OR, 7.72; 95% CI, 7.47-7.98), and in-hospital death (31,885 events; 12.5% vs 1.2%; OR, 4.63; 95% CI, 4.57-4.69), irrespective of bleeding complications.

Conclusions and relevance: Among patients undergoing PCI at US hospitals, there was considerable variation in blood transfusion practices, and receipt of transfusion was associated with increased risk of in-hospital adverse cardiac events. These observational findings may warrant a randomized trial of transfusion strategies for patients undergoing PCI.

Figure 1

Study Sample Flow Diagram -- Displays the selection of patient visits for analysis from the NCDR CathPCI database

Figure 2

Distribution of hospital risk-standardized rates of transfusion -- Displays the variations in frequency of receipt of transfusion by hospital site, after adjustment for patient risk factors such as age, gender, body mass index (BMI), ACS presentation, PCI status, cardiogenic shock, NYHA Class IV CHF, history of CHF, peripheral vascular disease (PVD), chronic lung disease, diabetes, dialysis, previous PCI, coronary lesion ≥ 50%, and glomerular filtration rate (GFR)

Figure 3

Use of RBC transfusion by post-procedure Hemoglobin at High, Middle, and Low Transfusing sites. Displays the frequency of RBC transfusion by post procedure hemoglobin value when the study sample of hospital sites is divided into High, Middle, and Low transfusing sites. Rates of transfusion are higher at High transfusing sites across all hemoglobin values.