Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial

Andrew P DeFilippis¹, J Dawn Abbott², Brandon M Herbert³, Marnie H Bertolet³, Bernard R Chaitman⁴, Harvey D White⁵, Andrew M Goldsweig⁶, Tamar S Polonsky⁷, Rajesh Gupta⁸, Caroline Alsweiler⁵, Johanne Silvain⁹, Pedro G M de Barros E Silva¹⁰, Graham S Hillis¹¹, Benoit Daneault¹², Meechai Tessalee⁷, Mark A Menegus¹³, Sunil V Rao¹⁴, Renato D Lopes¹⁵, Paul C Hébert¹⁶, John H Alexander¹⁴, Maria M Brooks³, Jeffrey L Carson¹⁷, Shaun G Goodman^{18

19}; MINT Investigators

Affiliations

¹ Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.P.D.).
² Lifespan Cardiovascular Institute and Department of Medicine, Division of Cardiology, Alpert Medical School of Warren Alpert Medical School. Brown University, Providence, RI (J.D.A.).
³ University of Pittsburgh School of Public Health, PA (B.M.H., M.H.B., M.M.B.).
⁴ St Louis University School of Medicine, MO (B.R.C.).
⁵ Green Lane Coordinating Center, Auckland, New Zealand (H.D.W., C.A.).
⁶ Department of Medicine, Baystate Medical Center, Springfield, MA (A.M.G.).
⁷ Department of Medicine, University of Chicago Medicine, IL (T.S.P.M.T.).
⁸ Department of Medicine, Division of Cardiovascular Medicine, University of Toledo, OH (R.G.).
⁹ Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Institut de Cardiologie Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (J.S.).
¹⁰ Brazilian Clinical Research Institute, Sao Paulo (P.G.M.dBeS.).
¹¹ Department of Cardiology, Royal Perth Hospital and Medical School, University of Western Australia, Perth (G.S.H.).
¹² Centre Hospitalier Universitaire de Sherbrooke, QC, Canada (B.D.).
¹³ Division of Cardiology, Montefiore Medical Center, NY (M.A.M.).
¹⁴ New York University Langone Health System, NY (S.V.R., J.H.A.).
¹⁵ Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC (R.D.L.).
¹⁶ Bruyere Research Institute, University of Ottawa, Canada (P.C.H.).
¹⁷ Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.).
¹⁸ St Michael's Hospital, Unity Health Toronto and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto (S.G.G.).
¹⁹ Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.G.G.).

PMID: 39206549
PMCID: PMC11611643 (available on 2025-12-03)
DOI: 10.1161/CIRCULATIONAHA.124.071208

Randomized Controlled Trial

Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial

Andrew P DeFilippis et al. Circulation. 2024.

. 2024 Dec 3;150(23):1826-1836.

doi: 10.1161/CIRCULATIONAHA.124.071208. Epub 2024 Aug 29.

Authors

Affiliations

¹ Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (A.P.D.).
² Lifespan Cardiovascular Institute and Department of Medicine, Division of Cardiology, Alpert Medical School of Warren Alpert Medical School. Brown University, Providence, RI (J.D.A.).
³ University of Pittsburgh School of Public Health, PA (B.M.H., M.H.B., M.M.B.).
⁴ St Louis University School of Medicine, MO (B.R.C.).
⁵ Green Lane Coordinating Center, Auckland, New Zealand (H.D.W., C.A.).
⁶ Department of Medicine, Baystate Medical Center, Springfield, MA (A.M.G.).
⁷ Department of Medicine, University of Chicago Medicine, IL (T.S.P.M.T.).
⁸ Department of Medicine, Division of Cardiovascular Medicine, University of Toledo, OH (R.G.).
⁹ Sorbonne Université, ACTION Study Group, INSERM UMRS1166, Institut de Cardiologie Hôpital Pitié-Salpêtrière (AP-HP), Paris, France (J.S.).
¹⁰ Brazilian Clinical Research Institute, Sao Paulo (P.G.M.dBeS.).
¹¹ Department of Cardiology, Royal Perth Hospital and Medical School, University of Western Australia, Perth (G.S.H.).
¹² Centre Hospitalier Universitaire de Sherbrooke, QC, Canada (B.D.).
¹³ Division of Cardiology, Montefiore Medical Center, NY (M.A.M.).
¹⁴ New York University Langone Health System, NY (S.V.R., J.H.A.).
¹⁵ Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC (R.D.L.).
¹⁶ Bruyere Research Institute, University of Ottawa, Canada (P.C.H.).
¹⁷ Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.).
¹⁸ St Michael's Hospital, Unity Health Toronto and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto (S.G.G.).
¹⁹ Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.G.G.).

PMID: 39206549
PMCID: PMC11611643 (available on 2025-12-03)
DOI: 10.1161/CIRCULATIONAHA.124.071208

Abstract

Background: The MINT trial (Myocardial Ischemia and Transfusion) raised concern for harm from a restrictive versus liberal transfusion strategy in patients with acute myocardial infarction (MI) and anemia. Type 1 and type 2 MI are distinct pathophysiologic entities that may respond differently to blood transfusion. This analysis sought to determine whether the effects of transfusion varied among patients with a type 1 or a type 2 MI and anemia. The authors hypothesized that the liberal transfusion strategy would be of greater benefit in type 2 than in type 1 MI.

Methods: The authors compared rates of death or MI at 30 days in patients with type 1 (n=1460) and type 2 (n=1955) MI and anemia who were randomly allocated to a restrictive (threshold, 7-8 g/dL) or a liberal (threshold, 10 g/dL) transfusion strategy.

Results: The primary outcome of death or MI was observed in 16% of type 1 MI and 15.4% of type 2 MI patients. The rate of death or MI was higher in patients with type 1 MI randomized to a restrictive (18.2%) versus liberal (13.8%) transfusion strategy (relative risk [RR], 1.32 [95% CI, 1.04-1.67]) with no difference observed between the restrictive (15.8%) and liberal (15.1%) transfusion strategies in patients with type 2 MI (RR, 1.05 [95% CI, 0.85-1.29]). The test for a differential effect of transfusion strategy by MI type was not statistically significant (P_interaction = 0.16).

Conclusions: The concern for harm with a restrictive transfusion strategy in patients with acute MI and anemia raised in the MINT primary outcome manuscript may be more apparent in patients with type 1 than type 2 MI.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02981407.

Keywords: acute coronary syndrome; blood transfusion; clinical trials as topic; myocardial infarction.

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Conflict of interest statement

Dr DeFilippis reports research grants from Ionis Pharmaceutical; and consulting for Velkor, Inc and Novo Nordisk. Dr Abbott reports consulting for Abbott, Medtronic, Penumbra. Research Boston Scientific, Recor, Med Alliance, Shockwave, and Microport. Dr White reports grant support paid to the institution for: ODYSSEY OUTCOMES trial (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; from Sanofi and Regeneron Pharmaceuticals); STRENGTH trial (Long-Term Outcomes Study to Assess Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemia; Omthera Pharmaceuticals); HEART-FID Study (Ferric Carboxymaltose in Heart Failure With Iron Deficiency; American Regent); Dal GenE study (Study Effect of Dalcetrapib Versus Placebo on CV Risk in a Genetically Defined Population With a Recent ACS; DalCor Pharma UK Inc); AEGIS II study (CSL Behring); Clear Outcomes Study (Cholesterol Lowering via Bempedoic Acid, an ACL-Inhibiting Regimen; Esperion Therapeutics); SOLIST-WHF (Effect of Sotagliflozin on Cardiovascular Events in Patients With Type 2 Diabetes Post Worsening Heart Failure) and SCORED (Effect of Sotagliflozin on Cardiovascular and Renal Events in Patients With Type 2 Diabetes and Moderate Renal Impairment Who Are at Cardiovascular Risk) studies (Sanofi Aventis Australia Pty Ltd); Librexia AF (A Study of Milvexian Versus Apixaban in Participants With Atrial Fibrillation) and ACS (A Study of Milvexian in Participants After a Recent Acute Coronary Syndrome) studies (Janssen); and ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) and MINT ([Myocardial Ischemia and Transfusion] National Institutes of Health); and personal fees as a steering committee member from DalCor Pharma UK, CSL Behring, Sanofi Australia Pty Ltd, Janssen, and Esperion Therapeutics; as well as membership on advisory boards for CSL Behring and Genentech. Dr Lopes reports grant support or contracts from Amgen, Bristol Myers Squibb, GlaxoSmithKline, Medtronic, Pfizer, and Sanofi-Aventis; funding for educational activities or lectures from Pfizer, Daiichi Sankyo, and Novo Nordisk; and funding for consulting or other services from Bayer, Boehringer Ingelheim, Bristol Myers Squibb, and Novo Nordisk. Dr Alexander reports grant support (to Duke University) from Artivion/CryoLife, Bayer, Bristol Myers Squibb, CSL Behring, Ferring, United States Food and Drug Administration, Humacyte, and National Institutes of Health; and advisory board or consulting payments from AbbVie, Artivion/CryoLife, AtriCure, Bayer, Bristol-Myers Squibb, Eli Lilly, Ferring, GlaxoSmithKline, Janssen, Novostia, Pfizer, Portola, Theravance, and Veralox. Drs Carson and Hébert report participation on the data safety monitoring board for Cerus. Dr Goodman reports research grant support (eg, steering committee or data and safety monitoring committee) and/or speaker/consulting honoraria (eg, advisory boards) from Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, CYTE Ltd, Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, HLS Therapeutics, Idorsia, JAMP Pharma, Merck, Novartis, Novo Nordisk A/C, Pendopharm/Pharmascience, Pfizer, Regeneron, Sanofi, Servier, Tolmar Pharmaceuticals, and Valeo Pharma; and salary support/honoraria from the Canadian Heart Failure Society, Canadian Heart Research Centre and MD Primer, Canadian VIGOUR Centre, Cleveland Clinic Coordinating Centre for Clinical Research, Duke Clinical Research Institute, New York University Clinical Coordinating Centre, PERFUSE Research Institute, Peter Munk Cardiac Centre Clinical Trials and Translation Unit, and Thrombolysis in Myocardial Infarction Study Group (Brigham Health). The other authors report no conflicts.

References

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Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial

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Restrictive Versus Liberal Transfusion in Patients With Type 1 or Type 2 Myocardial Infarction: A Prespecified Analysis of the MINT Trial

Authors

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Conflict of interest statement

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