Coronary Artery Disease
Relation of Baseline Hemoglobin Levels and Adverse Events in Patients With Acute Coronary Syndromes (from the Acute Catheterization and Urgent Intervention Triage strategY and Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction Trials)

https://doi.org/10.1016/j.amjcard.2017.02.052Get rights and content

The association between anemia at admission and adverse outcomes in patients with acute coronary syndrome (ACS) has been incompletely studied. Anemia was defined as serum hemoglobin <12 g/dl in women or <13 g/dl in men in 2 large trials of patients with ACS. We plotted hazard functions for major bleeding at 30 days and all-cause mortality, myocardial infarction, and stent thrombosis at 1 year according to baseline hemoglobin. Among 16,318 patients, 3070 (18.8%) had anemia at baseline. All-cause death at 1 year (2.9% vs 1.5%), major bleeding (7.6% vs 3.6%, p <0.001), and transfusions (6.7% vs 1.5%, p <0.001) were more common in patients with baseline anemia. Spline transformations of the hazard for adverse events as a function of hemoglobin level on admission showed that adverse outcomes increased in a nonlinear fashion with lower levels of baseline hemoglobin; the lowest rates were observed at a level of ∼14 g/dl. Baseline hemoglobin and anemia were independent predictors of major bleeding and death. In conclusion, in patients with ACS, baseline hemoglobin carries important independent prognostic information and demonstrates a nonlinear association with major bleeding and mortality.

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Methods

The design and results of the ACUITY and HORIZONS-AMI trials have been previously reported in detail.5, 6, 7 In brief, in ACUITY, 13,819 patients with non–ST-segment elevation ACS (NSTE-ACS) were randomized to 1 of the 3 antithrombotic regimes: bivalirudin alone, bivalirudin with a glycoprotein IIb/IIIa inhibitor, or heparin with a glycoprotein IIb/IIIa inhibitor. All patients underwent coronary angiography within 72 hours, after which the decision for revascularization was left to the

Results

Among 16,318 patients with complete data, 3,070 (18.8%) had anemia at baseline. Baseline and procedural characteristics according to the presence of anemia at presentation are listed in Table 1. Patients with anemia were older, more often women, and more likely to have concomitant risk factors for coronary artery disease. They were also significantly less likely to undergo revascularization. The hemoglobin level on admission was 12.0 ± 1.1 in anemic patients and 14.6 ± 1.2 in nonanemic patients

Discussion

The principal findings from the present study of more than 16,000 patients with ACS from 2 international randomized trials are as follows: (1) a nonlinear relation was present among baseline hemoglobin as a continuous variable and both 30-day major bleeding and 1-year adverse ischemic outcomes, with increasing event rates at low hemoglobin levels and a nadir at approximately 14 g/dl; (2) in contrast to patients with higher baseline hemoglobin levels, much of the excess of non-CABG major

Disclosures

Roxana Mehran and George D. Dangas receive research grant support from Eli Lilly, AstraZeneca, The Medicines Company, BMS/Sanofi-Aventis, DSI, and OrbusNeich; are a consultant for AstraZeneca, Bayer, CSL Behring, Janssen Pharmaceuticals Inc., Merck & Co., Osprey Medical Inc., and Watermark Research Partners; and are on the scientific advisory board of Abbott Laboratories, Boston Scientific Corporation, Covidien, Janssen Pharmaceuticals, The Medicines Company, and Sanofi-Aventis. Edwin Magnus

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