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Journal ArticleDOI

Impact of Anemia on In-Hospital, One-Month and One-Year Mortality in Patients with Acute Coronary Syndrome from the Middle East

TL;DR: Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year, Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.
Abstract: Aim The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS).

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Journal ArticleDOI
TL;DR: The epidemiology of anemia and RBC transfusion in hospitalized adults and children with cardiac disease, and on the outcome of anemic and transfused cardiac patients is reported.
Abstract: Anemia and red blood cell (RBC) transfusion occur frequently in hospitalized patients with cardiac disease. In this narrative review, we report the epidemiology of anemia and RBC transfusion in hospitalized adults and children (excluding premature neonates) with cardiac disease, and on the outcome of anemic and transfused cardiac patients. Both anemia and RBC transfusion are common in cardiac patients, and both are associated with mortality. RBC transfusion is the only way to rapidly treat severe anemia, but is not completely safe. In addition to hemoglobin (Hb) concentration, the determinant(s) that should drive a practitioner to prescribe a RBC transfusion to cardiac patients are currently unclear. In stable acyanotic cardiac patients, Hb level above 70 g/L in children and above 70 to 80 g/L in adults appears safe. In cyanotic children, Hb level above 90 g/L appears safe. The appropriate threshold Hb level for unstable cardiac patients and for children younger than 28 days is unknown. The optimal transfusion strategy in cardiac patients is not well characterized. The threshold at which the risk of anemia outweighs the risk of transfusion is not known. More studies are needed to determine when RBC transfusion is indicated in hospitalized patients with cardiac disease.

48 citations


Cites background or methods from "Impact of Anemia on In-Hospital, On..."

  • ...This table reports data from two meta-analyses [9,14] and six observational studies [15-20] that were not included in these meta-analyses....

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  • ...Table 1 summarizes the results of two meta-analyses [9,14] and six observational studies [15-20] on the relationship in cardiac adults between anemia and adverse outcomes; a statistically significant association is reported in almost each instance....

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Journal ArticleDOI
TL;DR: Estimated prevalence of anemia on admission in the setting of an acute coronary syndrome (ACS) is between 10% and 43% of the patients depending upon the specific population under investigation, and up to 57% of ACS patients may develop hospital-acquired anemia (HAA), even if different mechanisms contribute to their prognostic impact.
Abstract: Reference hemoglobin (Hb) values for the definition of anemia are still largely based on the 1968 WHO Scientific Group report, which established a cutoff value of <13 g/dL for adult men and <12 g/dL for adult nonpregnant women. Subsequent studies identified different normal values according to race and age. Estimated prevalence of anemia on admission in the setting of an acute coronary syndrome (ACS) is between 10% and 43% of the patients depending upon the specific population under investigation. Furthermore, up to 57% of ACS patients may develop hospital-acquired anemia (HAA). Both anemia on admission and HAA are associated with worse short- and long-term mortality, even if different mechanisms contribute to their prognostic impact. Baseline anemia can usually be traced back to preexisting disease that should be specifically investigated and corrected whenever possible. HAA is associated with clinical characteristics, medical therapy and interventional procedures, all eliciting cardiovascular adaptive response that can potentially worsen myocardial ischemia. The intrinsic fragility of anemic patients may limit aggressive medical and interventional therapy due to an increased risk of bleeding, and could independently contribute to worse outcome. However, primary angioplasty for ST elevation ACS should not be delayed because of preexisting (and often not diagnosed) anemia; delaying revascularization to allow fast-track anemia diagnosis is usually feasible and justified in non-ST-elevation ACS. Besides identification and treatment of the underlying causes of anemia, the only readily available means to reverse anemia is red blood cell transfusion. The adequate transfusion threshold is still being debated, although solid evidence suggests reserving red blood cell transfusions for patients with Hb level <8 g/dL and considering it in selected cases with Hb levels of between 8 and 10 g/dL. No evidence supports the use of iron supplements and erythropoiesis-stimulating agents in the setting of ACS.

42 citations

Journal ArticleDOI
TL;DR: Although anaemia (based on the WHO definitions) does not appear to be an independent predictor of all-cause mortality or major adverse cardiac events after PPCI on multivariate analysis, there appears to be a threshold value of Hb among men, below which there is an associated increased risk for PPCi.
Abstract: AIM The aim of this study was to investigate the effects of baseline anaemia on the outcome in patients treated by primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction. METHODS This study was a retrospective cohort study of 2418 patients with ST-elevation myocardial infarction treated by PPCI between January 2004 and August 2010 at a single centre. We investigated the outcome in patients with anaemia compared with that in patients with a normal haemoglobin (Hb) level. Anaemia was defined according to the WHO definition as an Hb level less than 12 g/dl for female individuals and less than 13 g/dl for male individuals. We also calculated hazard ratios using a stratified model according to the Hb level. RESULTS A total of 471 (19%) patients were anaemic at presentation. The anaemic cohort was older (72.2 vs. 62.4 years, P<0.0001) and had a higher incidence of diabetes (28 vs. 16%, P<0.0001), hypertension (57 vs. 43%, P=0.01), hypercholesterolaemia (48 vs. 40%, P=0.007), previous PCI (15 vs. 9%, P<0.0001), previous myocardial infarction (23 vs. 12%, P=0.002), and cardiogenic shock (12 vs. 5%, P<0.0001). Over a mean follow-up period of 3 years there was significantly higher all-cause mortality in the anaemic group compared with the normal Hb group (20.4 vs. 13.5%, P<0.0001). However, after adjustment for all variables using multivariate analysis, anaemia (on the basis of the WHO definitions) was found not to be an independent predictor of mortality or major adverse cardiac events over the follow-up period. Further, when we used a model stratified by g/dl, we found that there was an increased risk for adverse outcomes among men with low Hb levels. There appeared to be a threshold value of Hb (13 g/dl) associated with increased risk. Although a similar trend was observed among women, no significant difference was observed. CONCLUSION Patients with anaemia undergoing PPCI are at a higher risk of an adverse outcome. Anaemia is a simple and powerful marker of poor prognosis. Although anaemia (based on the WHO definitions) does not appear to be an independent predictor of all-cause mortality or major adverse cardiac events after PPCI on multivariate analysis, there appears to be a threshold value of Hb among men, below which there is an associated increased risk for PPCI.

27 citations

Journal ArticleDOI
TL;DR: This study shows that anemia adversely affects long-term survival following AMI, however, further studies are needed to confirm that the presence of anemia can solely explain worse long- term outcomes after AMI.
Abstract: Previous studies have shown that the presence of anemia is associated with increased short- and long-term outcomes in patients with acute myocardial infarction (AMI). This study aims at examining the impact of admission anemia on long-term, all-cause mortality following AMI in patients recruited from a population-based registry. Contrary to most prior studies, we distinguished between patients with mild and moderate to severe anemia. This prospective study was conducted in 2011 patients consecutively hospitalized for AMI that occurred between January 2005 and December 2008. Patients who survived more than 28 days after AMI were followed up until December 2011. Hemoglobin (Hb) concentration was measured at hospital admission and classified according to the World Health Organization (WHO). Mild anemia was defined as Hb concentration of 11 to < 12 g/dL in women and 11 to < 13 g/dL in men; moderate to severe anemia as Hb concentration of < 11 g/dL. Adjusted Cox regression models were calculated to compare survival in patients with and without anemia. Mild anemia and moderate to severe anemia was found in 183 (9.1%) and 100 (5%) patients, respectively. All-cause mortality after a median follow-up time of 4.2 years was 11.9%. The Cox regression analysis showed significantly increased mortality risks in both patients with mild (HR 1.74, 95% CI 1.23–2.45) and moderate to severe anemia (HR 2.05, 95% CI 1.37–3.05) compared to patients without anemia. This study shows that anemia adversely affects long-term survival following AMI. However, further studies are needed to confirm that anemia can solely explain worse long-term outcomes after AMI.

21 citations


Cites result from "Impact of Anemia on In-Hospital, On..."

  • ...They were less often treated with PCI, but more frequently with CABG, which might be an indicator of more advanced coronary artery disease....

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  • ...In line, previous studies demonstrated that anemic patients were less often treated with PCI [18, 21] and experienced worse outcomes after PCI, e....

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  • ...Due to the lower risk of bleeding, the radial access might also be preferable when performing PCI in patients with anemia....

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  • ...Three different models were calculated: 1) an unadjusted model, 2) a model adjusted for age and sex, and 3) a model adjusted for age, sex, previous MI, angina pectoris, hyperlipidemia, diabetes, stroke, eGFR, heart rate, AMI type, LVEF, discharge medications, PCI and in-hospital complications....

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  • ...In-hospital procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) were determined by chart review....

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Journal ArticleDOI
TL;DR: The impact of anaemia on cause specific of mortality seem to be different according to age subgroup, and in young patients the association between anaemia and mortality was significant only for non-cardiac causes.
Abstract: Background Prognostic impact of anaemia in the elderly with acute coronary syndromes has not been specifically analysed, and little information exists about causes of mortality in this setting. Methods We prospectively included consecutive patients with acute coronary syndromes. Anaemia was defined as haemoglobin Results We included 2128 patients, of whom 394 (18.6%) were aged 75 years or older. Anaemia was more common in the elderly (40.4% vs 19.5%, p Conclusions The impact of anaemia on cause specific of mortality seem to be different according to age subgroup. The association between anaemia and mortality was not observed in elderly patients from our series.

19 citations

References
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Journal ArticleDOI
TL;DR: WHO-defined anemia was common in both men and women among patients with acute stroke and predicted poor outcome and the association between admission hemoglobin and mortality was not linear; risk for death increased at both extremes of hemoglobin.
Abstract: In the setting of an acute stroke, anemia has the potential to worsen brain ischemia, however, the relationship between the entire range of hemoglobin to long-term outcome is not well understood. We examined the association between World Health Organization-defined admission anemia status (hemoglobin<13 in males, <12 g/dl in women) and hemoglobin concentration and 1-year outcome among 859 consecutive patients with acute stroke (ischemic or intracerebral hemorrhage). The mean baseline hemoglobin concentration was 13.8 ± 1.7 g/dl (range 8.1 - 18.7). WHO-defined anemia was present in 19% of patients among both women and men. After adjustment for differences in baseline characteristics, patients with admission anemia had an adjusted OR for all-cause death at 1-month of 1.90 (95% CI, 1.05 to 3.43) and at 1-year of 1.72 (95% CI, 1.00 to 2.93) and for the combined end-point of disability, nursing facility care or death of 2.09 (95% CI, 1.13 to 3.84) and 1.83 (95% CI, 1.02 to 3.27) respectively. The relationship between hemoglobin quartiles and all-cause death revealed a non-linear association with increased risk at extremes of both low and high concentrations. In logistic regression models developed to estimate the linear and quadratic relation between hemoglobin and outcomes of interest, each unit increment in hemoglobin squared was associated with increased adjusted odds of all-cause death [at 1-month 1.06 (1.01 to 1.12; p = 0.03); at 1-year 1.09 (1.04 to 1.15; p < 0.01)], confirming that extremes of both low and high levels of hemoglobin were associated with increased mortality. WHO-defined anemia was common in both men and women among patients with acute stroke and predicted poor outcome. Moreover, the association between admission hemoglobin and mortality was not linear; risk for death increased at both extremes of hemoglobin.

103 citations


"Impact of Anemia on In-Hospital, On..." refers background in this paper

  • ...In the present study, anemic patients with ACS were more likely to experience in-hospital complications including CHF,(4,5,9) recurrent ischemia,(2,3,19) reinfarction,(3,8,11) cardiogenic shock,(18) major bleed,(11) and stroke.(8,20) Furthermore, the presence of anemia in ACS patients doubled the risk of CHF and cardiogenic shock....

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Journal Article
TL;DR: There is room for improvement in using medications, reducing needle to door time and utilizing more cardiac catheterization services in patients hospitalized with ACS in the Gulf area.
Abstract: OBJECTIVES To identify the characteristics, treatments and hospital outcomes for patients diagnosed with acute coronary syndromes (ACS) in the Gulf area. METHODS Prospective, multinational, multicentre, observational survey of consecutive ACS patients who were admitted to 65 hospitals during May 2006. RESULTS A total of 1484 ACS patients were recruited. The mean age was 55 years, and 76% were men. The final discharge diagnosis was ST-segment elevation myocardial infarction (STEMI) in 37%, non-ST-segment elevation myocardial infarction (NSTEMI) in 32%, left bundle branch block myocardial infarction (LBBB MI) in 2%, and unstable angina in 29%. Among patients with STEMI and LBBB MI, the reperfusion rate was 65%, with use of primary percutaneous coronary intervention in 7% and thrombolytic therapy in 93%. When thrombolytic therapy was used, the median door to needle time was 45 minutes, with 37% receiving it within 30 minutes of hospital presentation. During the first day of hospitalization, aspirin was administered to 94%, clopidogrel to 51%, and beta blockers to 65%. Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers and statins were used in 62% and 82%, respectively. Coronary angiography during hospitalization was performed in 21%. In-hospital mortality was 3%. CONCLUSIONS We were able to determine the characteristics, treatments and in-hospital outcomes of patients hospitalized with ACS in our region. There is room for improvement in using medications, reducing needle to door time and utilizing more cardiac catheterization services.

94 citations


"Impact of Anemia on In-Hospital, On..." refers methods in this paper

  • ...Gulf RACE-II design and methods are similar to Gulf RACE-I that has been previously reported.(13) The Gulf RACE-II is a large prospective, multinational, multicenter registry of acute coronary events in the Middle East, focusing on the epidemiology, management practices, and outcomes of patients with ACS....

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Journal ArticleDOI
TL;DR: A low baseline haemoglobin level is an independent predictor of the risk of major bleeding in ACS as well as of therisk of death and death and MI, and should be taken into account in patients presenting with ACS.
Abstract: Aims In patients with acute coronary syndromes (ACS), the negative impact of baseline haemoglobin levels on ischaemic events, particularly death, is well established, but the association with bleeding risk is less well studied. The aim of this study was to assess the impact of baseline haemoglobin levels on major bleeding complications. Methods and results Pooled analysis of OASIS 5 and 6 data involving 32 170 patients with ACS with and without ST-segment elevation was performed. The association between baseline haemoglobin and major bleeding or ischaemic events was examined using multiple regression model. Main outcome measures were 30-day rates of major bleeding, death, and death/myocardial infarction (MI) analysed according to baseline haemoglobin levels. Baseline haemoglobin level independently predicted the risk of overall, procedure-related, and non-procedure-related major bleedings at 30 days [odds ratio (OR) 0.94, 95% CI 0.90–0.98; OR 0.94, 95% CI 0.90–0.99; and OR 0.89, 95% CI 0.83–0.95, respectively, per 1 g/dL haemoglobin increment above 10 g/dL]. In addition, a curvilinear relationship between baseline haemoglobin levels and death at 30 days was observed with a 6% decrease in the risk for every 1 g/dL haemoglobin increment above 10 g/dL up to 15.9 g/dL (OR 0.94, 95% CI 0.90–0.98) and a 19% increase above this value (OR 1.19, 95% CI, 0.98–1.43). A similar relationship for the composite outcome of death/MI was observed. Conclusion A low baseline haemoglobin level is an independent predictor of the risk of major bleeding in ACS as well as of the risk of death and death and MI. Among other predictors of bleeding risk, baseline haemoglobin should be taken into account in patients presenting with ACS. Clinical trial registration: ClinicalTrials.gov number, NCT00139815. .

88 citations

Journal ArticleDOI
TL;DR: In patients with complicated AMIs, anaemia on admission and/or reductions in haemoglobin during follow-up are independent risk factors for mortality and hospitalization.
Abstract: Aims The prevalence, incidence, and prognostic value of anaemia in patients with an acute myocardial infarction (AMI) complicated by heart failure is unclear. Methods and results We analysed the relationship between haemoglobin (Hb) and outcome in 5010 patients with AMI complicated by heart failure in the OPTIMAAL study. In 3921 patients, follow-up Hb levels were available at 365 (±90) days. In a subgroup of 224 patients, iron-related haematinics were assessed at baseline and during follow-up. At baseline, mean Hb was 12.6 ± 1.3 g/dL in women and 13.7 ± 1.4 g/dL in men. Hb < 11.5 g/dL was found in 9.3% of patients (women: 18.2%, men: 5.8%). Lower haemoglobin at baseline was clearly associated with female gender and the presence of diabetes, higher age and Killip class, lower body mass index, systolic blood pressure, total cholesterol, and the absence of current smoking (all P < 0.05). Higher Hb [per one standard deviation (SD)] related to lower mortality [adjusted hazard ratios (HR) 0.88; 95% confidence interval (CI) 0.83–0.93], CHF hospitalizations [HR 0.85 (0.77–0.93)], and all-cause hospitalizations [HR 0.96 (0.92–0.99), all P < 0.05]. In patients without anaemia at baseline, the anaemia incidence after 1 year of follow-up was 10.1% in women and 10.0% in men. Of patients with anaemia at baseline, 65% did not have anaemia at 12 months and 46% did not have anaemia at any time during follow-up (median 3.0 years, inter-quartile range, Q1–Q3 = 2.7–3.3 years). At 12 months, an increase in Hb (per SD) was related to lower mortality [HR 0.73 (0.63–0.85; P < 0.0001)] independent of baseline Hb and other clinical characteristics. Conclusion In patients with complicated AMIs, anaemia on admission and/or reductions in haemoglobin during follow-up are independent risk factors for mortality and hospitalization. Studies are warranted to determine whether correcting anaemia after a complicated AMI improves outcome.

87 citations


"Impact of Anemia on In-Hospital, On..." refers background or result in this paper

  • ...One of the main findings of the present study is that admission anemia during ACS was not only related to statistically significant higher in-hospital mortality,(2,8,18) but also predicted 1-month(1,3,11,18) and 1-year mortality.(5-7,9,23-26) The multiple regression models showed that this relationship persisted even after adjustment with GRACE risk score....

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  • ...Furthermore, the presence of anemia in ACS patients doubled the risk of CHF and cardiogenic shock.(4,5,8,9,18) However, these findings should be interpreted in the context of the study’s limitations....

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  • ...They were more likely to present with lower systolic blood pressure, higher heart rates, and higher Killip class and GRACE risk scores.(3,9,18,19) Sabatine et al(3) reported hypotension, higher heart rate, and Killip class in STEMI patients with anemia....

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Journal ArticleDOI
TL;DR: Lower levels of hemoglobin are associated with higher short-term mortality in patients with acute MI, and specific therapeutic strategies in anemic patients with MI should be further considered.

82 citations

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