Advertisement
Mayo Clinic Proceedings Home

Outcomes of Percutaneous Coronary Interventions in Patients With Anemia Presenting With Acute Coronary Syndrome

      Abstract

      Objective

      To study the influence of anemia on long-term outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).

      Patients and Methods

      The study included 5668 consecutive unique patients with acute coronary syndrome who underwent PCI at Mayo Clinic from January 1, 2004, through December 31, 2014. The patients were stratified on the basis of the presence (hemoglobin [Hgb] level, <13 g/dL in men and <12 g/dL in women) and severity (moderate to severe Hgb level, <11 g/dL in men and women) of pre-PCI anemia and compared with patients without anemia. The primary outcomes were in-hospital and long-term all-cause mortality after balancing baseline comorbidities using the inverse propensity weighting method.

      Results

      Unadjusted all-cause in-hospital mortality (4.6% [84 of 1831] vs 2.0% [75 of 3837]) and 5-year follow-up mortality (44.4% [509] vs 15.4% [323]) were higher in patients with anemia than in those without anemia (P<.001 for both). After applying inverse propensity weighting analysis, the all-cause in-hospital mortality (2.0% [37] vs 2.0% [75]; P=.85) and 5-year mortality (17.8% [203] vs 15.4% [323]; P=.05) were not significantly different between patients with and without anemia; however, there were higher rates of all-cause 5-year mortality in patients with moderate to severe anemia (22.3% [113] vs 15.4% [323]; P<.001) compared with patients without anemia. The trend in 5-year mortality was driven by increased noncardiac mortality in patients with anemia (10.2% [91] vs 7.1% [148]; P=.04) and moderate to severe anemia (10.4% [52] vs 7.1% [148]; P=.006) when compared with nonanemic patients.

      Conclusion

      After accounting for differences in risk profiles of anemic and nonanemic patients, anemia appeared to be an independent risk factor for increased long-term all-cause and noncardiac mortality.

      Abbreviations and Acronyms:

      ACS (acute coronary syndrome), Hgb (hemoglobin), IPW (inverse propensity weighting), MACE (major adverse cardiac events), MI (myocardial infarction), NSTEMI (non–ST-elevation MI), OR (odds ratio), PCI (percutaneous coronary intervention), RCT (randomized controlled trial), RR (risk ratio), STEMI (ST-elevation MI)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Mayo Clinic Proceedings
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with – acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines [published correction appears in J Am Coll Cardiol. 2014;64(24):2713–2714].
        J Am Coll Cardiol. 2014; 64: e139-e228
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: e78-e140
        • Anker S.D.
        • Voors A.
        • Okonko D.
        • et al.
        • OPTIMAAL Investigators
        Prevalence, incidence, and prognostic value of anaemia in patients after an acute myocardial infarction: data from the Optimaal trial.
        Eur Heart J. 2009; 30: 1331-1339
        • Sabatine M.S.
        • Morrow D.A.
        • Giugliano R.P.
        • et al.
        Association of hemoglobin levels with clinical outcomes in acute coronary syndromes.
        Circulation. 2005; 111: 2042-2049
        • Hasin T.
        • Sorkin A.
        • Markiewicz W.
        • Hammerman H.
        • Aronson D.
        Prevalence and prognostic significance of transient, persistent, and new-onset anemia after acute myocardial infarction.
        Am J Cardiol. 2009; 104: 486-491
        • Kurek T.
        • Lenarczyk R.
        • Kowalczyk J.
        • et al.
        Effect of anemia in high-risk groups of patients with acute myocardial infarction treated with percutaneous coronary intervention.
        Am J Cardiol. 2010; 105: 611-618
        • Al Falluji N.
        • Lawrence-Nelson J.
        • Kostis J.B.
        • Lacy C.R.
        • Ranjan R.
        Wilson AC; Myocardial Infarction Data Acquisition system (MIDAS #8) Study Group. Effect of anemia on 1-year mortality in patients with acute myocardial infarction.
        Am Heart J. 2002; 144: 636-641
        • Ang D.S.
        • Kao M.P.
        • Noman A.
        • Lang C.C.
        • Struthers A.D.
        The prognostic significance of early and late anaemia in acute coronary syndrome.
        QJM. 2012; 105: 445-454
        • Peterson E.D.
        • Dai D.
        • DeLong E.R.
        • et al.
        • NCDR Registry Participants
        Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588,398 procedures in the National Cardiovascular Data Registry.
        J Am Coll Cardiol. 2010; 55: 1923-1932
        • Mamas M.A.
        • Kwok C.S.
        • Kontopantelis E.
        • et al.
        Relationship between anemia and mortality outcomes in a national acute coronary syndrome cohort: insights from the UK Myocardial Ischemia National Audit Project registry.
        J Am Heart Assoc. 2016; 5: e003348
        • Lipsic E.
        • van der Horst I.C.
        • Voors A.A.
        • et al.
        Hemoglobin levels and 30-day mortality in patients after myocardial infarction [published correction appears in Int J Cardiol. 2007;123(1):74].
        Int J Cardiol. 2005; 100: 289-292
        • Tsujita K.
        • Nikolsky E.
        • Lansky A.J.
        • et al.
        Impact of anemia on clinical outcomes of patients with ST-segment elevation myocardial infarction in relation to gender and adjunctive antithrombotic therapy (from the HORIZONS-AMI trial).
        Am J Cardiol. 2010; 105: 1385-1394
        • Nikolsky E.
        • Aymong E.D.
        • Halkin A.
        • et al.
        Impact of anemia in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: analysis from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial.
        J Am Coll Cardiol. 2004; 44: 547-553
        • Giraldez R.R.
        • Sabatine M.S.
        • Morrow D.A.
        • et al.
        Baseline hemoglobin concentration and creatinine clearance composite laboratory index improves risk stratification in ST-elevation myocardial infarction.
        Am Heart J. 2009; 157: 517-524
        • Cooper H.A.
        • Rao S.V.
        • Greenberg M.D.
        • et al.
        Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study).
        Am J Cardiol. 2011; 108: 1108-1111
        • Levy P.S.
        • Quigley R.L.
        • Gould S.A.
        Acute dilutional anemia and critical left anterior descending coronary artery stenosis impairs end organ oxygen delivery.
        J Trauma. 1996; 41: 416-423
        • Willis P.
        • Voeltz M.D.
        Anemia, hemorrhage, and transfusion in percutaneous coronary intervention, acute coronary syndromes, and ST-segment elevation myocardial infarction.
        Am J Cardiol. 2009; 104: 34C-38C
        • Moscucci M.
        • Fox K.A.
        • Cannon C.P.
        • et al.
        Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE).
        Eur Heart J. 2003; 24: 1815-1823
        • Manoukian S.V.
        • Feit F.
        • Mehran R.
        • et al.
        Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial.
        J Am Coll Cardiol. 2007; 49: 1362-1368
        • Nikolsky E.
        • Mehran R.
        • Sadeghi H.M.
        • et al.
        Prognostic impact of blood transfusion after primary angioplasty for acute myocardial infarction: analysis from the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trial.
        J Am Coll Cardiol Intv. 2009; 2: 624-632
        • Rao S.V.
        • Jollis J.G.
        • Harrington R.A.
        • et al.
        Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.
        JAMA. 2004; 292: 1555-1562
        • Voeltz M.D.
        • Patel A.D.
        • Feit F.
        • Fazel R.
        • Lincoff A.M.
        • Manoukian S.V.
        Effect of anemia on hemorrhagic complications and mortality following percutaneous coronary intervention.
        Am J Cardiol. 2007; 99: 1513-1517
        • Mehran R.
        • Pocock S.
        • Nikolsky E.
        • et al.
        Impact of bleeding on mortality after percutaneous coronary intervention: results from a patient-level pooled analysis of the REPLACE-2 (Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events), ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy), and HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trials.
        J Am Coll Cardiol Intv. 2011; 4: 654-664
        • McKechnie R.S.
        • Smith D.
        • Montoye C.
        • et al.
        • Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)
        Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention.
        Circulation. 2004; 110: 271-277
        • Lawler P.R.
        • Filion K.B.
        • Dourian T.
        • Atallah R.
        • Garfinkle M.
        • Eisenberg M.J.
        Anemia and mortality in acute coronary syndromes: a systematic review and meta-analysis.
        Am Heart J. 2013; 165: 143-153.e5
        • Valeur N.
        • Nielsen O.W.
        • McMurray J.J.
        • Torp-Pedersen C.
        • Køber L.
        • TRACE Study Group
        Anaemia is an independent predictor of mortality in patients with left ventricular systolic dysfunction following acute myocardial infarction.
        Eur J Heart Fail. 2006; 8: 577-584
        • Singh M.
        • Lennon R.J.
        • Holmes Jr., D.R.
        • Bell M.R.
        • Rihal C.S.
        Correlates of procedural complications and a simple integer risk score for percutaneous coronary intervention.
        J Am Coll Cardiol. 2002; 40: 387-393
        • Singh M.
        • Rihal C.S.
        • Lennon R.J.
        • Spertus J.
        • Rumsfeld J.S.
        • Holmes Jr., D.R.
        Bedside estimation of risk from percutaneous coronary intervention: the new Mayo Clinic risk scores [published correction appears in Mayo Clin Proc. 2013;88(5):532].
        Mayo Clin Proc. 2007; 82: 701-708
      1. Nutritional anaemias: report of a WHO scientific group.
        World Health Organ Tech Rep Ser. 1968; 405: 5-37
        • Sachdev M.
        • Sun J.L.
        • Tsiatis A.A.
        • Nelson C.L.
        • Mark D.B.
        • Jollis J.G.
        The prognostic importance of comorbidity for mortality in patients with stable coronary artery disease.
        J Am Coll Cardiol. 2004; 43: 576-582
        • Spoon D.B.
        • Psaltis P.J.
        • Singh M.
        • et al.
        Trends in cause of death after percutaneous coronary intervention.
        Circulation. 2014; 129: 1286-1294
        • Raphael C.E.
        • Spoon D.B.
        • Bell M.R.
        • et al.
        Effect of preprocedural thrombocytopenia on prognosis after percutaneous coronary intervention.
        Mayo Clin Proc. 2016; 91: 1035-1044
        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • D'Agostino Jr., R.B.
        Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group.
        Stat Med. 1998; 17: 2265-2281
        • Wu W.C.
        • Rathore S.S.
        • Wang Y.
        • Radford M.J.
        • Krumholz H.M.
        Blood transfusion in elderly patients with acute myocardial infarction.
        N Engl J Med. 2001; 345: 1230-1236
        • Kunadian V.
        • Mehran R.
        • Lincoff A.M.
        • et al.
        Effect of anemia on frequency of short- and long-term clinical events in acute coronary syndromes (from the Acute Catheterization and Urgent Intervention Triage Strategy Trial).
        Am J Cardiol. 2014; 114: 1823-1829
        • Alexander K.P.
        • Chen A.Y.
        • Wang T.Y.
        • et al.
        • CRUSADE Investigators
        Transfusion practice and outcomes in non-ST-segment elevation acute coronary syndromes.
        Am Heart J. 2008; 155: 1047-1053
        • Singh M.
        • Rihal C.S.
        • Roger V.L.
        • et al.
        Comorbid conditions and outcomes after percutaneous coronary intervention.
        Heart. 2008; 94: 1424-1428
        • Antman E.M.
        • Cohen M.
        • Bernink P.J.
        • et al.
        The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.
        JAMA. 2000; 284: 835-842
        • Liu Y.
        • Yang Y.M.
        • Zhu J.
        • Tan H.Q.
        • Liang Y.
        • Li J.D.
        Anaemia and prognosis in acute coronary syndromes: a systematic review and meta-analysis.
        J Int Med Res. 2012; 40: 43-55
        • Afilalo J.
        • Lauck S.
        • Kim D.H.
        • et al.
        Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study.
        J Am Coll Cardiol. 2017; 70: 689-700
        • Singh M.
        • Rihal C.S.
        • Lennon R.J.
        • Spertus J.A.
        • Nair K.S.
        • Roger V.L.
        Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization.
        Circ Cardiovasc Qual Outcomes. 2011; 4: 496-502
        • Rao S.V.
        • O'Grady K.
        • Pieper K.S.
        • et al.
        A comparison of the clinical impact of bleeding measured by two different classifications among patients with acute coronary syndromes.
        J Am Coll Cardiol. 2006; 47: 809-816
        • Mehran R.
        • Rao S.V.
        • Bhatt D.L.
        • et al.
        Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium.
        Circulation. 2011; 123: 2736-2747
        • Chatterjee S.
        • Wetterslev J.
        • Sharma A.
        • Lichstein E.
        • Mukherjee D.
        Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis.
        JAMA Intern Med. 2013; 173: 132-139
        • Carson J.L.
        • Grossman B.J.
        • Kleinman S.
        • et al.
        • Clinical Transfusion Medicine Committee of the AABB
        Red blood cell transfusion: a clinical practice guideline from the AABB.
        Ann Intern Med. 2012; 157: 49-58
        • Carson J.L.
        • Stanworth S.J.
        • Roubinian N.
        • et al.
        Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion.
        Cochrane Database Syst Rev. 2016; 10: CD002042
        • Qaseem A.
        • Humphrey L.L.
        • Fitterman N.
        • Starkey M.
        • Shekelle P.
        Clinical Guidelines Committee of the American College of Physicians. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians [published correction appears in Ann Intern Med. 2014;160(2):144].
        Ann Intern Med. 2013; 159: 770-779
        • Roffi M.
        • Patrono C.
        • Collet J.P.
        • et al.
        • ESC Scientific Document Group
        2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2016; 37: 267-315