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April 11-13, 2019
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New ACP guideline presents evidence-based recommendations
for treating anemia in patients with heart disease
PHILADELPHIA, December 3, 2013 -- Red blood cell (RBC)
transfusions should be restricted to those individuals with severe
anemia in patients with heart disease, the American College of
Physicians (ACP) recommends in a new
clinical practice guideline published today in Annals of
Internal Medicine, ACP's flagship journal.
ACP also recommends against using erythropoiesis-stimulating
agents (ESAs) in patients with mild to moderate anemia and
congestive heart failure (CHF) or coronary artery disease (CHD)
because the harms, including increased risks of thromboembolic
events and stroke rates, outweigh the benefits.
"Transfusion may benefit patients with lower hemoglobin levels,
less than 7 - 8 g/dL, but the evidence suggests that red blood cell
transfusion for milder anemia in patients with heart disease does
not improve mortality," said Molly Cooke, MD, FACP, president, ACP.
"The evidence evaluating the impact of ESAs in patients with heart
disease did not show improved health outcomes."
ACP's guideline also includes advice to help physicians practice
high value care.
Anemia is common in patients with heart disease. Anemia is
present in approximately one-third of patients with CHF and 10 to
20 percent of patients with CHD. Anemia can worsen cardiac function
and is associated with poor outcomes, including increased risk of
hospitalization, decreased exercise capacity, and poor quality of
life. It is unclear whether anemia directly and independently leads
to these poor outcomes or whether it reflects a more severe
Because of the poor outcomes associated with anemia in patients
with heart disease, a number of treatments have been tried,
including RBC transfusions, ESAs, and iron replacement. Overall, it
is unclear whether these strategies improve outcomes.
Emerging evidence shows short term benefit of one form of
intravenous iron in patients with CHF and low ferritin (less than
100), but ACP found evidence lacking on long-term outcomes.
Additionally, the effect of oral iron and how it compares to
intravenous iron for treating anemic patients with heart disease is
To develop the guideline, ACP looked at the evidence to answer
three questions related to the treatment of anemia in patients with
CHF or CHD:
Annals of Internal Medicine also published a
summary for patients.
Candidate topics come from surveys of ACP members, other
clinicians, ACP's Clinical Guidelines Committee members, and other
committees and governance of ACP. In selecting a topic, the
Clinical Guidelines Committee considers the following criteria:
effect of the condition on morbidity and mortality, prevalence of
the condition, whether effective health care is available, areas of
uncertainty and evidence that current performance does not meet
best practices, cost of the condition, relevance to internal
medicine, and the likelihood that evidence is available to develop
recommendations. ACP's methodology
paper has more information about the guideline process.
About the American College of Physicians
The American College of Physicians is the largest
medical specialty organization and the second-largest physician
group in the United States. ACP members include 137,000 internal
medicine physicians (internists), related subspecialists, and
medical students. Internal medicine physicians are specialists who
apply scientific knowledge and clinical expertise to the diagnosis,
treatment, and compassionate care of adults across the spectrum
from health to complex illness. Follow ACP on Twitter and Facebook.