matthew w. sherwood, yongfei wang, jeptha p. curtis, eric d. peterson, sunil v. rao
DESCRIPTION
Patterns of red blood cell transfusion use and outcomes in patients undergoing percutaneous coronary intervention in contemporary clinical practice: Insights from the NCDR ®. Matthew W. Sherwood, Yongfei Wang, Jeptha P. Curtis, Eric D. Peterson, Sunil V. Rao. Disclosures. - PowerPoint PPT PresentationTRANSCRIPT
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Patterns of red blood cell transfusion use and outcomes in patients undergoing percutaneous coronary intervention in contemporary clinical practice: Insights
from the NCDR®
Matthew W. Sherwood, Yongfei Wang, Jeptha P. Curtis, Eric D.
Peterson, Sunil V. Rao
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DisclosuresMatthew W. Sherwood – None Yongfei Wang – NoneJeptha P. Curtis – None Eric D. Peterson – Research Support >10K :
Eli Lilly, Janssen Pharm., PI of Data Analytic Center for ACCSunil V. Rao – Research grants - Ikaria, sanofi-aventis;
Consultant/honoraria - The Medicines Co, Terumo Medical, ZOLL, Astra Zeneca, Daiichi Sankyo Lilly, Janssen
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Funding Support and Disclaimer This research was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR). The views expressed in this presentation represent those of the author(s), and do not necessarily represent the official views of the NCDR or its associated professional societies identified at www.ncdr.com.
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Background• Prior studies have shown that there is marked
variation in the use of red blood cell transfusion (RBCT) among patients with acute coronary syndromes
• Contemporary post-procedure RBCT patterns in patients undergoing PCI are unclear
• Documenting variation in RBCT practice is important since RBCT has been independently associated with morbidity and mortality in patients with ischemic heart disease
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Objectives• To determine the variability in use of RBCT in
hospitals across the United States• To determine patient factors associated with
RBCT• To determine whether RBCT has an
independent association with patient outcomes– Is an association of transfusion with outcomes
independent of bleeding
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Methods• Database – NCDR® Cath-PCI® database• Patients – 1,323,965 patients undergoing PCI
at 1282 hospitals between 7/2009-9/2011 • Exclusions
– patients who underwent in-hospital CABG– More then 1 PCI during hospital stay– Missing data on bleeding events, procedural
complications, d/c status
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Outcomes and Definitions• Primary – Transfusion rates• Secondary – Clinical Outcomes
– MI– Stroke– In-hospital Death
• Definition – Bleeding Events– Hemoglobin drop of ≥3 g/dL– Transfusion of whole blood or packed red blood cells– Procedural intervention/surgery at the bleeding site to
reverse/stop or correct the bleeding
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Analyses• Rates of transfusion by site were determined and
then risk adjusted rates were calculated• Patient clinical characteristics and in-hospital
outcomes were compared between patients who did and did not receive RBCT
• Logistic regression was used to determine the adjusted association between RBCT and in-hospital death, MI, or stroke– Secondary analyses performed to determine whether any
adverse effect of transfusion was independent of bleeding events
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Patient CharacteristicsPatient Characteristics
(%)
Without RBCTN=1294710
With RBCTN=29255
Age (mean, SD) 64.5 (12.1) 70.5 (12.1)
Gender (% Female) 32.2 57.4
HTN 81.8 86.2
Diabetes 34.1 44.3
ESRD on dialysis 2.2 7.8
Prior MI 29.9 32.4
Prior CHF 11.4 26.0
P values for all comparisons <0.001
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Transfusion Pattern by Hgb
<=7 8 9 10 11 12 13 14 >=150
10
20
30
40
50
60
70
80
90
100
With bleedingWithout bleeding
Post Procedure Hgb
% u
se o
f RBC
T
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Transfusion Rates by hospital site
0 1 2 3 4 5 6 7 >=80
5
10
15
20
25
30
% Patient receiving RBCT
% o
f Hos
ptia
ls
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Adjusted transfusion rates0
5010
015
020
025
0N
umbe
r of H
ospi
tals
0 2 4 6 8 10Risk-Standardized Rate of Patients Receiving RBCT(%)
Num
ber o
f hos
pita
ls
Risk adjusted for all variables in the established NCDR mortality and bleeding models
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Outcomes by transfusion statusPatient Outcomes
(%)
Without RBCTN=1294710
With RBCTN=29255
MI 1.9 4.8
Stroke 0.2 1.9
CHF 0.7 9.6
Cardiogenic Shock 0.7 9.9
In-hospital Death 1.1 11.9
Bleeding Events 0.9 36.2
Access Site bleeding 0.5 12.3
Non-Access Site bleeding 0.4 23.9
P values for all comparisons <0.001
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Independent assoc. of RBCT with outcomes
Patient Outcomes Odds Ratios
MI, Stroke, In-hospital Death 2.18 (2.09-2.26)
MI 1.96 (1.85-2.08)
Stroke 3.92 (3.53-4.35)
In-hospital Death 2.02 (1.92-2.13)
Model includes all variable in the established NCDR mortality model; Reference is no transfusion
All patients
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Patient Outcomes Odds Ratios
MI, Stroke, In-hospital Death 1.95 (1.86-2.05)
MI 1.71 (1.58-1.85)
Stroke 4.07 (3.60-4.60)
In-hospital Death 1.73 (1.62-1.84)
Model includes all variable in the established NCDR mortality model; Reference is no transfusion
Independent assoc. of RBCT with outcomesPatients without bleeding
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Limitations• Data is observational thus events are
reported, not adjudicated
• Temporal relationship between Hct, transfusion, and events is uncertain
• Cannot infer causality
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Conclusions• Considerable variation in transfusion practices
exists across the U.S., and persists after adjustment for patient differences
• Transfusion patterns by Hgb level are different in patient with bleeding vs. without bleeding
• RBCT is independently associated with adverse cardiac events in patients undergoing PCI– This association still holds in patients without
bleeding events
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Clinical Implications• Our results are consistent with prior reports
demonstrating the potential hazard associated with RBCT among ACS patients
• Randomized trials of transfusion strategies are needed in patients undergoing PCI to guide clinical practice
• Until these data are available, operators should continue to adopt practices that reduce the risk for bleeding and transfusion