Red Cell Transfusion in Acute Myocardial Infarction: AABB International Clinical Practice Guidelines

  • Pagano, Monica B. MD
  • Stanworth, Simon J. MD, DPhil
  • Dennis, Jane PhD
  • Bakhtary, Sara MD
  • Callum, Jeannie MD
  • Carson, Jeffrey L. MD
  • Cohn, Claudia S. MD, PhD
  • Dubon, Allan MLS
  • Grossman, Brenda J. MD, MPH
  • Gupta, Gaurav K. MD, PhD
  • Hess, Aaron S. MD, PhD
  • Jacobson, Jessica L. MD
  • Kaplan, Lewis J. MD
  • Karkouti, Keyvan MD
  • Lin, Yulia MD
  • Metcalf, Ryan A. MD
  • Miles, Lachlan F. MBBS, PhD
  • Mills, Nicholas L. MBChB, PhD
  • Murphy, Colin H. MD
  • Pavenski, Katerina MD
  • Prochaska, Micah T. MD
  • Raval, Jay S. MD
  • Salazar, Eric MD, PhD
  • Saifee, Nabiha H. MD, PhD
  • Shah, Kevin MD
  • Steg, Gabriel P. MD
  • Tobian, Aaron A.R. MD, PhD
  • So-Osman, Cynthia MD, PhD
  • Walsh, Timothy MD
  • Waters, Jonathan MD
  • Wood, Erica M. MD
  • Zantek, Nicole D. MD, PhD
  • Guyatt, Gordon H. MD

  • Department of Laboratory Medicine and Pathology, Department of Medicine, University of Washington, Seattle, Washington (M.B.P.)

    Radcliffe Department of Medicine, University of Oxford, and Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom, and International Collaboration for Transfusion Medicine Guidelines (ICTMG), Canada (S.J.S.)

    Musculoskeletal Research Unit, Southmead Hospital, University of Bristol, Bristol, United Kingdom (J.D.)

    Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California (S.B.)

    Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada (J.C.)

    Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J-L.C.)

    Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota (C.S.C., N.D.Z.)

    Patient Partner, Salt Lake City, Utah (A.D.)

    Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri (B.J.G.)

    Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (G.K.G.)

    Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin (A.S.H.)

    Department of Pathology, New York University Grossman School of Medicine, New York NYC Health + Hospitals/Bellevue, New York, New York (J-L.J.)

    Department of Surgery, Division of Trauma, Surgical Critical Care and Surgical Emergencies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (L-J.K.)

    University Health Network, Sinai Health, and Women's College Hospital Senior Scientist, Toronto General Hospital Research Institute, Toronto, Ontario, Canada (K.K.)

    Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada (Y.L.)

    Department of Pathology, University of Utah, Salt Lake City, Utah (R.A.M.)

    Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia, and Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia (L.F.M.)

    BHF Centre for Cardiovascular Science, University of Edinburgh, and Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (N.L.M.)

    Pathology Associates of Albuquerque, Albuquerque, New Mexico (C.H.M.)

    Department of Laboratory Medicine and Pathobiology, University of Toronto and St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada, and International Collaboration for Transfusion Medicine Guidelines (ICTMG), Canada (K.P.)

    Department of Medicine, University of Chicago, Chicago, Illinois (M.T.P.)

    Department of Pathology and Laboratory Medicine, The Robert Larner, M.D. College of Medicine at The University of Vermont and The University of Vermont Medical Center, Burlington, Vermont (J.S.R.)

    Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas (E.S.)

    Department of Laboratory Medicine and Pathology, Seattle Children's Hospital and University of Washington, Seattle, Washington (N.H.S.)

    Department of Internal Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah (K.S.)

    Université Paris-Cité, INSERM_U1148, and Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, Paris, France (P.G.S.)

    Department of Pathology, Johns Hopkins University, Baltimore, Maryland (A.A.R.T.)

    Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands, and Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands (C.S.-O.)

    Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (T.W.)

    Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (J.W.)

    Department of Haematology, Monash Health, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia (E.M.W.)

    Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada (G.H.G.).

Financial Support: Support for guideline development was provided by the Association for the Advancement of Blood & Biotherapies, Bethesda, Maryland.

Disclosures: Disclosure forms are available with the article online.

Corresponding Authors: Monica B. Pagano, MD, Professor, Laboratory Medicine and Pathology, University of Washington, Box 357110, 1959 NE Pacific Street, Seattle, WA 98195 (e-mail, e-mail; [email protected]); Simon J. Stanworth, MD, DPhil, NHS Blood and Transplant, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9BQ, United Kingdom (e-mail, e-mail; [email protected]).

Author Contributions: Conception and design: M.B. Pagano, S.J. Stanworth, J. Dennis, G.H. Guyatt.

Analysis and interpretation of the data: M.B. Pagano, S.J. Stanworth, J. Dennis, S. Bakhtary, J. Callum, J.L. Carson, C.S. Cohn, A. Dubon, B.J. Grossman, A.S. Hess, J.L. Jacobson, L.J. Kaplan, Y. Lin, R.A. Metcalf, L.F. Miles, N.L. Mills, K. Pavenski, M.T. Prochaska, J.S. Raval, T. Walsh, J. Waters, N.D. Zantek, G.H. Guyatt.

Drafting of the article: M.B. Pagano, S.J. Stanworth, J.L. Carson, A. Dubon, B.J. Grossman, A.S. Hess, L.J. Kaplan, N.L. Mills, C.H. Murphy, J. Waters.

Critical revision for important intellectual content: M.B. Pagano, S.J. Stanworth, J. Callum, J.L. Carson, B.J. Grossman, G.K. Gupta, A.S. Hess, L.J. Kaplan, K. Karkouti, Y. Lin, R.A. Metcalf, L.F. Miles, N.L. Mills, C.H. Murphy, M.T. Prochaska, E. Salazar, N.H. Saifee, K. Shah, P.G. Steg, A.A.R. Tobian, C. So-Osman, T. Walsh, J. Waters, E.M. Wood.

Final approval of the article: M.B. Pagano, S.J. Stanworth, J. Dennis, S. Bakhtary, J. Callum, J.L. Carson, C.S. Cohn, A. Dubon, B.J. Grossman, G.K. Gupta, A.S. Hess, J.L. Jacobson, L.J. Kaplan, K. Karkouti, Y. Lin, R.A. Metcalf, L.F. Miles, N.L. Mills, C.H. Murphy, K. Pavenski, M.T. Prochaska, J.S. Raval, E. Salazar, N.H. Saifee, K. Shah, P.G. Steg, A.A.R. Tobian, C. So-Osman, T. Walsh, J. Waters, E.M. Wood, N.D. Zantek, G.H. Guyatt.

Administrative, technical, or logistic support: J. Dennis, C.S. Cohn, E.M. Wood.

Collection and assembly of data: M.B. Pagano, S.J. Stanworth, J. Dennis, J.L. Carson, P.G. Steg, J. Waters.

This article was published at Annals.org on 19 August 2025.

*Drs. Pagano and Stanworth contributed equally to this manuscript.

Annals of Internal Medicine - Latest Publish Ahead of Print, August 19, 2025. | DOI: 10.7326/ANNALS-25-00706

Description:

Optimal transfusion strategies for patients with acute myocardial infarction (AMI) are uncertain. The aim of this guideline is to provide recommendations for red blood cell transfusion in patients with AMI.

Methods:

These guidelines are based on evidence from randomized controlled trials of patients presenting with AMI and assigned to 2 different transfusion strategies (restrictive or liberal) based on hemoglobin concentrations or hematocrit levels before receipt of a transfusion. A meta-analysis of eligible trials was performed using Cochrane methods. The international panel followed GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods to summarize evidence and formulate recommendations. This guideline's primary perspective is that of the patient, including medical, financial, and psychological effects, with secondary consideration of health care system issues, particularly conservation of the limited and costly blood supply.

Recommendation:

For hospitalized patients with AMI, the panel suggests a liberal red cell transfusion strategy when the hemoglobin concentration is less than 10 g/dL (conditional recommendation, low-certainty evidence). A restrictive strategy of 7 to 8 g/dL may result in increased mortality in patients with AMI. The direction of the recommendation for the liberal strategy was based on the great importance of mortality for patients. The conditional recommendation was based on the low certainty of evidence and the competing consideration of blood supply conservation. Clinicians should adopt mitigation strategies to reduce potential adverse events associated with a liberal transfusion strategy, and all transfusion decisions should incorporate the clinical context rather than solely the hemoglobin concentration.

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