What is the target hemoglobin (Hb) level in patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) and Gastrointestinal Bleeding (GIB)?

Target Hemoglobin Level in NSTEMI Patients with GI Bleeding

For patients with NSTEMI and gastrointestinal bleeding, a liberal transfusion strategy targeting a hemoglobin level around 10 g/dL is recommended over a restrictive strategy targeting above 7-8 g/dL. 1

Evidence-Based Recommendations

• The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes provides the most recent evidence on this topic, based on the MINT (Myocardial Ischemia and Transfusion) trial 1
• The MINT trial randomized 3,504 patients with acute STEMI or NSTEMI and anemia (Hb <10 g/dL) to either a restrictive transfusion strategy (transfusing if Hb <7-8 g/dL) or a liberal transfusion strategy (transfusing if Hb <10 g/dL) 1
• While the primary outcome difference didn't reach statistical significance, cardiac death occurred in 5.5% of patients in the restrictive strategy versus 3.2% in the liberal strategy (relative risk 1.74,95% CI 1.26-2.40) 1

Management Algorithm for NSTEMI with GIB

Initial Assessment

• Assess bleeding severity and hemodynamic stability 1
• Calculate CRUSADE bleeding risk score to estimate risk of major bleeding 2
• Monitor hemoglobin levels frequently 1

Transfusion Strategy

• For hemodynamically stable patients with NSTEMI and GIB:
  • Target hemoglobin around 10 g/dL (liberal strategy) 1
  • This approach may provide short-term clinical benefit over a restrictive strategy 1
• For hemodynamically unstable patients:
  • No restrictions apply to transfusion thresholds 1
  • Immediate transfusion is indicated regardless of hemoglobin level 1

Antithrombotic Management

• Consider temporary interruption of antiplatelet and anticoagulant therapies in case of major bleeding that cannot be controlled with specific hemostatic measures 1
• Resume antithrombotic therapy as soon as hemostasis is achieved 1
• Use weight-based and renal function-adjusted dosing of anticoagulants to decrease bleeding risk 1

Special Considerations

• The 2014 AHA/ACC guideline previously recommended against routine blood transfusion in hemodynamically stable patients with NSTE-ACS and hemoglobin levels >8 g/dL 1
• However, the more recent 2025 guideline now suggests a liberal transfusion strategy targeting around 10 g/dL based on newer evidence 1
• Patients with NSTEMI and anemia have more extensive coronary artery disease, receive fewer evidence-based therapies, and have increased mortality 3
• Lower hemoglobin levels are independently associated with increased mortality, with a 7% increase for each 1 g/dL decrease in hemoglobin below 15 g/dL 3

Potential Pitfalls

• Avoid unnecessary blood transfusions in patients with hemoglobin >10 g/dL as transfusion has been associated with detrimental effects including excess death, MI, and lung infections 1, 4
• Be cautious with antiplatelet therapy management - complete cessation increases risk of stent thrombosis, while continuation increases bleeding risk 5
• Consider co-administration of proton pump inhibitors with antithrombotic agents in patients at increased risk of gastrointestinal hemorrhage 1
• Avoid excess dosing of antithrombotic agents, particularly in patients at high risk for both bleeding and mortality 2

Conclusion

The most recent evidence from the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline supports a liberal transfusion strategy targeting a hemoglobin level around 10 g/dL in patients with NSTEMI and gastrointestinal bleeding, as this approach may reduce cardiac mortality compared to a more restrictive strategy targeting hemoglobin above 7-8 g/dL 1.