From the Guidelines
Transfusion should be considered in stroke patients at a hemoglobin concentration of 8 g/dL or less or for symptoms such as chest pain, orthostatic hypotension, or congestive heart failure, as this approach is supported by the FOCUS trial and other studies 1, 2, 3, 4. The FOCUS trial, which is one of the key studies guiding transfusion practices in patients with cardiovascular disease, including those with stroke, found no significant difference in outcomes between a restrictive and liberal transfusion strategy in terms of functional recovery, mortality, or hospital complications such as myocardial infarction, congestive heart failure, stroke, infection, or thromboembolism 1. Key points from the evidence include:
- The FOCUS trial allowed patients in the restrictive group to receive transfusions if they were symptomatic, even if their hemoglobin level was above 8 g/dL, highlighting the importance of symptoms in guiding transfusion decisions 1.
- The trial found that patients with symptoms were more likely to receive transfusions in the restrictive group than in the liberal group, but there was no significant difference in outcomes between the two groups 1.
- Other studies, such as the TRICC trial, have also compared restrictive and liberal transfusion strategies, although their findings may not be directly applicable to stroke patients due to differences in patient populations and study designs 2, 3, 4.
- The American Association of Blood Banks (AABB) recommends a restrictive transfusion strategy, with transfusion considered at a hemoglobin concentration of 8 g/dL or less or for symptoms, based on the available evidence 2, 3, 4. Overall, the evidence suggests that a restrictive transfusion strategy, with consideration of symptoms and a hemoglobin threshold of 8 g/dL, is a reasonable approach for managing stroke patients, although the quality of evidence is moderate and the strength of recommendation is weak 1, 2, 3, 4.
From the Research
Transfusion Trial Highlights in Stroke Patients
- The optimal hemoglobin threshold for red blood cell transfusion in stroke patients is still unknown 5, 6, 7, 8
- Studies have compared restrictive and liberal transfusion strategies, with restrictive strategies using lower hemoglobin thresholds (7-8 g/dL) and liberal strategies using higher thresholds (9-10 g/dL) 7, 8
- Restrictive transfusion strategies have been shown to reduce the risk of receiving a red blood cell transfusion by 41-43% across various clinical contexts, including stroke patients 7, 8
- However, restrictive transfusion strategies have not been shown to increase or decrease the risk of 30-day mortality or other clinical outcomes, such as cardiac events, myocardial infarction, or stroke, compared to liberal transfusion strategies 7, 8
- The safety of restrictive transfusion thresholds in certain clinical subgroups, including stroke patients, remains uncertain and requires further research 7, 8
Key Findings
- A survey of ICU physicians found that 54% used an Hb threshold of 7-8 g/dL to initiate RBC transfusion after acute brain injury, while 46% used a higher threshold 6
- A study of patients with severe ischemic stroke found that low hemoglobin levels and transfusion activity were associated with prolonged NICU stay and duration of mechanical ventilation, but not with mortality or long-term outcome 9
- A systematic review of 48 trials found that restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts, including stroke patients 8
Implications
- The findings of these studies suggest that restrictive transfusion strategies may be safe and effective in reducing the risk of red blood cell transfusion in stroke patients, but further research is needed to confirm these results 7, 8
- The optimal hemoglobin threshold for red blood cell transfusion in stroke patients remains uncertain and may depend on individual patient factors, such as the severity of the stroke and the presence of comorbidities 5, 6, 7, 8