From the Research
The 2025 guidelines for blood transfusion in Acute Coronary Syndrome (ACS) patients recommend a restrictive transfusion strategy, with transfusion generally indicated only when hemoglobin levels fall below 7-8 g/dL, rather than using higher thresholds. For most hemodynamically stable ACS patients, transfusion should be withheld until hemoglobin drops below 7 g/dL. In patients with ongoing ischemia, hemodynamic instability, or significant cardiovascular disease, a slightly higher threshold of 8 g/dL may be appropriate. Single-unit transfusions are preferred, followed by reassessment of clinical status and hemoglobin levels before additional units are given. This restrictive approach is based on evidence that liberal transfusion strategies (maintaining hemoglobin >10 g/dL) have not shown benefit and may increase risks including volume overload, inflammatory responses, and thrombotic complications, as suggested by the most recent study 1. Each unit of packed red blood cells typically increases hemoglobin by approximately 1 g/dL. During transfusion, patients should be monitored for vital sign changes, chest pain, dyspnea, or other signs of transfusion reactions or cardiac decompensation. The guidelines emphasize that transfusion decisions should ultimately be individualized based on the patient's overall clinical condition, comorbidities, and ongoing ischemic risk, as also supported by other recent studies 2. Some older studies, such as 3 and 4, have suggested different approaches, but these are less relevant given the more recent evidence. Additionally, a review of current clinical evidence and guidelines 5 highlights the need for personalized transfusion therapy, considering an individual patient's age, clinical status, and comorbidities. However, the most recent and highest quality study 1 provides the strongest evidence for the recommended approach.
Key considerations for transfusion in ACS patients include:
- Hemoglobin threshold for transfusion: 7-8 g/dL
- Single-unit transfusions preferred
- Reassessment of clinical status and hemoglobin levels before additional units are given
- Monitoring for transfusion reactions or cardiac decompensation
- Individualized transfusion decisions based on patient's clinical condition, comorbidities, and ongoing ischemic risk.