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From bench to practice: anaemia in acute coronary syndromes

Session presentations
Acute Coronary Syndromes (ACS)

Dr. M Kelm (Duesseldorf, DE) opened the session with a review of the role of red blood cells (RBC) in vascular function. He first explained briefly the physiology of RBC and the importance not only of their number but of their morphology, integrity and functionality, aspects that are influenced by risk factors such as hypertension, diabetes or diseases such as heart failure or ischemic heart disease. Then he explained how RBC participate in the regulation of vascular function through the regulation of blood levels of nitric oxide (NO) both participating in its synthesis and in its degradation. This dual action of the RBC on NO depends on the local conditions of the blood (oxygenation, acidosis) and plays an important role on the regulation of vascular tone, the aggregability of platelets and the deformability of RBCs. All these factors have an influence on blood flow, particularly in the microcirculation. Therefore, the importance of anemia goes well beyond the reduced oxygen transport capacity, and factors such as changes in the internal RBC signaling and outside signaling could play a role in the worse prognosis associated with anemia seen in patients with acute coronary syndromes (ACS).

Prof. JP Bassand (Besançon, FR) illustrated the importance of anaemia in the prognosis of several cardiac and non-cardiac diseases, including ACS, and showed the J-shape curve that represents the increase in risk associated with haemoglobin levels, being lowest in those with values between 14 and 15 gr/dL and highest in those with lowest levels or values >17 gr/dL. He mentioned that the prevalence of anaemia, as defined by the WHO, could be found in 15% of patients, and as many as 40% of elderly patients although the prevalence of severe anemia (<10 gr/dL) was much lower. Potential mechanisms by which anemia could influence prognosis were discussed (increased heart rate and cardiac output, imbalance between oxygen demand/supply, inflammatory response, negative impact of transfusions and comorbidities causing anaemia). He showed how anaemia is associated with higher rates of mortality, cardiac outcomes and non-cardiac outcomes both in the short- and the long-term and questioned whether the relationship between anaemia and worse prognosis was causal. He emphasized the importance of hospital-acquired anaemia in terms of prevalence (seen in more than half of patients in some series) and duration (persistent in 13% of patients). Finally, he reminded us of the relationship observed between anaemia and bleeding risk, and speculated about the potential links (occult GI bleed, inflammation, haemorrhagic diathesis, reduced platelet deposition in vessels).

Dr C Vrints (Antwerp, BE) reviewed the multiplicity of clinical definitions used to classify bleeding and explained the need for a standardized definition. He showed the BARC (Bleeding Academic Research Consortium) bleeding definitions, which range from Type 0 (no bleeding) to Type 5 (fatal bleeding) as a tool for reaching a uniform way of communicating bleedings. He explained tools for bleeding risk assessment, and showed the CRUSADE bleeding risk score in particular. A number of preventive strategies to reduce bleeding in ACS patients were reviewed, including the role of vascular closure devices (probably useful), the use of a radial approach as compared with the femoral approach in coronary angiography/interventions (definitely useful), and the reduction of the potency of antithrombotic treatments (to be individually tailored). Finally, he discussed the treatment of bleeding, emphasizing the risks of red blood cell transfusions in ACS and non-ACS patients and the need to be restrictive in its use.

Dr. SD Anker (Berlin, DE) started his presentation by underlining the importance of not using blood transfusion if no life-threatening anaemia is present and discussed the options to treat in patients with milder levels of anaemia. He reviewed the experiences with erythropoietin and darbepoietin in patients with anaemia and heart failure as well as the positive results on functional outcomes of the trials performed with intravenous or oral iron loading in heart failure patients with iron-deficiency anaemia. He showed the design of the ongoing RED-HF Trial, a study comparing darbepoietin alfa versus placebo in 2600 patients with heart failure and anaemia. He mentioned that none of these interventions should be applied to patients with ACS in the acute phase.




From bench to practice: anaemia in acute coronary syndromes

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.