Clinical question: Does a liberal transfusion strategy decrease the risk of death or major ischemic events after major surgical operations in patients at high risk of cardiac events?
Background: Post-operative anemia is associated with an increase in short-term morbidity and mortality. Current guidelines recommend a restrictive transfusion strategy (hemoglobin under 7 g/dL) for most stable inpatients; however, recent trials have suggested harm from a restrictive strategy in those with acute myocardial infarction (MI). Little is known about the optimal transfusion strategy for patients undergoing major surgery who are at high cardiac risk.
Study design: Parallel, single-blind, randomized clinical superiority trial
Setting: 16 Veterans Affairs medical centers
Synopsis: 1,428 high-risk cardiac patients (ischemic heart disease, MI, peripheral arterial disease, or cerebrovascular accident) were randomized to a transfusion threshold of under 7 g/dL or under 10 g/dL after major non-cardiac surgery. Despite a mean hemoglobin difference of 2.0 g/dL five days after randomization, there was no difference in the primary composite outcome of all-cause death, MI, coronary revascularization, acute kidney failure, or ischemic stroke between the liberal (9.1%) and restrictive (10.1%) transfusion strategies at 90 days. There was a higher incidence of cardiac complications excluding MI in the restrictive group (9.9% versus 5.9%; risk ratio, 0.59; 99% CI, 0.36 to 0.98), which was primarily attributed to new arrhythmias and heart failure.
These findings are consistent with prior trials showing that more restrictive transfusion thresholds are generally safe and add to that literature by including high-risk cardiac patients. However, given the findings of increased cardiac complications when excluding MI and the recent MINT trial results suggesting more liberal transfusion strategies may be safer in acute MI, future research should focus on optimizing transfusion thresholds for inpatients across clinical settings.
Bottom line: A liberal post-operative transfusion strategy (hemoglobin <10) in high cardiac risk patients did not reduce postoperative death or major ischemic events.
Citation: Kougias P, et al. Liberal or restrictive postoperative transfusion in patients at high cardiac risk: the TOP randomized clinical trial. JAMA. 2025;334(24):2197-2207. doi:10.1001/jama.2025.20841.
Dr. Neustadtl is a hospitalist at the Cleveland Clinic, an associate program director in the Cleveland Clinic internal medicine residency program, and a clinical instructor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, all in Cleveland.