A liberal transfusion strategy following major vascular or general surgery did not significantly improve outcomes at 90 days post procedure in patients at high risk of a cardiac event when compared to a restrictive strategy, according to findings from the TOP trial presented at AHA 2025 and simultaneously published in JAMA.

Panos Kougias, MD, MSc, et al., included 1,428 veterans (mean age, 70 years; 98% male, 19% Black, 4% Hispanic) undergoing major vascular or general surgery between February 2018 and March 2023 with postoperative hemoglobin <10 g/dL, randomized to either liberal or restrictive transfusion strategy.

The primary outcome was a composite of all-cause death, myocardial infarction (MI), coronary revascularization, acute kidney injury or ischemic stroke at 90 days. The primary outcome was observed in 9.1% of patients in the liberal strategy group and 10.1% in the restrictive group (relative risk, 0.90; 95% CI, 0.65-1.24).

A secondary outcome of cardiac complications other than MI – including arrythmias, heart failure and nonfatal cardiac arrest – was seen in 5.6% of patients in the liberal group and 9.9% of patients in the restrictive group (relative risk, 0.59; 99% CI, 0.36-0.98).

“No significant differences were observed in the primary composite outcome, most secondary outcomes or prespecified subgroup analyses for age and cardiac risk level,” write the authors. “However, compared with the liberal group, more patients in the restrictive group developed cardiac complications other than [MI].”

In an accompanying editorial comment, Jeremy W. Jacobs, MD, MHS, and Evan M. Bloch, MBChB, MS, add that “although liberal transfusion did not significantly reduce the primary outcome, the findings suggest that individualized approaches that integrate both clinical (e.g., cardiac risk profile, symptom burden and postoperative course) in concert with laboratory indexes (e.g., hemoglobin and biomarkers such as brain natriuretic peptide) – rather than universal thresholds alone – may better serve this complex population.”

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Interventions and Vascular Medicine

Keywords: AHA Annual Scientific Sessions, AHA25, Cardiac Surgical Procedures, Aneurysm