A new treatment guideline for patients with acute myocardial infarction (AMI) recommends a liberal red cell transfusion strategy rather than a restrictive strategy. The guideline from the Association for the Advancement of Blood and Biotherapies, published in the Annals of Internal Medicine, is conditional because of the low certainty of evidence and consideration of blood supply conservation.

For hospitalized patients with AMI, a liberal strategy is recommended when the hemoglobin concentration is <10 g/dL. The restrictive strategy of 7-8 g/dL results in increased mortality, according to the guideline. The guideline recommendation is based on a meta-analysis of four randomized clinical trials by Monica B. Pagano, MD, and Simon J. Stanworth, MD, DPhil, et al.

The majority of the data for the analysis were gathered from the MINT and REALITY trials, with all four trials providing data for 4,311 patients. Results from the analysis found that the absolute risk difference estimated 1.2% fewer deaths with the liberal strategy. The pooled risk ratio for 30-day mortality was 0.87.

Researchers recommend that "clinicians should adopt mitigation strategies to reduce potential adverse events associated with a liberal transfusion strategy, and all transfusion decisions should incorporate the clinical context rather than solely the hemoglobin concentration."

In an accompanying editorial comment, Julianah O. Oguntala, MD, and Andrew T. Yan, MD, FACC, write that red blood cell transfusion in patients with AMI is overused, with potential harms outweighing benefits. "Given the potential complications of transfusion and the scarcity of the blood supply, more definitive data are needed. These guidelines mark only the beginning, not the culmination, of a worthwhile scientific inquiry. Meanwhile, clinicians should apply these guidelines with sound clinical judgment to tailor transfusion therapy in shared decision-making that incorporates individual patients' values and preferences."

"The recommendation in the AABB guideline for red blood cell transfusion when the hemoglobin value is less than 10 g/dL is consistent with the recommendation in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes, which gives a Class 2b recommendation ("may be reasonable") for blood transfusion to correct anemia in patients with an AMI," says Sunil V. Rao, MD, FACC, chair of the Writing Committee for the ACC/AHA guideline. "Both documents underscore the need for more data to guide transfusion decisions in this group of patients," he adds.