To the Editor: We are concerned by the conclusion of the study by Dr Rao and colleagues1 that use of blood transfusion in patients with acute coronary syndromes is associated with higher mortality. The results are inconsistent with previous studies of transfusion use in patients with ischemic heart disease. Our previous study2 of 78 974 Medicare beneficiaries hospitalized with myocardial infarction (which used medical record data, not administrative billing data as was suggested in the article) demonstrated a mortality reduction associated with transfusion use in patients with a hematocrit of 30% or less. Moreover, our findings are similar to an earlier report of a transfusion-associated survival benefit in patients with ischemic heart disease.3 The 3 randomized studies4 - 6 cited as evidence of no transfusion benefit enrolled 25, 38, and 99 patients, respectively, and thus may have been insufficiently powered to detect any survival difference. In contrast, the largest randomized controlled trial of transfusion in patients with cardiovascular disease7 suggested that restrictive use of transfusions may be harmful in patients experiencing acute coronary syndromes.
The finding that transfusion is associated with a nearly 4-fold increased hazard of 30-day mortality in this study is even more concerning. This risk is much higher than any previously reported transfusion-associated harm; the magnitude exceeds the risks of encainide or flecainide for arrhythmia suppression after myocardial infarction.8 Although transfusion may not be beneficial in patients with a nadir hematocrit greater than 35%, the finding that transfusion would subject patients in this subgroup to a nearly 300-fold increase in their odds of 30-day mortality is extremely surprising, as is the absence of a nadir hematocrit level as low as 20% at which transfusion may be beneficial in patients with acute coronary syndromes. We believe that the preponderance of available data suggest that transfusion remains a reasonable therapy in patients with acute coronary syndromes with hematocrit levels below 30%.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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