Treating Anemia in Patients with Heart Disease

Guideline Watch |
January 21, 2014

Treating Anemia in Patients with Heart Disease

  1. Jamaluddin Moloo, MD, MPH

The American College of Physicians recommends that transfusions and erythropoiesis-stimulating agents be restricted to patients with more-severe anemia.

  1. Jamaluddin Moloo, MD, MPH

Sponsoring organization: American College of Physicians (ACP)

Target Population: Primary care physicians, cardiologists

Background and Objective

Treatments for anemia in patients with heart disease include erythropoiesis-stimulating agents (ESAs), red blood cell (RBC) transfusions, and iron replacement, but whether these treatments improve outcomes is unclear. The ACP's new guideline is based on a systematic review of evidence on benefits and harms of these treatments in patients with congestive heart failure (CHF) or coronary heart disease (CHD).

Key Points

— Treatment with RBC transfusions (low-quality evidence)

  • No short-term mortality benefit was found for liberal RBC transfusion versus more restrictive transfusion (hemoglobin trigger level, >10 g/dL vs. 8–9 g/dL) in medical and surgical patients with anemia and heart disease.

  • Aggressive treatment of anemia with RBC transfusions doesn't benefit and might harm patients with acute coronary syndrome or myocardial infarction or those who are undergoing percutaneous coronary interventions.

— Treatment with ESAs (moderate- to high-quality evidence)

  • Among anemic patients with stable CHF, ESA use does not lower all-cause mortality or risk for adverse cardiovascular events but might be associated with harms, such as venous thromboembolism.


  • Use a restrictive RBC transfusion strategy (trigger hemoglobin threshold, 7–8 g/dL) in hospitalized patients with anemia and CHD (grade: weak recommendation; low-quality evidence).

  • Do not use ESAs in patients with mild-to-moderate anemia and CHF or CHD (grade: strong recommendation; moderate-quality evidence).


Patients with heart disease often have anemia, and treating them aggressively intuitively seems like the best choice. However, this clinical practice guideline emphasizes that more (e.g., red blood cells) is not always better and clarifies how and when we should intervene.

Editor Disclosures at Time of Publication

  • Disclosures for Jamaluddin Moloo, MD, MPH at time of publication Grant / research support NIH


Reader Comments (2)

Virella-Santana, Wilma, MD Physician, Pathology, Private surgical laboratory and Hospital clinical laboratories

It is my experience that physicians are too eager to transfuse, evaluating not the whole patient but the hemoglobin levels. As a transfusion service director I'm trying to change this way of practicing medicine.

S DAVID KRIMINS Physician, Pulmonary Medicine

One of the lessons learned in med school in the 60's from the great cardiologist William Likoff, M.D., is essentially that "a little anemia in a patient with coronary artery disease is usually a good thing - don't be too quick to reverse it". Though our understandings have changed, the lesson sticks.

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