Journal of Geriatric Cardiology (2020) 17: 3542 ©2020 JGC All rights reserved; www.jgc301.com Research Article  Open Access  Anemia in patients with high-risk acute coronary syndromes admitted to Intensive Cardiac Care Units Victòria Lorente1, Jaime Aboal2, Cosme Garcia3, Jordi Sans-Roselló4, Antonia Sambola5, Rut Andrea6, Carlos Tomás7, Gil Bonet8, David Viñas2, Nabil el Ouaddi3, Santiago Montero4, Javier Cantalapiedra5, Margarida Pujol6, Isabel Hernández7, María Pérez-Rodriguez8, Isaac Llaó1, José C Sánchez-Salado1, Miquel Gual1, Albert Ariza-Solé1,#; on behalf of the Grup de Treball de Cures Agudes Cardiològiques de la Societat Catalana de Cardiologia 1 Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain 2 Hospital Unversitari Josep Trueta, Girona, Spain 3 Hospital Universitari Germans Trias i Pujol Badalona, Barcelona, Spain 4 Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica IIB Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain 5 Hospital Universitari de la Vall d’Hebron, Barcelona, Spain 6 Hospital Clínic i Provicial, Barcelona, Spain 7 Hospital Arnau de Vilanova, Lleida, Spain 8 Hospital Joan XXIII, Tarragona, Spain Abstract Background Little information exists about the role of anemia in patients with acute coronary syndromes (ACS) admitted to Intensive Cardiac Care Units (ICCU). The aim of this study was to assess the prevalence of anemia and its impact on management and outcomes in this clinical setting. Methods All consecutive patients admitted to eight different ICCUs with diagnosis of non-ST segment elevation ACS (NSTEACS) were prospectively included. Anemia was defined as hemoglobin < 130 g/L in men and < 120 g/L in women. The association between anemia and mortality or readmission at six months was assessed by the Cox regression method. Results A total of 629 patients were included. Mean age was 66.6 years. A total of 197 patients (31.3%) had anemia. Coronary angiography was performed in most patients (96.2%). Patients with anemia were significantly older, with a higher prevalence of comorbidities, poorer left ventricle ejection fraction and higher GRACE score values. Patients with anemia underwent less often coronary angiography, but underwent more often intraaortic coun- terpulsation, non-invasive mechanical ventilation and renal replacement therapies. Both ICCU and hospital stay were significantly longer in patients with anemia. Both the incidence of mortality (HR = 3.36, 95% CI: 1.43–7.85, P = 0.001) and the incidence of mortality/readmission were significantly higher in patients with anemia (HR = 2.80, 95% CI: 2.03–3.86, P = 0.001). After adjusting for confounders, the association between anemia and mortality/readmission remained significant (P = 0.031). Conclusions Almost one of three NSTEACS patients admit- ted to ICCU had anemia. Most patients underwent coronary angiography. Anemia was independently associated to poorer outcomes at 6 months. J Geriatr Cardiol 2020; 17: 3542. doi:10.11909/j.issn.1671-5411.2020.01.006 Keywords: Acute coronary syndromes; Anemia; Intensive cardiac care units; Prognosis 1 Introduction acute coronary syndromes (ACS), especially in elderly pa- tients with comorbidities.[1] The progressive ageing of Anemia is a common clinical condition in patients with population is leading to an increase in the number of pa- # tients with ACS and anemia.[2] Importantly, patients with Correspondence to: Albert Ariza-Solé, Intensive Cardiac Care Unit, Heart anemia are usually excluded from clinical trials, and infor- Diseases Institute, Hospital Universitari de Bellvitge, Feixa Llarga s/n. 08907 L’Hospitalet de Llobregat, Barcelona, Spain. mation regarding their optimal management is scarce.[3] E-mail: aariza@bellvitgehospital.cat Patients with anemia are commonly managed conserva- Received: November 15, 2019 Revised: December 10, 2019 tively in routine clinical practice.[4,5] In a not negligible Accepted: January 16, 2020 Published online: January 28, 2020 proportion of cases, these patients are denied intensive http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology 36 Lorente V, et al. Anemia in high risk acute coronary syndromes therapies because of perception of short life expectancy and arrhythmias or cardiorespiratory arrest. Likewise, high-risk fear of complications. Little information exists about anemia patients were considered those with elevated serum troponin, in ACS patients admitted to intensive care units.[6,7] The aim diabetes mellitus or GRACE scale values > 140, without of this study was to assess the prevalence of anemia and its very high risk criteria. impact on management and outcomes in consecutive pa- Management of patients was done according to current tients with non ST segment elevation ACS (NSTEACS) recommendations. Antithrombotic treatment and coronary admitted to Intensive Cardiac care Units (ICCU). angiography were left to the discretion of the medical team. If coronary angiography was performed, vascular access, 2 Methods antithrombotic drugs and the choice of stents and other devices were lead to operator’s decision. 2.1 Design and study population Clinical follow-up was carried out at six months by This is a multicenter registry carried out in eight hospitals medical visit, review of medical records or telephone of Catalonia during a period of 6 months (between October contact with the patient, family or referring physician. The 1, 2017 to March 31, 2018). This study was endorsed and main outcome measured of the study was mortality or re- coordinated by the Working Group on Acute Cardiac Care admission at six months of follow-up. The assignment of of the Catalan Society of Cardiology. the cause of death was based on clinical judgment of the All consecutive patients admitted to the ICCUs of the physician taking care of the patient at the time of death. participating centers with a diagnosis of NSTEACS were Death was deemed cardiac when it was be due to myocar- prospectively included. NSTEACS was defined as the dial infarction, heart failure or sudden death. The incidence presence of chest pain compatible with acute coronary syn- of reinfarction and new coronary revascularizations were drome with at least one of the following: (1) electrocardio- also recorded. graphic abnormalities suggesting myocardial ischemia and 2.3 Statistical analysis (2) elevation of troponin. The only exclusion criteria was the impossibility of obtaining informed consent for partici- The analysis of normal distribution of variables was per- pation in the registry. formed using the Shapiro-Wilk test. Quantitative variables are expressed as mean ± SD. Non-normally distributed 2.2 Data collection variables are expressed as median and interquartile range. Data were prospectively collected during admission by Categorical variables are expressed as number and percentage. local researchers, using specific standardized case report Baseline characteristics, clinical management and in-hos- forms. Demographic data, baseline clinical characteristics, pital clinical course were compared across if anemia was analytical, electrocardiographic and echocardiographic data present. The association between categorical variables was were recorded, as well as the performance of coronary an- analyzed with the Chi-square test, with the correction of giography. Information about in-hospital clinical course continuity when indicated. The analysis of quantitative (treatments administered, requirement of invasive proce- variables according to anemia status was performed by Stu- dures, complications and in-hospital mortality) was also dent’s t test. The association between anemia and mortality collected. The CRUSADE[8] and GRACE[9] risk scores were or readmission at 6 months was assessed by the Cox regres- calculated for each patient. The hemodynamic parameters sion method. Variables included in the multivariate analy- (heart rate, systolic blood pressure) and Killip class were sis[14] were those with an association (P < 0.2) both with recorded upon admission to the ICCU. Creatinin clearance exposition (anemia) and effect (mortality or readmission at was calculated by the Cockcroft-Gault formula.[10] Body 6 months, see table), and not considered to be an intermedi- surface area was calculated using the Mosteller formula.[11] ate variable between them. Anemia at admission was defined by the World Health Survival analysis was performed using Kaplan Meier Organisation criteria (hemoglobin < 130 g/L in men and < curves. Statistical significance of differences was assessed 120 g/L in women).[12] by log rank test. The PASW Statistics 18 (Chicago, IL, USA) Patients’ risk profile was defined by the criteria of the was used for all analysis. European Society of Cardiology.[13] Patients with very high risk were considered those who presented at least one of the 3 Results following conditions: refractory angina, hemodynamic in- stability, cardiogenic shock, acute heart failure, ventricular A total of 629 patients were included across the study pe- Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Lorente V, et al. Anemia in high risk acute coronary syndromes 37 riod, of whom 483 (76.7%) were male. Mean age was 66.6 majority of patients (605/629, 96.2%). A total of 197 pa- years. tients (31.3%) had anemia at admission. Globally, patients from this series had a high risk profile, with a significant proportion of comorbidities such as dia- 3.1 Clinical characteristics according to anemia status betes mellitus (238/629, 37.8%), peripheral artery disease Patients with anemia were significantly older, with a (106/629, 16.9%) or previous stroke (56/629, 8.9%). Most higher prevalence of cardiovascular risk factors and comor- patients had elevated serum troponin levels (574/629, bidities such as peripheral artery disease, previous stroke or 91.3%), and almost one of each five patients had signs of previous malignancy. They also had a higher prevalence of heart failure at admission (119/629, 18.9%). Coronary an- previous myocardial infarction and higher degree of comor- giography during the admission was performed in the vast bidity as measured by the Charlson index (Table 1). Patients Table 1. Clinical characteristics according to anemia status. Anemia (n = 197) No anemia (n = 432) P-value Age, yrs 71.6 ± 11 64.3 ± 12 0.001 Male sex 154 (78.2%) 329 (76.2%) 0.579 BMI, kg/m2 27.3 (7%) 27.9 (5%) 0.201 BSA, m2 1.85 (0.2%) 1.91 (0.2%) 0.001 Active smoking 31 (15.8%) 151 (35.3%) 0.001 Diabetes mellitus 110 (55.8%) 128 (29.6%) 0.001 Hypertension 173 (88.3%) 289 (66.9%) 0.001 Dyslipidemia 161 (83%) 373 (63.3%) 0.001 Previous myocardial infarction 74 (37.8%) 89 (20.7%) 0.001 Previous percutaneous coronary intervention 63 (32.1%) 78 (18.1%) 0.001 Previous treatment with ASA 122 (61.9%) 124 (28.7%) 0.001 Previous treatment with P2Y12 inhibitors 49 (24.9%) 57 (13.2%) 0.001 Previous treatment with OAC 22 (11.1%) 45 (10.4%) 0.745 Previous heart failure 22 (11.2%) 33 (7.7%) 0.143 Previous atrial fibrillation 23 (11.7%) 43 (10%) 0.501 Previous stroke 27 (13.7%) 29 (6.7%) 0.009 Peripheral artery disease 52 (26.4%) 54 (12.5%) 0.001 Previous malignancy 35 (17.9%) 45 (10.4%) 0.010 Previous bleeding 16 (8.2%) 13 (3%) 0.004 Charlson comorbidity index 3.2 ± 2% 2.2 ± 2 0.001 Clinical characteristics Creatinine clearance, mL/min 60 (35%) 99 (41%) 0.001 Haemoglobin at admission, g/dL 10.9 (1.4%) 14.5 (1.2%) 0.001 Glucose at admission, mg/dL 165 (84%) 146 (77%) 0.008 LDL cholesterol, mg/dL 77 (29%) 106 (72%) 0.001 Killip class at admission > I 65 (33%) 54 (12.5%) 0.001 Systolic blood pressure, mmHg 138 (25%) 137 (26%) 0.712 Heart rate, beats/min 80 (20%) 78 (17%) 0.065 Positive troponin 180 (91.4%) 394 (91.2%) 0.945 GRACE score 156 ± 34 133 ± 34 0.001 CRUSADE score 43 ± 17 22 ± 14 0.001 PRECISE-DAPT score 35 ± 15 17 ± 12 0.001 High-risk criteria 102 (51.8%) 290 (67.6%) 0.001 Very high risk criteria 93 (47.2%) 132 (30.8%) 0.001 Data are presented as mean ± SD or n (%). ASA: acetilsalicyilic acid; BMI: body mass index; BSA: body surface area; LDL: low density lipoprotein; OAC: oral anticoagulant drugs. http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology 38 Lorente V, et al. Anemia in high risk acute coronary syndromes with anemia had also poorer renal function and higher glu- giography during the admission, with a higher proportion of cose levels at admission and lower levels of LDL choles- multivessel disease and left main coronary stenosis, but terol. These patients had higher risk criteria than the rest of without significant differences regarding coronary revascu- patients, with a higher incidence of heart failure at admis- larization (Table 2). sion, poorer left ventricle ejection fraction and higher Significant differences were also observed regarding GRACE, CRUSADE and PRECISE-DAPT scores values. in-hospital medical treatment, with a higher proportion of treatment with clopidogrel, amiodarone, diuretics and iv- 3.2 In hospital clinical management and outcomes abradine and a lower proportion of treatment with ticagrelor according to anemia status and ACE inhibitors in patients with anemia. In addition, Patients with anemia underwent less often coronary an- these patients underwent more often invasive in-hospital Table 2. In-hospital management according to anemia status. Anemia (n = 197) No anemia (n = 432) P-value In-hospital medical treatment ASA 195 (99%) 431 (99%) 0.183 Clopidogrel 158 (80.6%) 257 (60%) 0.001 Ticagrelor 42 (21.3%) 187 (43.4%) 0.001 Prasugrel 6 (3.1%) 24 (5.6%) 0.226 Enoxaparin 101 (51.8%) 246 (57.6%) 0.175 Fondaparinux 44 (22.7%) 117 (27.3%) 0.225 Unfractionated heparin 54 (27.7%) 108 (25.2%) 0.506 Abciximab 2 (1%) 2 (0.5%) 0.373 Inotropes 19 (9.6%) 28 (6.5%) 0.169 Amiodarone 19 (9.6%) 21 (4.9%) 0.023 Diuretics 106 (54.1%) 110 (25.6%) 0.001 Betablockers 154 (78.2%) 344 (80.8%) 0.455 Ivabradin 16 (8.1%) 15 (3.5%) 0.013 Ranolazine 5 (2.5%) 4 (0.9%) 0.149 ACEI 114 (58.2%) 301 (70.3%) 0.003 Eplerenone 18 (9.1%) 26 (6.1%) 0.167 Statins 193 (98%) 420 (97.4%) 0.786 Ezetimibe 10 (5.1%) 23 (5.4%) 0.882 Insulin 113 (57.4%) 136 (31.6%) 0.001 Oral antidiabetic drugs 8 (4.1%) 17 (4%) 0.948 Proton pump inhibitors 196 (99.5%) 416 (97.2%) 0.117 In-hospital procedures Angiography 181 (91.9%) 424 (98.1%) 0.001 Time to angiography, h 21.8 (4–61) 19.6 (3–44) 0.123 Multivessel disease 109 (60.2%) 191 (45%) 0.009 Left main disease 39 (21.5%) 57 (13.4%) 0.015 Revascularization None 72 (36.5%) 134 (31.0%) 0.488 Percutaneous 108 (54.8%) 254 (58.8%) Surgical 19 (9.6%) 44 (10.2%) Temporary pacemaker 7 (3.6%) 8 (1.9%) 0.193 Intraaortic counterpulsation 12 (6.1%) 9 (2.1%) 0.015 Invasive mechanical ventilation 24 (12.2%) 44 (10.2%) 0.453 Non-invasive mechanical ventilation 26 (13.2%) 20 (4.6%) 0.001 Therapeutic hypothermia 0 4 (0.9%) 0.417 Renal replacement therapies 13 (6.6%) 3 (0.7%) 0.001 High flow nasal cannula 12 (6.1%) 9 (2.1%) 0.015 Data are presented as n (%) or median (interquartile range). ASA: acetil salycilic acid; ACEI: angiotensin converter enzyme inhibitors. Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Lorente V, et al. Anemia in high risk acute coronary syndromes 39 Table 3. In-hospital clinical outcomes according to anemia 4 Discussion status. The main findings from this study are: (1) a significant Anemia No anemia (n = 197) (n = 432) P-value proportion (31.3%) of these patients with NSTEACS had Refractory ischemia 20 (10.2%) 16 (3.7%) 0.002 anemia at admission to ICCU; (2) patients with anemia had Reinfarction 6 (3.1%) 5 (1.2%) 0.107 a significantly higher prevalence of comorbidities and higher Atrioventricular block 9 (4.6%) 5 (1.2%) 0.015 risk criteria at admission; (3) despite the proportion was Ventricular fibrillation 3 (1.5%) 6 (1.4%) 0.895 lower in patients with anemia, the vast majority of patients Atrial fibrillation 28 (14.4%) 31(7.2%) 0.005 underwent coronary angiography during the admission (96.2%), Stroke 0 3 (0.7%) 0.584 and (4) patients with anemia had a higher incidence of mor- CRUSADE major bleeding 17 (8.6%) 44 (10.2%) 0.541 tality or readmission at 6 months, and this association was Need for transfusion 14 (77.8%) 11 (44%) 0.027 independent from potential confounders. In-hospital mortality 3 (1.5%) 9 (2.1%) 0.634 Anemia is a common comorbidity in ACS, and is ICCU stay 3 (2–5) 3 (2–4) 0.013 strongly associated with poorer clinical outcomes in these Hospital stay 9 (5–15) 6 (4–10) 0.001 patients[15–20] and also in other clinical settings.[21,22] Preva- Data are presented as n (%) or median (interquartile range). ICCU: Inten- lence of anemia in patients with ACS ranges between 20% sive cardiac Care Unit. 30% in most series, and is especially higher in elderly pa- tients with comorbidities.[23–25] In contrast, other studies procedures such as intraaortic counterpulsation, non-in- including highly selected ACS patients from clinical tri- vasive mechanical ventilation and renal replacement thera- als[26,27] or assessing only patients treated with potent anti- pies as compared to patients without anemia. platelet drugs[28] reported a significantly lower prevalence of Patients with anemia had a higher incidence of in-hos- anemia, around 10%. A not negligible proportion of patients pital complications such as refractory ischemia, atrioven- with ACS and anemia are denied ICU admission in routine tricular block or atrial fibrillation, without differences in the clinical practice because of a high degree of comorbidities rate of major bleeding or in-hospital mortality. Both ICU and perception of a low life expectancy. Information about and in-hospital stay were significantly longer in patients with anemia (Table 3). Table 4. Management at discharge according to anemia status. 3.3 Post-discharge management and clinical outcomes Anemia No anemia according to anemia status P-value (n = 194) (n = 423) Patients with anemia were more commonly treated with ASA 181 (93.3%) 394 (93.1%) 0.944 clopidogrel, diuretics, ivabradine, ranolazine and proton Clopidogrel 114 (58.8%) 149 (35.2%) 0.001 pump inhibitors at hospital discharge (Table 4). In contrast, Ticagrelor 28 (14.4%) 151 (35.7%) 0.001 the rate of prescription of ticagrelor and prasugrel was sig- Prasugrel 3 (1.5%) 24 (5.7%) 0.020 nificantly lower in these patients. Direct anticoagulants 8 (4.1%) 13 (3.1%) 0.497 From 617 patients surviving at hospital discharge, data Vitamin K antagonists 18 (9.3%) 51 (12%) 0.314 on clinical follow up was available in 586 cases (95%). Of Amiodarone 10 (5.2%) 20 (4.7%) 0.819 them, 33 patients (5.6%) presented new ACS and 17 (2.9%) Diuretics 93 (47.9%) 101 (23.9%) 0.001 clinically significant bleeding at 6 months. Betablockers 146 (75.3%) 317 (75.1%) 0.970 Globally, a total of 23 patients died at 6 months and 140 Ivabradin 22 (11.3%) 12 (2.8%) 0.001 patients dead or were readmitted at 6 months. Both the in- Ranolazine 9 (4.6%) 6 (1.4%) 0.034 cidence of mortality (HR = 3.36, 95% CI: 1.43–7.85, P = ACEI 98 (50.5%) 245 (57.9%) 0.086 0.001) and the incidence of mortality or readmission were Eplerenone 21 (10.8%) 27 (6.4%) 0.056 significantly higher in patients with anemia (HR = 2.80, Statins 186 (95.9%) 391 (92.4%) 0.107 95% CI: 2.03–3.86, P = 0.001). After adjusting for potential Ezetimibe 17 (8.8%) 36 (8.6%) 0.937 confounders, the association between anemia and mortality Insulin 61 (31.4%) 54 (12.8%) 0.001 or readmission at 6 months was still significant (HR = 2.22, Oral antidiabetic drugs 68 (35.2%) 99 (23.6%) 0.003 95% CI: 1.32–3.71, P = 0.031, Table 5). Figure 1 shows the Proton pump inhibitors 173 (89.2%) 346 (81.8%) 0.020 cumulative incidence of mortality and mortality or readmis- Data are presented as n (%). ASA: acetil salycilic acid; ACEI: angiotensin sion at 6 months according to anemia status. converter enzyme inhibitors. http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology 40 Lorente V, et al. Anemia in high risk acute coronary syndromes Table 5. Predictors of mortality or readmission at 6 months. Univariate analysis Multivariate analysis Variable Hazard ratio (95% CI) P-value Hazard ratio (95% CI) P-value Anemia 2.80 (2.03–3.86) 0.001 2.22 (1.32–3.71) 0.031 Age 1.03 (1.02–1.05) 0.001 1.02 (1.00–1.04) 0.062 BSA 0.46 (0.21–1.02) 0.057 Active smoking 0.88 (0.72–1.08) 0.229 Diabetes 1.91 (1.39–2.64) 0.001 Hypertension 1.94 (1.26–2.98) 0.002 Dyslipidemia 1.56 (1.06–2.30) 0.025 Peripheral artery disease 2.36 (1.66–3.37) 0.001 1.88 (1.27–2.79) 0.002 Previous stroke 2.76 (1.89–4.02) 0.001 2.13 (1.41–3.22) 0.001 Previous myocardial infarction 2.08 (1.49–2.89) 0.001 Previous PCI 1.34 (0.93–1.92) 0.119 Previous malignancy 1.66 (1.10–2.51) 0.016 Previous bleeding 1.79 (0.97–3.30) 0.064 Charlson comorbidity Index 1.22 (1.12–1.32) 0.001 Killip class on admission >= II 2.69 (1.91–3.77) 0.001 Heart rate 1.02 (1.01–1.02) 0.001 Creatinin clearance 0.99 (0.98–0.99) 0.001 Glucose at admission 1.00 (1.00–1.01) 0.001 LDL cholesterol 0.99 (0.99–1.00) 0.041 Left ventricle ejection fraction 0.97 (0.96–0.98) 0.001 0.99 (0.97–1.00) 0.082 Multivessel disease 1.39 (0.99–1.96) 0.058 1.24 (1.02–1.50) 0.028 Left main disease 2.01 (1.35–2.97) 0.001 BSA: body surface area; PCI: percutaneous coronary intervention. Figure 1. Cumulative incidence of mortality (A) and mortality or readmission at 6 months (B) according to anemia status. the real prevalence of anemia in high-risk ACS patients (42.9%) had diagnosis of ACS. The authors described a admitted to critical care units is scarce. In an interesting high prevalence of anemia according to WHO criteria in the contribution, Uscinska, et al.[6] assessed a series of 392 pa- whole cohort (64%), which was significantly lower in pa- tients admitted to an Intensive Cardiac Care Unit between tients with ACS. Biomarkers of iron status but not anemia 2008–2011 (mean age, 70 ± 13.8 year). Of them, 168 predicted in-hospital mortality. In another subanalysis of Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Lorente V, et al. Anemia in high risk acute coronary syndromes 41 that series,[7] haemoglobin levels—along with age, parame- events at follow up, as observed by Uscinska, et al.[7] In our ters of iron status, and LVEF—were strong predictors of opinion, these data support the need for a careful manage- long-term mortality. Another small series[29] also described ment and follow up in this group of complex ACS patients. a high prevalence of anemia in ACS patients admitted to an This study has some limitations, such as the moderate ICCU. To our knowledge, no other study focused on ACS sample size of subgroups and the moderate number of patients admitted to ICCU. Data from our study revealed events. It was an observational study, so we cannot rule out that, despite being a relatively young population, almost one the presence of selection bias or residual confounding. In of each three of these high risk ACS patients admitted to addition, data regarding type of anemia or iron status was ICCU had anemia at admission. This proportion is signifi- not available. Finally, a longer follow up might have con- cantly lower than those observed in the series by Uscinska, tributed to fully assess the association between anemia and et al.[6] Ours was a significantly younger homogeneous po- outcomes. pulation in which we only assessed patients with NSTEACS Despite these limitations, in our opinion this study re- diagnosis. On the other hand, different criteria for ICCU trieves interesting and novel data about the real prevalence admission might also have contributed to the lower preva- of anemia and its impact on management and prognosis of lence of anemia in our patients. high-risk ACS patients admitted to ICCU in routine clinical Patients with ACS and anemia are commonly managed practice. Improving risk stratification and outcomes in this conservatively in routine clinical practice,[4,5,23–25] with a growing group of complex patients often excluded form lower likelihood of receiving potent antithrombotic drugs clinical trials might lead to important clinical and social and undergoing coronary angiography or other intensive consequences. therapies. Therefore, little information exists about patients In conclusion, this study showed that almost one of each with high-risk ACS and anemia admitted to critical care three patients with NSTEACS admitted to ICCU had ane- units. In our opinion this is a crucial issue, since these pa- mia at admission. Patients with anemia had a significantly tients are usually fully candidates to intensive therapies. higher prevalence of comorbidities and higher risk criteria at admission, although they underwent less often coronary Despite the performance of coronary angiography was less angiography. Anemia was independently associated to poor- common in patients with anemia from our series, this inva- er outcomes in this group of high risk ACS patients under- sive approach was selected in a high proportion of them going a contemporary management at ICCU. (more than 90%). Interestingly, the performance of some ICCU procedures such as counterpulsation, non-invasive mechanical ventilation or renal replacement therapies were Ethics statement more common in this group, probably reflecting their higher All patients or their representatives signed an informed profile of risk. In addition, a more conservative antithrom- consent before being recruited for the study. Confidential botic approach was used in patients with anemia, with a information of the patients was protected according to na- higher proportion of clopidogrel and lower of ticagrelor. tional normative. This protocol has been approved by the Clopidogrel was the P2Y12 blocker more commonly used Clinical Research Ethics Committee of Bellvitge University even in patients with normal haemoglobin values. This is Hospital (IRB00005523). also an interesting point, since recent data suggest that more antiplatelet drugs can be safely used in ACS patients with References anemia with a careful assessment of ischemic and bleeding risk.[28] 1 Willis P, Voeltz MD. Anemia, hemorrhage, and transfusion in Anemia was associated with a higher prevalence of co- percutaneous coronary intervention, acute coronary syn- morbidities and severity of coronary disease in our patients. dromes, and ST-segment elevation myocardial infarction. Am However, no significant differences were observed regard- J Cardiol 2009; 104: 34C–38C. ing the rate of revascularization according to anemia status. 2 Degano IR, Elosua R, Marrugat J. Epidemiology of acute coronary syndromes in Spain: estimation of the number of A potential reason for this might be the presence of more cases and trends from 2005 to 2049. Rev Esp Cardiol 2013; complex coronary lesions not suitable for revascularization 66: 472–481. in patients with anemia. The higher prevalence of comor- 3 Krumholz HM, Gross CP, Peterson ED, et al. Is there evi- bidities in patients with anemia might probably have con- dence of implicit exclusion criteria for elderly subjects in tributed to the worse outcomes observed in these patients. randomized trials? Evidence from the GUSTO-1 study. Am However, after adjusting for potential confounders, anemia Heart J 2003; 146: 839–847. was independently associated to a higher incidence of 4 Ariza-Solé A, Formiga F, Salazar-Mendiguchía J, et al. Im- http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology 42 Lorente V, et al. 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