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(Circulation. 2007;116:471-479.)
© 2007 American Heart Association, Inc.

Cardiovascular Surgery

Impact of Preoperative Anemia on Outcome in Patients Undergoing Coronary Artery Bypass Graft Surgery

Alexander Kulier, MD; Jack Levin, MD; Rita Moser, MD; Gudrun Rumpold-Seitlinger, MD; Iulia Cristina Tudor, PhD; Stephanie A. Snyder-Ramos, MD; Patrick Moehnle, MD; Dennis T. Mangano, PhD, MD, for the Investigators of the Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation

From the Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria (A.K., R.M., G.R.-S); Multicenter Study of Perioperative Ischemia Research Group (A.K., J.L., R.M., G.R.-S., S.A.S.-R., P.M., D.T.M.); Department of Laboratory Medicine, University of California School of Medicine, San Francisco (J.L.); Ischemia Research and Education Foundation, San Bruno, Calif (I.C.T., D.T.M.); Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany (S.A.S.-R.); and Department of Anesthesiology, Ludwig-Maximilians University, München, Germany (P.M.).

Reprint requests to Alexander Kulier, MD, c/o Editorial Office, Ischemia Research and Education Foundation, 1111 Bayhill Dr, Suite 480, San Bruno, CA 94066. E-mail akulier{at}aon.at, cc: dtb@iref.org

Received July 21, 2006; accepted May 15, 2007.

Background— The risk of preoperative anemia in patients undergoing heart surgery has not been described precisely. Specifically, the impact of low hemoglobin per se or combined with other risk factors on postoperative outcome is unknown. Thus, we determined the effects of low preoperative hemoglobin and comorbidities on postoperative adverse outcomes in patients with coronary artery bypass graft in a large comprehensive multicenter study.

Methods and Results— The Multicenter Study of Perioperative Ischemia investigated 5065 patients with coronary artery bypass graft at 70 institutions worldwide, collecting 7500 data points per patient. In 4804 patients who received no preoperative transfusions, we determined the association between lowest preoperative hemoglobin levels and in-hospital cardiac and noncardiac morbidity and mortality and the impact of concomitant risk factors, assessed by EuroSCORE, on this effect. In patients with EuroSCORE <4 (n=2054), only noncardiac outcomes were increased, whereas patients with EuroSCORE 4 (n=2750) showed an increased incidence of all postoperative events, starting at hemoglobin <11 g/dL. Low preoperative hemoglobin was an independent predictor for noncardiac (renal>cerebral; P<0.001) outcomes, whereas the increase in cardiac events was due to other factors associated with preoperative anemia.

Conclusions— Anemic patients undergoing cardiac surgery have an increased risk of postoperative adverse events. Importantly, the extent of preexisting comorbidities substantially affects perioperative anemia tolerance. Therefore, preoperative risk assessment and subsequent therapeutic strategies, such as blood transfusion, should take into account both the individual level of preoperative hemoglobin and the extent of concomitant risk factors.

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