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Restrictive vs Liberal Transfusion Strategy After Myocardial Infarction
M BertoletFrançois Martin CarrierGlynn, Simone, 1960-J. Dawn AbbottAndrew P. DeFilippisTabassome SimonC B FordyceSenaratne JwBrian J. PotterBrandon M. HerbertSunil V. RaoAdriano CaixetaMeechai TessaleeHoward A. CooperPedro Beraldo de AndradeFrederico Toledo Campo Dall'OrtoJohanne SilvainCarson JlMaria Mori BrooksMyocardial Ischemia and Transfusion (MINT) Trial InvestigatorsCarson JlFei ChenPatrick DesantoKaren DragertWilliam J. KostisSarang KimDeborah McCloskeyHelaine NoveckSheila ReddingAmi PatelShahab GhafghaziSharon VincentHardeep DholiyaDinesh KalraJennifer MooreMallory HatfieldHoward A. CooperSyed HaidryAhmed HassaninRisheek KaulFnu NamrataParija SharedalalJayakumar SreenivasanJasjit BhinderMohammed Hasan KhanAnna KoulovaBehram ModyYogita RochlaniAnuritha TirumaniFrances WoodRhonda NortonLaMonica DanielMark MenegusSamanta BaboolallSheila DavilaNoelle ManningMollie MachadoJudah RauchAngeline CamiloEstefanía HernándezMuhammad IqbalErvin MaznikuO RamírezVeronica DayBarry UretskyJesse ByrdKristin MillerSrikanth VallurupalliGregory ManiatisRichard DimaRoman RoyzmanSean TaylorAmanda TiceBrandon DilluvioLuis GrubergPuneet GandotraRachel GentlesBarbara ShannonMaria MasihR.L. RoswellAlana GulliverMeriton RuhaniEmily StroberSamia TamaziAdam GershonKristie ColemanBernard KadoshRajiv JauharHarsha AdnaniKyle AgostiniLoukas BoutisIan DalanginBarry KaplanJae S. LeePerwaiz MerajRiona TimmonsCarl ReimersCraig BasmanUmar RashidA. Garvey Rene
Key result
Liberal transfusion strategy reduces 30-day death or MI ~14% vs. restrictive strategy in MINT reanalysis.
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Why the study?
Transfusion decisions in MI and anemia require balancing potential reductions in 30-day death or MI against potential heart failure risks.
Does a liberal transfusion strategy reduce the composite of death or recurrent MI in adults hospitalized with myocardial infarction and anemia?
Key Points
- To evaluate Bayesian posterior probabilities and risk differences for 30-day death, myocardial infarction, and heart failure comparing a liberal versus restrictive blood transfusion strategy in patients with myocardial infarction and anemia.
- Bayesian post hoc analysis of the multicenter MINT randomized clinical trial conducted across 144 sites in 6 countries from April 26, 2017, to April 14, 2023, among 3504 adults hospitalized with myocardial infarction and anemia.
- Participants were randomized to a restrictive transfusion strategy (transfuse if hemoglobin <7 to 8 g/dL; n = 1749) or a liberal transfusion strategy (maintain hemoglobin >10 g/dL; n = 1755).
- Bayesian posterior risk differences were calculated for 30-day death or myocardial infarction and heart failure under 3 prior distributions: noninformative, liberal strategy superiority, and restrictive strategy superiority.
- The primary outcome of 30-day death or myocardial infarction occurred in 14.5% of liberal strategy participants (255 of 1755) versus 16.9% of restrictive strategy participants (295 of 1749; RR, 1.16; 95% CI, 1.00-1.35), representing a 1.4% (95% credible interval, -0.8% to 3.5%) to 2.4% (95% credible interval, 0.3%-4.6%) lower risk with the liberal strategy depending on prior beliefs.
- The posterior probability that the liberal strategy reduced 30-day death or myocardial infarction ranged from 89.1% to 98.8%, with a 62.7% to 90.4% probability of preventing at least 1 death or myocardial infarction per 100 patients treated.
- Heart failure occurred in 6.3% of liberal strategy participants (111 of 1755) compared with 5.8% of restrictive strategy participants (102 of 1749; RR, 0.92; 95% CI, 0.71-1.20), representing a 0.2% (95% credible interval, -1.6% to 1.2%) to 0.6% (95% credible interval, -2.0% to 0.8%) higher risk with the liberal strategy.
Study Design
Type
RCT (n=3,504)
Blinding
unmasked
Randomization
parallel-group
Multicenter
Yes
Structured PICO
Does a liberal transfusion strategy reduce the composite of death or recurrent MI in adults hospitalized with myocardial infarction and anemia?
P
Population
3,504 adults (mean age 72.1, 45.5% female) hospitalized with myocardial infarction and anemia (hemoglobin <10 g/dL) across 6 countries, followed for 30 days.
I
Intervention
Liberal transfusion strategy (transfuse to maintain hemoglobin >10 g/dL).
C
Comparator
Restrictive transfusion strategy (transfuse if hemoglobin is <7 to 8 g/dL).
O
Outcome
Composite of death or recurrent MI within 30 days after randomization.composite
Main Result
Relative Risk: 1.16 (95% CI 1–1.35)
Absolute Event Rate: 16.9% vs 14.5%
A bayesian reanalysis of the MINT trial suggests a high probability that a liberal transfusion strategy reduces 30-day death or MI compared to a restrictive strategy, outweighing a small increased risk of heart failure.
Limitations
- Prior distributions and MCIDs may not reflect the beliefs or value judgments of all clinicians or patients
- Bayesian analysis was not prespecified, potentially introducing biases
- Did not analyze less-common adverse effects
- Did not collect detailed data regarding peritransfusion volume management strategies
- Prior distributions and MCIDs applied may not reflect the beliefs or value judgments of all clinicians or patients.
- Bayesian analysis was not prespecified, potentially introducing biases and increasing overall error rates.
- Did not analyze less-common adverse effects associated with liberal transfusion strategies.
- Did not collect detailed data regarding peritransfusion volume management strategies (eg, diuretic administration or mechanical circulatory support).
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
JLJeffrey L. CarsonDistinguished Professor of Medicine, Rutgers
“We cannot claim that a liberal transfusion strategy is definitively superior based on our primary outcome, but the 95% confidence interval is consistent with treatment effects corresponding to no difference between the two transfusion strategies and to a clinically relevant benefit with the liberal strategy.”
“Given the lack of acute harm associated with liberal transfusion and the preponderance of evidence favoring liberal transfusion in the largest trial to date, liberal transfusion appears to be a viable management strategy, particularly among patients with non-STEMI type 1 MI and as clinical judgment dictates.”
CSClaudia S. CohnChief medical officer, AABB
“Transfusion decisions in acute myocardial infarction are never one-size-fits-all. This guideline encourages clinicians to consider the full clinical context, potential risks and strategies to mitigate adverse events when deciding when to transfuse these patients.”
Implication
Supports liberal transfusion in anemic MI patients; extends MINT trial with Bayesian confirmation of net benefit.
Abstract
Importance: The decision to transfuse a patient with myocardial infarction (MI) and anemia at a higher vs lower hemoglobin threshold must consider the potential benefit of reduced risk of 30-day death or MI and the potential risk of heart failure. Objectives: To estimate bayesian posterior risk differences and posterior probabilities that a liberal vs restrictive transfusion strategy is associated with reduced risk of 30-day death or MI and whether the probabilities exceed predefined thresholds. Design, Setting, and Participants: The Myocardial Ischemia and Transfusion (MINT) trial recruited adults from April 26, 2017, to April 14, 2023, who were hospitalized with MI and anemia at 144 sites in 6 countries. Statistical analysis was performed from July 31, 2024, to February 18, 2026. Intervention: The MINT trial randomized participants to a restrictive (transfuse if hemoglobin is <7 to 8 g/dL) or liberal (maintain hemoglobin at >10 g/dL) transfusion strategy. Main Outcomes and Measures: Bayesian posterior risk differences were estimated for 30-day death or MI and for heart failure using 3 prior beliefs regarding the treatment strategies: noninformative, liberal strategy superiority, or restrictive strategy superiority. Results: The mean (SD) age of the 3504 participants was 72.1 (11.6) years and 1911 (54.5%) were men. Compared with the restrictive strategy, the risk of 30-day death or MI with the liberal strategy was 1.4% (95% credible interval, -0.8% to 3.5%) to 2.4% (95% credible interval, 0.3%-4.6%) lower, depending on prior beliefs. The probability that the liberal strategy was associated with a lower risk of 30-day death or MI ranged from 89.1% to 98.8%, and the probability that a liberal strategy was associated with at least 1 less death or MI per 100 treated was between 62.7% and 90.4%. Conversely, the risk of heart failure with the liberal strategy was 0.2% (95% credible interval, -1.6% to 1.2%) to 0.6% (95% credible interval, -2.0% to 0.8%) higher compared with the restrictive strategy, depending on prior beliefs. The probability that the liberal strategy was associated with a higher risk of heart failure ranged from 60.6% to 80.0%, and the probability that a liberal strategy was associated with at least 1 more heart failure event per 100 treated was between 13.3% and 29.3%. Conclusions and Relevance: This post hoc analysis of a randomized clinical trial of patients with MI and anemia suggests that a liberal transfusion strategy was associated with a lower risk of 30-day death or MI, outweighing the increased risk of heart failure. Consistent with guideline recommendations and according to patients' values and clinician risk assessment, a liberal transfusion strategy may be reasonable. Trial Registration: ClinicalTrials.gov Identifier: NCT02981407.
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Cite This Study
Bertolet et al. (2026) conducted an RCT in Myocardial infarction and anemia (n=3,504). Restrictive transfusion strategy vs. Liberal transfusion strategy (maintain hemoglobin >10 g/dL) was evaluated on Composite of death or recurrent MI within 30 days (RR 1.16, 95% CI 1.00-1.35). A bayesian reanalysis of the MINT trial found that a liberal transfusion strategy was associated with a lower risk of 30-day death or MI compared to a restrictive strategy, outweighing a small increased risk of heart failure.