Key result
Restrictive transfusion yields similar mortality to liberal transfusion, though liberal strategies reduce ischaemic events.
Why the study?
It remained uncertain whether a restrictive or liberal red blood cell transfusion strategy leads to better clinical outcomes in surgical patients with high cardiovascular risk, as randomised controlled trials had reported mixed results.
Does a restrictive versus liberal red blood cell transfusion strategy reduce all-cause mortality, MACE, and ischaemic events in surgical patients with high cardiovascular risk?
Meta-Analysis (n=8,371)
Does a restrictive versus liberal red blood cell transfusion strategy reduce all-cause mortality, MACE, and ischaemic events in surgical patients with high cardiovascular risk?
In surgical patients with high cardiovascular risk, restrictive and liberal red blood cell transfusion strategies yielded similar rates of mortality and MACE, though liberal transfusion was associated with a lower risk of ischaemic events (stroke or myocardial infarction).
Background It remains uncertain whether a restrictive or a liberal red blood cell transfusion strategy leads to better clinical outcomes in surgical patients with high cardiovascular risk, as randomised controlled trials (RCTs) have reported mixed results. Purpose To compare restrictive and liberal haemoglobin-guided red blood cell transfusion strategies applied during the perioperative or critical care period among surgical patients with high cardiovascular risk. Methods We conducted a systematic review and meta-analysis of RCTs. We searched PubMed, Embase, and the Cochrane Library for trials comparing restrictive and liberal haemoglobin-guided transfusion strategies in surgical patients with high cardiovascular risk. Trials in any surgical setting were eligible if they reported outcomes in this population. Restrictive strategies targeted haemoglobin ≤8 g/dL and liberal strategies targeted haemoglobin ≥9 g/dL. Outcomes were all-cause mortality at 30 days or during hospitalisation, major adverse cardiovascular events (MACE), and ischaemic events defined as stroke or myocardial infarction. We calculated risk ratios (RR) with 95% confidence intervals (CI) using random-effects models with Hartung–Knapp adjustment and assessed heterogeneity using the I² statistic. Results Six RCTs including 8,371 participants were analysed. Four trials were conducted in cardiac surgery, one in hip fracture surgery, and one in vascular or general surgery. Restrictive and liberal strategies showed similar risks of all-cause mortality (RR 0.87, 95% CI 0.77–1.00; I² = 0%) and MACE (RR 0.99, 95% CI 0.81–1.21; I² = 0%). Liberal transfusion was associated with a lower risk of ischaemic events (RR 0.93, 95% CI 0.90–0.97; I² = 0%). Conclusion In surgical patients with high cardiovascular risk, restrictive and liberal transfusion strategies showed no clear difference in mortality or MACE. Liberal transfusion was associated with a lower risk of ischaemic events.
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Silva et al. (2026) conducted a meta-analysis in Surgical patients with high cardiovascular risk (n=8,371). Restrictive red blood cell transfusion strategy vs. Liberal red blood cell transfusion strategy (haemoglobin target ≥9 g/dL) was evaluated on All-cause mortality at 30 days or during hospitalisation (RR 0.87, 95% CI 0.77-1.00). Restrictive vs liberal RBC transfusion showed similar all-cause mortality (RR 0.87, 95% CI 0.77-1.00) and MACE, while liberal transfusion lowered ischaemic events (RR 0.93, 95% CI 0.90-0.97).
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