Vignette
You’re working a shift on community medicine rotation in a medium-sized community-based ED one afternoon when you encounter Mr. S, a 62-year-old male here visiting his son from Florida, with a history of hypertension, hyperlipidemia, chronic iron-deficiency anemia, and coronary artery disease with a stent to his RCA ten years previously. He presents now with substernal chest heaviness that began while climbing the stairs at his son’s home and has persistent since. He took three sublingual nitroglycerin tablets with some relief, but is currently having 3/10 discomfort. He is not short of breath or diaphoretic. His physical exam is unremarkable.
The patient’s ECG reveals sinus rhythm with very mild ST depression in the anterior leads and normal T-waves. You have no old records in your system for comparison. After one additional sublingual nitro he is now pain free. His labs begin coming back and reveal a high-sensitivity troponin T of 250 ng/L and a hemoglobin of 8.4 g/dL with a microcytic pattern. You go back and ask the patient about recent bloody stools or melena, both of which he denies.
After giving the patient an appropriate dose of aspirin and starting him on a heparin drip for a non-ST elevation MI, you contact the on-call cardiologist with plans to admit to the hospitalist. The cardiologist agrees with the plan but given the patient’s obvious myocardial infarction she suggests you transfuse the patient up to a hemoglobin of 10 g/dL. When you ask your attending, you are told this is not necessary and that there is prior evidence that restrictive transfusion strategies are just as efficacious (even in the setting of an acute MI), citing a prior journal club on this topic. You successfully admit the patient to the hospitalist without a transfusion but wonder what the evidence showed and if there has been any additional evidence published in the interim. After your shift, you decide to dive into the literature and see what the evidence shows…