Evidence Questions Benefits of ESAs for Anemia in Heart Disease

Erythropoiesis-stimulating agents (ESAs) are not beneficial—and may be harmful—in the treatment of mild to moderate anemia in patients with heart disease, according to a review in the Annals of Internal Medicine.

A systematic review of the literature was performed to evaluate the benefits and harms of treatments for anemia in patients with heart disease. The analysis focused on studies of blood transfusion, iron, or ESAs for adults with anemia and congestive heart failure or coronary heart disease.

On the basis of six trials and 26 observational studies, there was “low-strength” evidence of improvement in short-term mortality among patients treated with liberal transfusion protocols, compared with less aggressive protocols. The difference was not significant on meta-analysis. However, one small trial in patients with acute coronary syndrome reported lower mortality in patients treated with a liberal transfusion strategy: 1.8 versus 13.0 percent. Three trials of intravenous iron therapy provided “moderate-strength” evidence of improvements in short-term exercise tolerance and quality of life in anemic patients with heart failure.

The review identified 17 randomized trials of ESAs, most conducted in patients with heart failure. The studies provided “high-strength” evidence that ESAs did not lead to reductions in mortality, cardiovascular events, or hospitalizations. There was also “moderate-strength” evidence that ESAs did not lead to improved quality of life. The review also identified moderately strong evidence linking ESAs to serious harms, including hypertension, venous thromboembolism, and possibly mortality, in patients with congestive heart failure.

The review analyzes the growing body of evidence on strategies for correcting anemia in patients with heart disease. The data provide no consistent evidence of reduced mortality with higher transfusion thresholds, but they do suggest symptomatic improvements with intravenous iron. Further studies of both treatments are warranted.

The authors conclude: “Erythropoiesis-stimulating agents do not seem to benefit patients with mild to moderate anemia and heart disease and may be associated with serious harms.” The review serves as the basis for a new American College of Physicians guideline on the treatment of anemia in patients with heart disease: http://annals.org/article.aspx?articleid=1784292 [Kansagara D, et al. Treatment of anemia in patients with heart disease: a systematic review. Ann Intern Med 2013; 159:746–757].

January 2014 (Vol. 6, Number 1)