Hospital-Acquired Anemia: Epidemiology, Prevention and Management in Patients with Acute Coronary Syndromes

Transcription

1 Hospital-Acquired Anemia: Epidemiology, Prevention and Management in Patients with Acute Coronary Syndromes Adam C. Salisbury, MD, MSc January 23, 2012

2 Case 64 year old woman with no cardiac history, medical history of hypertension, type II diabetes Presents Friday night to her local ED sudden substernal chest pain, EKG shows anterolateral ST depression Symptoms resolve with nitroglycerin, metoprolol Started on aspirin, clopidogrel and heparin Transferred to Saint Luke s Hospital Baseline hemoglobin 12.4 g/dl, admit creatinine 1.5 mg/dl

3 Clinical Scenario Remains pain free, admission EKG shows resolution of her ST segment changes Managed medically over the weekend Coronary angiography Monday Pre-procedure : Hgb 11.0 g/dl, creatinine % mid-distal LAD lesion stented with a single drug-eluting stent Manual compression for sheath pull; small hematoma Discharged home next day Hgb 10.7 g/dl

4 Hospital-Acquired Anemia (HAA) Not an uncommon scenario normal admission hemoglobin, anemic at discharge How frequent at the time of acute coronary syndrome (ACS)? Is this important? Poor outcomes? What can/should we do about HAA?

5 Chronic Anemia & Outcomes After Acute Coronary Syndromes Chronic anemia associated with poorer survival and worse health status acute coronary syndrome patients

6 Sabatine et al. Circulation. 2005;111:

7 Anker et al. Eur Heart J. 2009(30):

8 Anemia and Mortality Decreased blood oxygen carrying capacity Promote arrhythmia Exacerbate myocardial ischemia Increase sympathetic tone Exacerbate shock in setting of compromised ventricular function Levy, et al. Am J Physiol. 1993;265:H Levy, et al. J Trauma. 1996;41:

9 Chronic Anemia & Outcomes After Acute Coronary Syndromes Is it actionable? Challenges in addressing chronic anemia Complex interplay of underlying illness and inflammation No opportunity for prevention Treatments - disappointing results Transfusion benefit transient and may increase mortality Erythropoietin stimulating agents augment hemoglobin but increase risk for stroke and thromboembolic events

10 Hospital-Acquired Anemia (HAA) New anemia in patients with normal admission hemoglobin Common at the time of acute coronary syndromes Associated with greater mortality Worse physical functioning Commonly persistent in recovery after ACS Salisbury, et. al. Circ Cardiovasc Qual Outcomes; 2010: 3(4): Salisbury, et. al. Am J Cardiol; 2011: 108(7): Salisbury, et. al. Am Heart J; 2011: 162(2): e3

11 HAA is Common Without HAA 55% With HAA 45% Mod- Severe 26% Mild 74% Salisbury, et. al. Circ Cardiovasc Qual Outcomes; 2010: 3(4):

12 HAA is Associated with Poor Outcomes 12 month mortality HR (95% CI) Multivariable Adjusted Hospital acquired: mild Hospital acquired: moderate/severe Chronic Anemia 1.20 (0.75, 1.90) 1.82 (1.11, 2.98) 2.31 (1.57, 3.40) <<Lower Mortality Risk Higher Mortality Risk>> Salisbury, et al. Circ Cardiovasc Qual Outcomes; 2010: 3(4):

13 Salisbury, et al. Am J Cardiol. 2011; 162(2): e3.

14 Why is HAA Important? HAA is often persistent in follow-up Persistent 31% Resolved 69% Persistence is associated with worse health status Salisbury, et al. Am J Cardiol; 2011: 108(7):

15 SF-12 PCS Scores Across Follow-up Points (95% CI) Unadjusted Persistent vs. Resolved (-3.71, -0.55) Multivariable Adjusted Persistent vs. Resolved (-3.95, -0.84) Salisbury, et al. Am J Cardiol; 2011: 108(7):

16 Why is HAA Important? In contrast to chronic anemia, may be preventable Related to processes of care Peri-procedural bleeding Other modifiable risk factors?

17 HAA Incidence Across TRIUMPH Hospitals % 90.00% 80.00% 70.00% Range 33.3% to 69.2% Median rate ratio for hospital site: 1.13 (95% CI ) 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Hospital Salisbury, et al. Circ Cardiovasc Qual Outcomes; 2010: 3(4):

18 HAA commonly occurs in the absence of bleeding Without In-Hospital Bleeding 87% Inpatient Bleeding 13% Even in pts with severe HAA 48% had no documented bleeding Salisbury, et al. Circ Cardiovasc Qual Outcomes; 2010: 3(4):

19 Potentially Modifiable Risk Factors Bleeding Phlebotomy Unrecognized Iron Deficiency HAA Non-Modifiable Risk Factors Age Gender Underlying comorbidities (i.e. renal disease, heart failure) Acute inflammation from myocardial necrosis Hemodilution

20 Diagnostic Blood Loss From Phlebotomy and HAA HAA commonly develops in the absence of recognized bleeding Could phlebotomy be a risk factor for HAA? Small studies in non-cardiac populations More blood transfusions, in-hospital Hgb declines No studies had tested the relationship between diagnostic blood loss and HAA in AMI patients Thavendiranathan P, et al. J Gen Intern Med. 2005; 20(6): Chant C.Crit Care. 2006; 10(5):R140.

21 Cerner Health Facts Health Facts captured de-identified data of consecutive AMI hospitalizations Detailed demographic and comorbidity data as well as all in-hospital labs, medications, procedures, complications Date & time of all labs drawn and tests ordered with each draw known for all patients

22 AMI Dx, elevated biomarkers, > 24 hour stay, only 1 st AMI N=38,422 n=37,892 Transfers from other hospitals (n=81), from hospital enrolling < 20 pts (n=57), LOS > 31 days (n=392) CABG during admission (n=3,990) n=33,902 n=28,100 No Hgb 1 st 24 hrs (n=2,225), Fewer than 2 Hgb values (n=3,577) Anemic on admit Hgb N = 17,676 (from 57 hospitals) with AMI & no anemia at admission (n=10,424)

23 Anemia Definition Age, gender and race specific more accurate than WHO Beutler and Waalen Anemia Definition (g/dl) Male <60 Male 60 Female Caucasian Non-Caucasian Beutler and Waalen. Blood. 2006;107(5):

24 HAA Severity Definitions Mild - Hgb > 11.0 g/dl Moderate-Severe - Hgb 11.0 g/dl Only moderate-severe HAA associated with poor outcomes Used as outcome of present study Salisbury, et. al. Circ Cardiovasc Qual Outcomes; 2010: 3(4):

25 Blood Loss from Phlebotomy Date/time of all phlebotomy events known Based upon tests obtained, types of tubes needed to run labs identified Conservative assumptions - assumed a single tube of each type per phlebotomy event Did not account for wasted blood volume # and type of tubes multiplied by standard volumes for each type of tube based on prior literature

26 Blood Volumes Per Tube Chemistries 5 ml CBCs (EDTA tube) 5 ml Coagulation Studies (citrate) 4.5 ml ABGs 2 ml Blood cultures 10 ml per culture Chant C.Crit Care. 2006; 10(5):R140.

27 Between Hospital Variability Mean estimated diagnostic blood loss from phlebotomy over course of hospitalization at each Health Facts hospital Shrinkage estimates to account for smaller enrollments

28 Statistical Analyses Multivariable Poisson regression with robust error variance Adjusted for potential confounders based upon clinical experience and prior literature Zou, G. Am J Epidemiol. 2004;159(7):

29 Incidence of Moderate-Severe HAA 20.1% 3551 patients (20.1%) developed moderatesevere HAA 79.9% Salisbury, et al. Arch Intern Med; 171(18):

30 Patient Characteristics Moderate-severe HAA (n=3,551) Mild HAA or No HAA (n=14,125) p-value Age (mean±sd) 71.9 ± ± 14.5 < Gender (% female) 2481 (69.9%) 4651 (32.9%) < Race (% Caucasian) 2933 (82.6%) (87.2%) < Heart failure 1377 (38.8%) 2995 (21.2%) < Chronic kidney disease 454 (12.8%) 648 (4.6%) < Diabetes 1134 (31.9%) 3566 (25.2%) < Cardiogenic shock 336 (9.5%) 305 (2.2%) < In hospital mechanical ventilation 390 (11.0%) 422 (3.0%) < Length of stay (Median (IQR)) 6.5 (4.1, 10.1) 3.5 (2.5, 5.0) < 0.001

31 Diagnostic Blood Loss Diagnostic Blood Loss (ml) % 173.8of patients p<0.001 with moderatesevere HAA had > 300 ml drawn 3.8% > 500 ml of blood drawn Moderate-severe HAA No Moderate-severe HAA Salisbury, et al. Arch Intern Med; 171(18):

32 Shrinkage Estimates of Diagnostic Blood Loss Across Hospitals Total diagnostic blood loss (ml) Moderate-severe HAA No Moderate-severe HAA Moderate-severe HAA: range ml Mild HAA or No HAA: range ml Hospital

33 Multivariable Model Variable RR Lower CI Upper CI p-value Diagnostic blood loss <.0001 (per 50 ml) Age (10 year increase) <.0001 Female <.0001 Non-Caucasian <.0001 ST elevation MI Acute Renal Failure Heparin Cardiogenic Shock In hospital Cath or PCI Glycoprotein IIb/IIIa <0.001 inhibitor Bivalirudin Antiplatelet Beta-Blocker Statin ACE/ARB Aspirin Thrombolytics Mechanical ventilation <.0001 CKD <.0001 Prior MI Diabetes Heart failure Hypertension <.0001 Adjusted for a broad spectrum of potential confounders: Each 50 ml of diagnostic blood loss associated with a 15% increase in the risk of moderate-severe HAA

34 Potential Impact of Pediatric Tubes Low volume pediatric tubes require no changes in clinical practice of ordering diagnostic tests, little change in cost to hospitals Compared with the primary analyses 64% reduction in mean blood loss in moderatesevere group 68% reduction in mean blood loss in other pts Salisbury, et al. Arch Intern Med; 171(18):

35 Reducing Diagnostic Blood Loss Widespread use of pediatric tubes Little to no extra cost to hospitals, often compatible with existing equipment Important reductions in diagnostic blood loss without changes in physician behavior Increasing use of stored serum samples Routinely batching lab draws Eliminating unnecessary scheduled phlebotomy

36 Hematologic/Iron Deficiency Evaluation 100% % with moderate-severe HAA 90% 80% 70% 60% 50% 40% 30% 20% 10% 18.3% 28.0% p< % 45.5% 0% Normal RDW & MCV Normal RDW & low MCV Elevated RDW & normal MCV Elevated RDW & low MCV Salisbury, et al. Am J Cardiol. 2012; 109(1):13-18.

37 Periprocedural Bleeding Avoidance Variety of catheterization lab strategies have been advocated

38 Current Study Pilot project Implementing common sense measures to reduce diagnostic phlebotomy volumes 800 patients 400 pre, 400 post intervention Multidisciplinary team Process of care changes

39 As part of the Hospital Acquired Anemia study you are involved in use 2ml Tubes (Pedi Tubes) for lab draws Smaller tube volume (2ml) White ring = Pediatric tube Routine microdraws for ABG (<1 ml) Place sign above patient s bed and magnet on door frame for communication to phlebotomist

40 As part of the Hospital Acquired Anemia (HAA) study you are involved in please use the new reinfusion kit for all of your central line draws

41 As part of the Hospital Acquired Anemia (HAA) study you are involved in please use the SIL process for lab draws whenever possible Automatic SIL labs, unless specified by MD

42 As part of the Hospital Acquired Anemia (HAA) study you are involved in routine labs will now batch All routine labs batched 0830, 1430, and 2300 Draw and result times are approximate Timed and Stat lab orders: no changes 0830 Batching Time 0900 Labels print, phlebotomist to draw 1130 Results available 1430 Batching Time 1500 Labels print, phlebotomist to draw 1730 Results available 2300 Batching Time: same as current practice

43 As part of the Hospital Acquired Anemia (HAA) study you are involved in you may see In addition to the previous interventions you may see this sticker on the outside of your patient s chart. This sticker is to communicate to the physician that your patient is at high risk for anemia and to consider limiting blood draws. Monthly resident education sessions to reinforce judicious blood draw practices

44 Conclusions HAA is common at the time of acute coronary syndromes HAA portends a poor prognosis May be preventable by changing processes of in-hospital care Future directions Impact of phlebotomy reduction on outcomes Role of iron deficiency screening, hematologic evaluation Combined approach including bleeding prevention measures in the CV lab for high risk patients

45 Thank you! Contact information: Adam Salisbury, MD, MSc Saint Luke s Mid America Heart Institute 4401 Wornall Road, Kansas City, MO Phone: Fax: salisbury.adam@yahoo.com