Liberal or Restrictive Transfusion Thresholds for Surgery Patients with High Cardiac Risk

Current RBC transfusion guidelines recommend a restrictive transfusion strategy for most patients, but ambiguity still remains for patients with high cardiac risk. The Transfusion Trigger after Operations in High Cardiac Risk Patients (TOP) trial compared restrictive (<7 g/dL) and liberal (<10 g/dL) transfusion strategies in adult veterans with high cardiac risk (e.g., heart or arterial disease, myocardial infarction, or stoke) undergoing vascular or general surgery. From 2018 to 2023, 1428 adult veterans (mean age, 70 years; 98% male; 75% White) with anemia and high cardiac risk were randomized 1:1 to receive RBC transfusions after vascular (91%) or general surgery based on a restrictive or liberal transfusion threshold and followed for 90 days or until death. A total of 1878 RBC units were transfused in the liberal arm during the study compared to 307 units in the restrictive arm with 6.5% and 77% of patients not transfused, respectively. The primary composite outcome (death or major ischemic event) at 90 days was similar—9.1% in the liberal arm compared to 10.1% in the restrictive arm (relative risk [RR] = 0.90; 95% CI: 0.65-1.24). However, the 90-day composite of cardiac complications other than myocardial infarctions was significantly lower in the liberal arm compared with the restrictive arm (6% vs 10%, respectively; RR = 0.59; 99% CI: 0.36-0.98), and most point estimates for outcomes slightly favored a liberal strategy.  Overall, the TOP trial suggests no difference in death or major ischemic event rates between liberal and restrictive transfusion thresholds for patients at high cardiac risk, but an individualized patient approach for transfusions that takes into account other clinical and laboratory markers may be warranted.

References:

1. Kougias P, Sharath SE, Zhan M, Carson JL et al. Liberal or Restrictive Postoperative Transfusion in Patients at High Cardiac Risk: The TOP Randomized Clinical Trial. JAMA. Published online November 08, 2025. doi:10.1001/jama.2025.20841
2. Jacobs JW, Bloch EM. Postoperative Transfusion in Patients at High Cardiac Risk: Evidence, Uncertainty, and Nuance. JAMA. Published online November 08, 2025. doi:10.1001/jama.2025.21559