doi:10.1016/j.jacc.2004.03.080 2004;44;547-553 J. Am. Coll. Cardiol.

Alexandra J. Lansky, and Gregg W. Stone Guagliumi, Thomas Stuckey, Mark Turco, David A. Cohen, Manuela Negoita,

Eulogio Garcia, Roxana Mehran, James E. Tcheng, John J. Griffin, Giulio Eugenia Nikolsky, Eve D. Aymong, Amir Halkin, Cindy L. Grines, David A. Cox,

(cadillac) trialabciximab and device investigation to lower late angioplasty complicationsprimary percutaneous coronary intervention: Analysis from the controlled Impact of anemia in patients with acute myocardial infarction undergoing

This information is current as of May 24, 2011

http://content.onlinejacc.org/cgi/content/full/44/3/547located on the World Wide Web at:

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Journal of the American College of Cardiology Vol. 44, No. 3, 2004© 2004 by the American College of Cardiology Foundation ISSN 0735-1097/04/$30.00Published by Elsevier Inc. doi:10.1016/j.jacc.2004.03.080

mpact of Anemia in Patients Withcute Myocardial Infarction Undergoingrimary Percutaneous Coronary Interventionnalysis From the Controlled Abciximab and Device Investigation

o Lower Late Angioplasty Complications (CADILLAC) Trialugenia Nikolsky, MD, PHD,*† Eve D. Aymong, MD, FACC,*† Amir Halkin, MD,*†indy L. Grines, MD, FACC,‡ David A. Cox, MD, FACC,§ Eulogio Garcia, MD,�oxana Mehran, MD, FACC,*† James E. Tcheng, MD, FACC,¶ John J. Griffin, MD, FACC,#iulio Guagliumi, MD,** Thomas Stuckey, MD, FACC,†† Mark Turco, MD, FACC,‡‡avid A. Cohen, MD, FACC,§§ Manuela Negoita, MD,*† Alexandra J. Lansky, MD, FACC,*†regg W. Stone, MD, FACC*†ew York, New York; Royal Oak, Michigan; Charlotte, Durham, and Greensboro, North Carolina; Madrid, Spain;irginia Beach, Virginia; Bergamo, Italy; Tacoma Park, Maryland; and Boston, Massachusetts

OBJECTIVES We sought to investigate the impact of anemia in patients with acute myocardial infarction(AMI) undergoing primary percutaneous coronary intervention (PCI).

BACKGROUND The prognostic importance of anemia on primary PCI outcomes is unknown.METHODS In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications

(CADILLAC) trial, 2,082 patients of any age with AMI within 12 h onset undergoing primaryPCI were randomized to balloon angioplasty versus stenting, each � abciximab. Outcomes werestratified by the presence of anemia at baseline, as defined by World Health Organization criteria(hematocrit �39% for men and �36% for women).

RESULTS Anemia was present in 260 (12.8%) of 2,027 randomized patients with baseline laboratoryvalues. Patients with versus without baseline anemia more frequently developed in-hospitalhemorrhagic complications (6.2% vs. 2.4%, p � 0.002), had higher rates of blood producttransfusions (13.1% vs. 3.1%, p � 0.0001), and had a prolonged (median 4.1 vs. 3.5 days, p� 0.0001) and more expensive (median costs $12,434 vs. $11,603, p � 0.002) index hospital-ization. Patients with versus without anemia had strikingly higher mortality during hospitalization(4.6% vs. 1.1%, p � 0.0003), at 30 days (5.8% vs. 1.5%, p � 0.0001), and at 1 year (9.4% vs. 3.5%,p � 0.0001). The rates of disabling stroke at 30 days (0.8% vs. 0.1%, p � 0.005) and at 1 year(2.1% vs. 0.4%, p � 0.0007) were also significantly higher in patients with anemia. By multivariateanalysis, anemia was an independent predictor of in-hospital mortality (hazard ratio, 3.26; p �0.048) and one-year mortality (hazard ratio, 2.38; p � 0.016).

CONCLUSIONS Anemia at baseline in patients with AMI undergoing primary PCI is common, and is stronglyassociated with adverse outcomes and increased mortality. (J Am Coll Cardiol 2004;44:547–53) © 2004 by the American College of Cardiology Foundation

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arly and late prognosis of patients with acute myocardialnfarction (AMI) is principally dependent on three majorariables: left ventricular function, susceptibility to ventric-lar arrhythmias, and residual ischemia after reperfusion1–3). Reduction in the hemoglobin concentration mayompromise oxygen supply to infarcted or ischemic myo-ardium, which may promote arrhythmias, worsen hypoten-ion, and increase infarct size (4–6). Two prior studies inatients with AMI treated conservatively suggest that early

From the *Cardiovascular Research Foundation, New York, New York; †Lenoxill Heart and Vascular Institute, New York, New York; ‡William Beaumontospital, Royal Oak, Michigan; §Mid Carolina Cardiology, Charlotte, Northarolina; �Hospital Gregorio Maranon, Madrid, Spain; ¶Duke Clinical Research

nstitute, Durham, North Carolina; #Virginia Beach General Hospital, Virginiaeach, Virginia; **Ospedali Riuniti di Bergamo, Bergamo, Italy; ††Moses Coneemorial Hospital, Greensboro, North Carolina; ‡‡Washington Adventist Hospital,

acoma Park, Maryland; and §§Beth Israel Hospital, Boston, Massachusetts.Manuscript received January 12, 2004; revised manuscript received February 24,

(004, accepted March 11, 2004.

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nd late mortality may be increased in patients presentingith anemia (7,8). No data are available regarding the

mpact of anemia on outcomes of patients undergoingrimary percutaneous coronary intervention (PCI) for AMI.herefore, we examined the database from the large, mul-

icenter randomized Controlled Abciximab and Devicenvestigation to Lower Late Angioplasty ComplicationsCADILLAC) trial to determine the effect of anemia onarly and late outcomes of patients with AMI undergoingrimary PCI.

ETHODS

he CADILLAC protocol, inclusion and exclusion criteria,nd principal results have been reported in detail elsewhere9). Briefly, 2,082 patients of any age with AMI within 12 hnset undergoing primary PCI were randomized to balloonngioplasty versus stenting with the Multilink stent

Guidant Corp., Santa Clara, California), each with versus

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548 Nikolsky et al. JACC Vol. 44, No. 3, 2004Anemia and Primary Angioplasty Outcomes August 4, 2004:547–53

ithout abciximab (Centocor, Malvern, Pennsylvania).ith regard to hemorrhagic risk, patients were excluded

ith a history of bleeding diathesis, major surgery withinhe preceding six weeks, gastrointestinal or genitourinaryleeding within six months, cerebrovascular event withinwo years, or any permanent residual neurological defect, aistory of leukopenia, thrombocytopenia, hepatic or renalysfunction, or recent administration of a thrombolyticgent. Anemia at baseline was not an exclusion criterion,owever, and baseline laboratory values were not required toe available before enrollment and performance of PCI.The primary composite end point included death from

ny cause, reinfarction, repeat target vessel revascularizationTVR) as a result of ischemia, or disabling stroke after the

able 1. Baseline Clinical Characteristics and Angiographic Featu

Patientsn

linical characteristicsMale genderAge (years) 65Diabetes mellitusHypertensionHyperlipidemiaCurrent smokingPrior myocardial infarctionPrior percutaneous coronary interventionPrior coronary bypass surgeryPrior stroke or transient ischemic attackHistory of peripheral vascular diseaseHistory of gastrointestinal bleedingHistory of genitourinary bleedingKillip class �IIBody mass index (kg/m2) 26.2Baseline hemoglobin (g/dl) 12.3Baseline hematocrit (%) 36.0

Hematocrit range 1Baseline platelet count (�103 cells/mm3) 219Baseline serum creatinine (mg/dl) 1.1ST-segment elevation or left bundle branch blockSymptom onset to balloon inflation (h) 4.1

ngiographic featuresSingle-vessel diseaseDouble-vessel diseaseTriple-vessel diseaseLeft ventricle ejection fraction (%) 50Infarct related artery

Left anterior descending arteryLeft circumflex arteryRight coronary artery

Abbreviations and AcronymsAMI � acute myocardial infarctionCADILLAC � Controlled Abciximab and Device

Investigation to Lower Late AngioplastyComplications trial

PCI � percutaneous coronary interventionTIMI � Thrombolysis In Myocardial InfarctionTVR � target vessel revascularizationWHO � World Health Organization

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ndex procedure. The definitions of the primary end pointave been previously described (9). Anemia was definedsing World Health Organization (WHO) criteria as aematocrit value at initial presentation �39% for men and36% for women (10).Clinical follow-up at 30 days, 6 months, and 1 year were

erformed in all patients. All events were adjudicated by anndependent clinical events committee. Medical care costsere assessed for all U.S. patients using previously validatedethodology (11). Detailed resource utilization data were

ecorded for all revascularization procedures, and proceduralosts were based on measured resource utilization and 2001nit costs. Nonprocedural hospital costs were estimated byonverting hospital charges to costs according to hospitalnd cost-center specific cost-to-charge ratios. Costs fornpatient and outpatient physician services were calculatedsing the 2001 Massachusetts Medicare fee schedule.tatistical analysis. Categorical variables were comparedith the Fisher exact test. Continuous variables are pre-

ented as medians with interquartile ranges, and wereompared using the Kruskal-Wallis test. Survival data wasstimated by the Kaplan-Meier method and compared byhe log-rank test. Multivariate analysis of predictors ofeath at several time periods was performed using Cox

h Anemia60

Patients Without Anemian � 1,767 p Value

73.9% 0.054) 58 (50, 68) � 0.0001

15.8% 0.0346.7% 0.00337.9% 0.6845.2% � 0.000113.8% 0.8510.9% 0.212.0% 0.992.9% 0.562.2% 0.020.9% 0.020.2% � 0.99

10.0% 0.0009, 29.7) 27.4 (24.9, 30.6) 0.0005, 13.0) 14.9 (14.0, 15.7) � 0.0001, 38.2) 43.7 (41.1, 46.2) � 0.00018.9 36.0–66.8 —276) 232 (195, 273) 0.061.4) 1.0 (0.9, 1.2) � 0.0001

87.5% 0.396.0) 4.0 (2.9, 6.1) 0.40

51.7% 0.2132.5% 0.1415.8% 0.93

0) 50 (40, 55) 0.46

37.5% 0.3418.3% 0.1244.1% 0.03

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549JACC Vol. 44, No. 3, 2004 Nikolsky et al.August 4, 2004:547–53 Anemia and Primary Angioplasty Outcomes

roportional hazards regression with stepwise selectionsing entry and exit criteria of p � 0.1. The candidateariables entered in the model included age, gender, diabe-es mellitus, hypertension, hypercholesterolemia, currentmoking, history of prior myocardial infarction or coronaryrtery bypass graft surgery, Killip class �2 creatinine clear-nce, left anterior descending artery as an infarct vessel,riple-vessel disease, treatment with abciximab or stent, timerom the symptom onset to the first balloon inflation, andaseline anemia (as a binary variable) or baseline hematocritas a continuous variable). Separate models were thenenerated adding in baseline medication use. All analysesere two-sided, and significance was established at the 0.05

evel.

ESULTS

aseline clinical characteristics. A baseline hematocritefore PCI was available in 2,027 (97.4%) of the 2,082atients enrolled in the CADILLAC trial, 260 (12.8%) ofhom had anemia. As seen in Table 1, patients with anemiaere older, more frequently female, and had smaller bodyass index. Pre-existing diabetes mellitus, hypertension,

eripheral arterial disease, and past gastrointestinal bleedingere all significantly more common in patients with anemia.ongestive heart failure at the time of presentation was also

Table 2. Procedural Results

Patients Withn � 2

TIMI flowBaseline

Grade 0 or 1 67.9%Grade 2 9.1%Grade 3 23.0%

FinalGrade 0 or 1 2.0%Grade 2 3.2%Grade 3 94.8%

Reference diameter (mm)Baseline 2.93 (2.60Final 2.94 (2.66

Minimal luminal diameter (mm)Baseline 0 (0, 0Final 2.47 (2.10

Diameter stenosis (%)Baseline 100 (73.4Final 17.4 (9.1,

Procedural success 89.2%Stent implanted

Per randomization 48.8%As bail-out for complications 6.5%

Abciximab administeredPer randomization 55.0%As bail-out for complications 4.6%

TIMI � Thrombolysis In Myocardial Infarction.

ore frequent in anemic patients. p

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rocedural and in-hospital results. Pre- and post-PCIumen dimensions, procedural success rates, and finalhrombolysis In Myocardial Infarction (TIMI) flow gradesere similar in patients with and without anemia (Table 2),

s were peak creatine phosphokinase levels (median 1,339s. 1,413 U/l, respectively, p � 0.13). Patients with versusithout anemia more frequently developed moderate or

evere hemorrhagic complications in-hospital (6.2% vs..4%, p � 0.002), and had higher rates of blood productransfusions (13.1% vs. 3.1%, respectively, p � 0.0001).artly as a result, the index hospitalization was significantlyrolonged in patients with anemia (4.1 [3.0, 6.5] vs. 3.52.8, 5.1] days, p � 0.0001), and in-hospital costs wereignificantly greater ($12,434 [$10,158, $16,412] vs.11,603 [$9,587, $14,631], p � 0.002).linical follow-up. As seen in Table 3 and Figure 1, rates

f mortality (all-cause, cardiac, and noncardiac) and dis-bling stroke were markedly higher in patients with baselinenemia compared with those without anemia, during then-hospital phase and at 30 days and 1 year. Mortality waslso higher in patients with baseline anemia between theime of discharge and one year (6.2% vs. 2.4%, p � 0.001).n patients with anemia, the majority of disabling strokes atne year were ischemic (1.7%), and the minority (0.1%)ere hemorrhagic. In patients without anemia, stroke wasemorrhagic in 0.1% of patients, ischemic in 0.1% of

mia Patients Without Anemian � 1,767 p Value

68.0% 0.9910.0% 0.7422.0% 0.75

1.3% 0.393.0% 0.84

95.6% 0.51

) 2.95 (2.61, 3.33) 0.31) 2.99 (2.63, 3.37) 0.31

0 (0, 0.72) 0.80) 2.46 (2.09, 2.81) 0.58

) 100 (75.5, 100) 0.6918.1 (8.9, 27.1) 0.83

91.6% 0.22

49.9% 0.798.4% 0.33

49.7% 0.112.8% 0.12

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550 Nikolsky et al. JACC Vol. 44, No. 3, 2004Anemia and Primary Angioplasty Outcomes August 4, 2004:547–53

Mortality was significantly increased in both men andomen with anemia (Fig. 2A); the increase in disabling

troke with anemia was significant in women, and a similarrend was present in men (Fig. 2B). There were noifferences in the rates of reinfarction or recurrent ischemiaecessitating repeat TVR between anemic and nonanemicatients.

ultivariate analysis. Considering baseline clinical andngiographic variables, anemia was identified as an inde-endent predictor of in-hospital and one-year mortality byultivariate analysis (Table 4). Similarly, when baseline

ematocrit as a continuous variable rather than anemia wasntroduced into the regression model, hematocrit was also aignificant predictor of one-year mortality (hazard ratio �.06 [95% confidence interval 1.01 to 1.12], p � 0.042).

hen added to these models, neither nadir hematocritalue, absolute decrease in hematocrit, or blood transfusionsorrelated with mortality. There was no statistically signif-cant interaction between baseline hematocrit and otherariables (age, gender, prior myocardial infarction, priororonary bypass surgery, hypertension, diabetes, hypercho-esterolemia, smoking, peripheral vascular disease, conges-ive heart failure, and creatinine clearance) when specificallyssessed with an interaction term in either in-hospital or inne-year multivariable models.

edication use. At admission, patients with anemia were

Table 3. In-Hospital, 30-Day, and 1-Year Ou

Patients WAnemin � 26

All-cause mortalityIn-hospital 4.6%30-day 5.8%1-year 10.2%

Cardiac mortalityIn-hospital 2.4%30-day 2.8%1-year 6.1%

Noncardiac mortalityIn-hospital 2.3%30-day 3.2%1-year 4.2%

Disabling strokeIn-hospital 0.4%30-day 0.8%1-year 2.1%

ReinfarctionIn-hospital 0.8%30-day 1.6%1-year 2.9%

Target vessel revascularizationIn-hospital 2.7%30-day 3.5%1-year 14.2%

Composite adverse eventsIn-hospital 7.7%30-day 10.4%1-year 20.3%

ess likely to be treated with aspirin than those without p

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nemia. At discharge, 30-day, and 1-year follow-up, signif-cantly fewer patients with baseline anemia were treatedith aspirin, beta-blockers, and statins (Table 5). Whileore patients with anemia were prescribed angiotensin-

onverting enzyme inhibitors or receptor blockers at dis-harge, use of this class of drugs was similar in patients withnd without anemia at 30 days and 1 year. When admissionedication use was added to the multivariate models,

aseline anemia continued to be an independent predictorf mortality during both the in-hospital period (hazard ratio

3.36 [95% confidence interval 1.10 to 11.20], p � 0.05)nd at 1 year (hazard ratio � 2.38 [95% confidence interval.18 to 14.80], p � 0.016).

ISCUSSION

rior studies have suggested a link between baseline hematocritnd adverse outcomes in patients with cardiac disease andMI treated conservatively. In a retrospective analysis of8,974 Medicare beneficiaries, lower baseline hematocrit val-es were associated with higher 30-day mortality rates afterMI; only 10% of patients were treated by PCI in this series,owever (7). Similarly, one-year mortality was higher innemic patients in a report from the Myocardial Infarctionata Acquisition System (8). The association between baseline

ematocrit and outcomes after primary PCI have not been

es Stratified by Baseline Anemia

Patients WithoutAnemia

n � 1,767 p Value

1.1% 0.00031.5% � 0.00013.5% � 0.0001

1.0% 0.061.4% 0.022.5% 0.002

0.2% 0.0010.3% � 0.00011.1% 0.0002

0.0% 0.120.1% 0.0050.4% 0.0007

0.2% 0.120.7% 0.162.3% 0.58

2.4% 0.833.8% 0.85

16.7% 0.34

3.6% 0.0045.2% 0.0008

17.3% 0.15

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551JACC Vol. 44, No. 3, 2004 Nikolsky et al.August 4, 2004:547–53 Anemia and Primary Angioplasty Outcomes

In the present large trial of contemporary mechanicaleperfusion strategies in AMI, anemia, as defined by WHOriteria, was common, occurring in 12.8% of patients. Asatients with hemorrhagic diatheses and recent bleedingere excluded from the CADILLAC trial, the true inci-ence of anemia in a more general population of patientsresenting for primary PCI is likely to be higher, especiallyiven the increasing incidence of anemia as the populationges (7,12,13). Patients with anemia had an increasedrequency of comorbid risk factors known to worsen prog-osis after AMI, including advanced age, female gender,nd diabetes mellitus (14,15). Despite similar rates ofrocedural success and infarct size, patients with baselinenemia had a significantly more complicated hospitalourse, including greater rates of hemorrhagic complicationsnd blood product transfusion requirements. Hospitaliza-ion was significantly prolonged in patients with anemia,nd costs were significantly greater. Most importantly,aseline anemia was strongly associated with an approxi-ate three-fold increase in in-hospital, 30-day, and 1-yearortality. The impact of anemia on early and late death was

resent in both genders (though was especially profound inomen), despite the different gender-based thresholds for

nemia as established by WHO (10). Anemia was alsotrongly associated with an increased risk of disablingtroke, especially in women, a finding not previously re-orted.The reasons for the worse outcomes in anemic patients

ith AMI treated with primary PCI are likely multifacto-ial. Anemia may by itself confer excess risk; decreasedlood oxygen levels may be arrhythmogenic, directly exac-rbate myocardial ischemia, activate the sympathetic ner-

Figure 1. Cumulative risk of death

ous system, and result in cerebral hypoperfusion (4–6). p

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lternatively, anemia was a covariate with other high-riskeatures known to reduce survival after AMI. Patients withnemia were older, more commonly women, and had aigher prevalence of cardiovascular risk factors includingiabetes and chronic renal insufficiency, factors known toorsen the prognosis of patients after AMI and primaryCI (14–19). Peripheral arterial disease, which is a markerf diffuse atherosclerosis (20,21), was more prevalent inatients with anemia. Clinical congestive heart failure waslso significantly more common at presentation in patientsith anemia, although left ventricular ejection fraction wasot measured to be different. Even after multivariate adjust-ent for the important confounders, anemia remained an

ndependent predictor of in-hospital and one-year mortal-ty. However, multivariate models cannot entirely accountor the baseline differences, and adjusted effects may still benfluenced by residual confounding. Additional clinical

easurements not included in this analysis (e.g., certainomorbidities or inflammatory markers) may also interactith anemia.Differences in pharmacologic treatment may also have

ontributed to the worse late prognosis in patients withnemia. Specifically, anemic patients were less likely to bereated with aspirin, beta-blockers, and statins, all of whichre known to prolong survival after AMI (22–25). Whenifferences in medication use at the time of admission wereonsidered in the multivariate model, aspirin continued toe an independent determinate of mortality both in-hospitalnd at one year. These models are unable to correct forostdischarge medication use, however, as approximatelyne-half of the deaths in patients with anemia occurredefore hospital discharge. Notably, almost one-fifth of

tients with versus without anemia.

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ne-year follow-up, presumably due to their increasedncidence of preadmission gastrointestinal bleeding, theirreater rate of hemorrhagic events during the index hospi-alization, and possible concerns about recurrent bleeding.onsidering the impact of anemia on late survival inospital survivors, the decreased mortality between the timef discharge and one year in patients with a reduced baselineematocrit may be, at least partly, explained by the lowerate of aspirin prescription at discharge. Of note, priortudies demonstrating increased late mortality in patients

igure 2. Rates of survival (A) and disabling stroke (B) at 1 year in patientsndergoing percutaneous coronary intervention for acute myocardial in-arction stratified by baseline anemia and gender. Open bars � 30 days;olid bars � 1 year.

Table 4. Multivariate Predictors of Mortality

In-hospital mortalityEjection fraction (lower)Creatinine clearance (lower)Baseline anemia

1-year mortalityEjection fraction (lower)Age (older)Left anterior descending infarct arteryTriple-vessel diseaseBaseline anemiaFemale gender

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ith anemia and cardiovascular disorders did not examinehe extent to which differences in medication usage mayave contributed to the worse prognosis with this condition8,26).tudy limitations. This post-hoc analysis was not pre-pecified and should, thus, be considered hypothesis-enerating, and complementary to large, prospectively col-ected observational databases. The causes of anemia in theatients in our study were not known, and the prognosticmportance of anemia may vary with different etiologies.he indications for and timing of blood product transfu-

ions were not protocol-specified but, rather, left to localtandards of care; whether a policy of early routine bloodransfusion in anemic patients would improve their prog-

Hazard Ratio5% Confidence Interval) p Value

1.10 (1.05, 1.15) � 0.00011.03 (1.01, 1.06) 0.023.26 (1.01, 10.52) 0.048

1.05 (1.03, 1.09) � 0.00011.05 (1.02, 1.08) 0.00042.60 (1.32, 5.09) 0.0062.27 (1.20, 4.30) 0.012.38 (1.18, 4.81) 0.0161.89 (1.02, 3.50) 0.04

able 5. Medication Use at Different Time Intervals as aunction of Baseline Anemia

PatientsWith

Anemian � 260

PatientsWithoutAnemia

n � 1,767 p Value

t admissionAspirin 33.1% 26.1% 0.02Thienopyridine 3.1% 2.5% 0.53ACE inhibitor or ARB 12.7% 9.0% 0.07Beta-blocker 17.3% 14.4% 0.22Statin 13.1% 11.8% 0.53

t dischargeAspirin 91.2% 96.0% 0.001Thienopyridine 65.0% 66.7% 0.57ACE inhibitor or ARB 41.2% 33.3% 0.01Beta-blocker 67.7% 79.2% � 0.0001Statin 20.8% 30.5% 0.001

t 30 daysAspirin 88.5% 93.3% 0.01Thienopyridine 52.7% 55.5% 0.38ACE inhibitor or ARB 31.9% 31.9% 0.99Beta-blocker 69.6% 82.1% � 0.0001Statin 29.2% 40.7% 0.0004

t 1 yearAspirin 81.2% 87.5% 0.006Thienopyridine 6.1% 5.9% 0.89ACE inhibitor or ARB 30.8% 29.7% 0.71Beta-blocker 62.3% 72.6% 0.0009Statin 39.2% 48.7% 0.004

CE � angiotensin-converting enzyme; ARB � angiotensin receptor blocker.

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553JACC Vol. 44, No. 3, 2004 Nikolsky et al.August 4, 2004:547–53 Anemia and Primary Angioplasty Outcomes

osis is unknown. Finally, no information was availableegarding the correction of anemia at follow-up, or whetherdditional hemorrhagic events occurred.onclusions and clinical implications. Baseline anemia

n patients with AMI undergoing primary PCI should beecognized as an important risk factor for prolonged hospi-alization, increased hospital costs, and adverse short-termnd late outcomes, including death and disabling stroke.

edications known to improve survival in AMI patients,ncluding enteric-coated aspirin, beta-blockers, and statinshould not be withheld from this high-risk population if atll possible. Further study is warranted to determinehether early red blood cell transfusions would improve therognosis of patients with anemia and AMI undergoingrimary PCI.

cknowledgmenthe authors are grateful to Prof. Stuart J. Pocock for his

tatistical review of this manuscript.

eprint requests and correspondence: Dr. Gregg W. Stone,ardiovascular Research Foundation, 55 East 59th Street, 6thloor, New York, New York 10022. E-mail: gstone@crf.org

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doi:10.1016/j.jacc.2004.03.080 2004;44;547-553 J. Am. Coll. Cardiol.

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(cadillac) trialabciximab and device investigation to lower late angioplasty complicationsprimary percutaneous coronary intervention: Analysis from the controlled Impact of anemia in patients with acute myocardial infarction undergoing

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