The REALITY trial showed that a restrictive PRBC transfusion strategy (transfusion for Hgb ≤8 g/dl, goal Hgb 8-10 g/dl) is noninferior to a more liberal strategy (transfusion for Hgb ≤10 g/dl, goal Hgb >11 g/dl).
The goal of the trial was to assess the safety and efficacy of a restrictive versus liberal red blood cell (RBC) transfusion strategy among patients with acute myocardial infarction (AMI) and anemia.
Patients with AMI and hemoglobin (Hgb) ≤8 to ≤10 g/dl during admission were randomized in a 1:1 fashion to either a liberal (for Hgb ≤10 g/dl, goal Hgb >11 g/dl) (n = 342) or a restrictive (for Hgb ≤8 g/dl, target Hgb 8-10 g/dl) (n = 324) RBC transfusion strategy. The strategies should be maintained until discharge from hospital or for 30 days, whichever comes first.
Inclusion criteria:
Exclusion criteria:
Other salient features/characteristics:
The primary outcome, all-cause death, reinfarction, stroke, and emergency revascularization prompted by ischemia for restrictive vs. liberal transfusion strategy, was 11.0% vs. 14.0% (hazard ratio 0.77, 95% confidence interval 0.50-1.18, p < 0.05 for noninferiority, p = 0.22 for superiority).
Secondary outcomes for restrictive vs. liberal transfusion strategy:
The results of this trial indicate that a restrictive PRBC transfusion strategy (transfusion for Hgb ≤8 g/dl, goal 8-10 g/dl) is noninferior to a more liberal strategy (transfusion for Hgb ≤10 g/dl, goal Hgb >11 g/dl). In addition, infections and acute lung injury were higher with a more liberal strategy. Total blood utilization and costs were both lower with the restrictive strategy; this strategy was considered cost-dominant.
This is an important trial, and argues against the 10/30 rule that was once commonly practiced post-ACS. One minor point is that transfusions are frequently administered for Hgb ≤7 in clinical practice in the United States; the threshold studied in this trial was slightly higher (8 g/dl), possibly due to lack of equipoise for Hgb levels ≤7 g/dl. Similar results in favor of a restrictive strategy have been noted for post-cardiac and noncardiac surgery patients.
https://www.acc.org/latest-in-cardiology/clinical-trials/2020/08/29/13/09/reality