Anemia Is Associated With Increased One-Year Mortality

and Ischemic Events in Patients With ACS: Results

From the ACUITY TrialSteven V. Manoukian, George D. Dangas, Michele D. Voeltz, Frederick Feit,

Roxana Mehran, and Gregg W. StoneEmory University School of Medicine, Atlanta, GA; Columbia University Medical Center and The Cardiovascular Research Foundation, New York, NY; New York

University School of Medicine, New York, NY

● The ACUITY Trial randomized 13,819 patients with moderate and high-risk NSTE-ACS.

Moderate-high risk

ACS

Ang

iogr

aphy

with

in 7

2h

Aspirin in allClopidogrel

dosing and timingper local practice

UFH orUFH orEnoxaparinEnoxaparin+ GP IIb/IIIa+ GP IIb/IIIa

BivalirudinBivalirudin+ GP IIb/IIIa+ GP IIb/IIIa

BivalirudinBivalirudinAlone Alone

R*

Medicalmanagement

PCI

CABG

STUDY DESIGN

ACUITY Primary Results – 30 Days

7.3%5.7%

11.7%

7.7%

11.8%

5.3%

3.0%

10.1%

7.8%

Net clinicaloutcome

Compositeischemia

Major bleeding(non-CABG)

30 d

ay e

vent

s (%

)

UFH/Enox+ GP IIb/IIIa (N=4603)Bivalirudin+GP IIb/IIIa (N=4604)Bivalirudin alone (N=4612)

PNI = 0.011 PSup = 0.32

PNI <0.001PSup <0.001

PNI <0.001PSup = 0.015

ACUITY Primary Results – 1 Year

0 1 2

0.96 (0.77-1.18)

HR (95% CI)Hazard ratio

±95% CIHazard ratio

±95% CI

Bivalirudin alone betterBivalirudin alone better Heparin + GPI betterHeparin + GPI better

CompositeIschemia

Mortality

1.06 (0.95-1.17)

P-value

0.67

0.29

● Baseline anemia is associated with an increased risk of short-term (30-day) ischemic complications and mortality in ACS. Whether anemia adversely impacts long-term outcomes is less clear.

● Anemia was defined using WHO criteria:- hgb <13 g/dL men- hgb <12 g/dL women

● We assessed the impact of anemia on rates of long-term (1-year) ischemic events and mortality in patients with ACS in the ACUITY trial.

BACKGROUND & OBJECTIVES

Baseline CharacteristicsAnemic

(N=2,200, 16.9%)Non-Anemic

(N=10,839, 83.1%) P value

Age (median [range], yrs) 68 (23, 95) 62 (20, 92) <0.0001

Male 64.6 71.3 <0.0001

Weight (median [IQR], kg) 82 (70, 94) 84 (73, 95) <0.0001

Diabetes 42.9 24.7 <0.0001

Hypertension 79.3 64.5 <0.0001

Hyperlipidemia 65.7 55.3 <0.0001

Current smoker 17.1 31.5 <0.0001

Prior MI 36.6 30.1 <0.0001

Prior PCI 49.7 36.8 <0.0001

Prior CABG 24.1 16.5 <0.0001

Hemoglobin (mean) 11.6 14.5 <0.0001

Baseline CrCl <60 mL/min 33.5 16.2 <0.0001

CKMB/Troponin 55.4 60.0 <0.0001

10.3%

7.2%

3.9%

9.9%

16.4%

8.8%

Net clinicaloutcome

Compositeischemia

Major bleeding(non-CABG)

30 d

ay e

vent

s (%

)

Anemic patients (N=2200)Non-anemic patients (N=10,839)

P=<0.0001

P=<0.0001P=<0.0001

Anemic vs Non-Anemic Population30-Day Event Rates

Anemic vs Non-Anemic Population:1-Year Ischemic Event Rates

14.6%

20.8%

Composite ischemia

1 Ye

ar e

vent

s (%

)

Anemic patients (N=2,200)Non-anemic patients (N=10,839)

P<0.0001

Anemic Population30-Day Event Rates by Treatment

9.6% 9.8%

16.5%

10.1%

17.2%

9.5%

7.0%

15.5%

10.0%

Net clinicaloutcome

Compositeischemia

Major bleeding(non-CABG)

30 d

ay e

vent

s (%

)UFH/Enox+ GP IIb/IIIa (N=732)Bivalirudin+GP IIb/IIIa (N=739)Bivalirudin alone (N=729)P=0.74 P=0.59

P=0.71 P=0.77P=0.052P=0.81

Anemic vs Non-Anemic Population:1-Year Mortality

3.1%

7.0%

Mortality

1 Ye

ar e

vent

s (%

)

Anemic patients (N=2,200)Non-anemic patients (N=10,839)

P<0.0001

Baseline Independent Predictors of 1-Year Mortality

HR (95% CI)

Age (≥75 years) 2.66 (2.14-3.32)Anemia 1.61 (1.32-1.98)Baseline CrCl <60 mL/min 1.55 (1.24-1.93)Prior CVA 1.44 (1.18-1.76)CKMB/Troponin+ 1.77 (1.44-2.17)ECG changes 1.87 (1.55-2.25)History of CAD 1.35 (1.10-1.65)Diabetes 1.61 (1.35-1.93)Male gender 1.43 (1.16-1.76)

0.1 1 10

HR ±95% CI

CONCLUSIONS

● Anemia is not uncommon in patients

with ACS (16.9%).

● Anemia is associated with a

significant increase in rates of long-

term (1-year) ischemic events.

● Anemia is associated with an over

2-fold increase in rates of long-term

(1-year) mortality and is an

independent predictor of long-term

(1-year) mortality in patients with

ACS.