Obie przywołane skale zostały zweryfikowane w populacji składającej się wyłącznie z pacjentów z OZW, wykazując dobrą dyskryminację w identyfikacji chorych z niedokrwistością56. Narzędzia te mogą zatem pomóc lekarzom w optymalizacji i personalizacji czasu trwania oraz intensywności strategii leczenia przeciwzakrzepowego, zwłaszcza u pacjentów ze zwiększonym ryzykiem zarówno krwawień, jak i incydentów zakrzepowych.

Wytyczne postępowania w niedokrwistości w przebiegu ostrego zespołu wieńcowego

Biorąc pod uwagę, że postępowanie w OZW obejmuje leczenie przeciwzakrzepowe (które może nasilać krwawienie), ważne jest zidentyfikowanie przyczyny niedokrwistości, a zwłaszcza utajonych krwawień u pacjentów z OZW. Wskazania do inwazyjnej angiografii wieńcowej, wybór miejsca dostępu (korzystny dostęp promieniowy) oraz konieczność rewaskularyzacji należy dokładnie rozważyć, aby uniknąć dalszej utraty krwi. Podobnie wybór leku przeciwzakrzepowego wymaga oceny ryzyka niedokrwienia i krwawienia, co sprzyja stosowaniu krótszego okresu półtrwania lub środków odwracalnych. W przypadku niedokrwistości związanej z nieznanym/nieuleczalnym źródłem stosowanie stentów uwalniających lek powinno być ograniczone do urządzeń nowej generacji o udowodnionych profilach bezpieczeństwa w krótkoterminowej DAPT. Zgodnie z rekomendacjami Europejskiego Towarzystwa Kardiologicznego (ESC – European Society of Cardiology) u pacjentów z niedokrwistością i bez oznak aktywnego krwawienia transfuzja krwi może być rozważona w przypadku zagrożonego stanu hemodynamicznego, stężenia hematokrytu poniżej 25% lub Hb poniżej 8 g/dl (klasa IIb, poziom rekomendacji C)57. Podobnie, zgodnie z wytycznymi Amerykańskiego Kolegium Kardiologicznego (ACC – American College of Cardiology) i Amerykańskiego Stowarzyszenia na rzecz Serca (AHA – American Heart Association), nie ma korzyści z rutynowej transfuzji krwi u stabilnych hemodynamicznie pacjentów ze stężeniem Hb powyżej 8 g/dl (klasa III, poziom rekomendacji B)58.

Podsumowanie

Niedokrwistość jest jedną z najczęstszych chorób współistniejących u pacjentów z OZW, a jej częstość dodatkowo zwiększa niedokrwistość szpitalna, będąca wynikiem powikłań krwotocznych i stanu zapalnego. Anemia jest silnym predyktorem zdarzeń niepożądanych, w tym krwawienia i śmiertelności. Pomimo znaczącego wpływu na niekorzystne wyniki, możliwości terapeutyczne pozostają ograniczone i obejmują głównie transfuzję czerwonych krwinek, chociaż optymalny próg dla Hb stanowiący wskazanie do transfuzji krwi pozostaje niejasny. Zapobieganie dalszym krwawieniom i uważna obserwacja pacjentów mają pierwszorzędne znaczenie w tej populacji wysokiego ryzyka.

ABSTRACT

Anemia in patients with acute coronary syndrome

As defined by the World Health Organization, anemia refers to hemoglobin levels below 13 g/dl in adult men and below 12 g/dl in adult non-pregnant women. The underlying anemic status significantly impacts the prognosis of patients with a cardiovascular disease, including acute coronary syndrome (ACS). Anemia may affect 10.5 to 46.4% of patients hospitalized for ACS, although the definition of anemia significantly differs across trials and registries. Anemia is a highly important factor because it adds to the imbalance between myocardial oxygen requirement and delivery. Moreover, it strongly impacts the periprocedural management, including the choice of revascularization strategy as well as the use and duration of antithrombotic treatment. This paper presents an overview of the prevalence, mechanisms, impact and therapeutic management of anemia associated with ACS.

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