Relation Between Hemoglobin Level and Recurrent Myocardial Ischemia in Acute Coronary Syndromes Detected by Continuous Electrocardiographic Monitoring
Abstract
Anemia has been associated with adverse outcomes in patients with acute coronary syndromes (ACS). However, the underlying pathophysiologic mechanisms have not been well elucidated. We sought to determine the independent relation between the hemoglobin level and recurrent ischemia in patients with non-ST-segment elevation ACS using continuous electrocardiographic monitoring. In the Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) trial, 746 patients presenting with non-ST-segment elevation ACS underwent continuous ST-segment monitoring for 48 hours. The data were analyzed independently at a core laboratory. We stratified the study population according to their hemoglobin level on presentation. The primary outcome of the study was recurrent ischemia, defined as ST-segment shifts on continuous electrocardiographic monitoring. Of the 705 patients with analyzable data, 64 had a baseline hemoglobin level <120 g/L, 259 had a level of 120 to 139 g/L, 315 had a level of 140 to 159 g/L, and 67 had a level >160 g/L. The corresponding rates of recurrent ischemia were 39.1%, 22.0%, 15.6%, and 11.9% (p for trend <0.001). A lower hemoglobin level was associated with advanced age, co-morbidities, and a higher GRACE risk score. In multivariable analysis adjusting for these confounders, lower hemoglobin levels retained a significant independent association with recurrent ischemia (p for trend = 0.004). In conclusion, a lower hemoglobin level at presentation was independently associated with recurrent ischemia detected by continuous electrocardiographic monitoring in the setting of non-ST-segment elevation ACS. This suggests that anemia might predispose patients to recurrent ischemia, which could be an important underlying mediator of worse outcomes in patients with lower hemoglobin levels.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Therapeutic interventions aimed to increase the circulating number of RBCs (transfusion of blood or administration of erythropoiesis-stimulating agents) were not always effective in the tested cohorts.
“However, therapeutic interventions aimed to increase the circulating number of RBCs (e.g., by transfusion of blood or by administration of erythropoiesis-stimulating agents [ESAs] to stimulate the production of RBCs by the bone marrow), were not always effective in the tested cohorts (48, 91, 156).”
From Red Blood Cell Function and Dysfunction: Redox Regulation, Nitric Oxide Metabolism, Anemia (2017) · cites this paper as [156]
Cites
Atherosclerosis--an inflammatory disease
Ross, R. (1999) · New England Journal of Medicine · doi:10.1056/nejm199901143400207 · Cited by 21,725 · see citing works
Predictors of Hospital Mortality in the Global Registry of Acute Coronary Events
Granger, C. B. (2003) · Archives of Internal Medicine · doi:10.1001/archinte.163.19.2345 · Cited by 2,349 · see citing works
Relationship of Blood Transfusion and Clinical Outcomes in Patients With Acute Coronary Syndromes
Rao, S. V. (2004) · JAMA · doi:10.1001/jama.292.13.1555 · Cited by 999 · see citing works
Blood Transfusion in Elderly Patients with Acute Myocardial Infarction
Wu, W. C., Rathore, S. S., Wang, Y., Radford, M. J., & Krumholz, H. M. (2001) · New England Journal of Medicine · doi:10.1056/nejmoa010615 · Cited by 935 · see citing works
Association of Hemoglobin Levels With Clinical Outcomes in Acute Coronary Syndromes
Sabatine, M. S., Morrow, D. A., Giugliano, R. P., Burton, P. B. J., Murphy, S. A., McCabe, C. H., Gibson, C. M., & D, E. B. M. (2005) · Circulation · doi:10.1161/01.cir.0000162477.70955.5f · Cited by 736 · see citing works
Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients
Gottlieb, S. O. (1988) · JAMA · doi:10.1001/jama.259.7.1030 · Cited by 282 · see citing works
Nikolsky, E., Aymong, E. D., Halkin, A., Grines, C. L., Cox, D. A., Garcı́a, E., Mehran, R., Tcheng, J. E., Griffin, J. J., Guagliumi, G., et al. (2004) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2004.03.080 · Cited by 260 · see citing works
Acute Coronary Syndromes in the GUSTO-IIb Trial
Armstrong, P. W., Fu, Y., Chang, W.-C., Topol, E. J., Granger, C. B., Betriu, A., de Werf, F. V., Lee, K. L., & Califf, R. M. (1998) · Circulation · doi:10.1161/01.cir.98.18.1860 · Cited by 260 · see citing works
Goodman, S. G., FITCHETT, D. H., Armstrong, P. W., Tan, M., & Langer, A. (2003) · Circulation · doi:10.1161/01.cir.0000050144.67910.13 · Cited by 199 · see citing works
Self-citationMost, A. S., Ruocco, N. A., & Gewirtz, H. (1986) · Circulation · doi:10.1161/01.cir.74.5.1085 · Cited by 146 · see citing works
Relation of inflammation to vascular function in patients with coronary heart disease
Sinisalo, J. P., Paronen, J., Mattila, K. J., Syrjälä, M. T., Alfthan, G., Palosuo, T., Nieminen, M. S., & Vaarala, O. (2000) · Atherosclerosis · doi:10.1016/s0021-9150(99)00333-0 · Cited by 126 · see citing works
Early postinfarction ischemia: clinical, angiographic, and prognostic significance.
Bosch, X., Théroux, P., Waters, D. D., Pelletier, G. B., & Roy, D. (1987) · Circulation · doi:10.1161/01.cir.75.5.988 · Cited by 106 · see citing works
Stone, G. W., Grines, C. L., Browne, K. F., Marco, J., ROTHBAUM, D. A., O’Keefe, J. H., Hartzler, G. O., OVERLIE, P. A., Donohue, B. C., Chelliah, N., et al. (1995) · Journal of the American College of Cardiology · doi:10.1016/0735-1097(95)00138-p · Cited by 90 · see citing works
Levy, P. S., Quigley, R. L., & Gould, S. A. (1996) · doi:10.1097/00005373-199609000-00006 · Cited by 86 · see citing works
Heart failure and anemia: mechanisms and pathophysiology
Anand, I. S. (2008) · Heart Failure Reviews · doi:10.1007/s10741-008-9088-8 · Cited by 86 · see citing works
Twomley, K. M., Rao, S. V., & Becker, R. C. (2006) · Journal of Thrombosis and Thrombolysis · doi:10.1007/s11239-006-5206-4 · Cited by 84 · see citing works
Hemoglobin levels and 30-day mortality in patients after myocardial infarction
Lipšic, E., van der Horst, I. C. C., Voors, A. A., van der Meer, P., Nijsten, M. W., van Gilst, W. H., van Veldhuisen, D. J., & Zijlstra, F. (2005) · International Journal of Cardiology · doi:10.1016/j.ijcard.2004.10.043 · Cited by 80 · see citing works
Akkerhuis, K. M. (2001) · European Heart Journal · doi:10.1053/euhj.2001.2750 · Cited by 75 · see citing works
Bleeding Complications in Patients With Anemia and Acute Myocardial Infarction
Dauerman, H. L., Lessard, D., Yarzebski, J., Gore, J. M., & Goldberg, R. J. (2005) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2005.06.088 · Cited by 63 · see citing works
Ischemia Detected on Continuous Electrocardiography After Acute Coronary Syndrome
Scirica, B. M., Morrow, D. A., Budaj, A., Dalby, A. J., Mohanavelu, S., Qin, J., Aroesty, J. M., Hedgepeth, C. M., Stone, P. H., & D, E. B. M. (2009) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.12.053 · Cited by 62 · see citing works
Goodman, S. G., Barr, A., Sobtchouk, A., Cohen, M. C., Fromell, G. J., Laperrière, L., Hill, C., & Langer, A. (2000) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(00)00915-3 · Cited by 56 · see citing works
Self-citationLanger, A., Minkowitz, J., Dorian, P., Casella, L., Harris, L., Morgan, C. D., & Armstrong, P. W. (1992) · Journal of the American College of Cardiology · doi:10.1016/0735-1097(92)90242-f · Cited by 51 · see citing works
Self-citationSingla, I., Zahid, M., Good, C. B., Macioce, A., & Sonel, A. F. (2007) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2006.11.056 · Cited by 49 · see citing works
Relation of Anemia at Discharge to Survival After Acute Coronary Syndromes
Vaglio, J. C., Safley, D. M., Rahman, M., Kosiborod, M., Jones, P. G., Thompson, R. C., Krumholz, H. M., & Spertus, J. A. (2005) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2005.04.008 · Cited by 48 · see citing works
Increased production of inflammatory cytokines in patients with silent myocardial ischemia
Mazzone, A., Cusa, C., Mazzucchelli, I., Vezzoli, M., Ottini, E., Pacifici, R., Zuccaro, P., & Falcone, C. (2001) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(01)01660-6 · Cited by 47 · see citing works
Cohen, M., Stinnett, S. S., Davison, B. A., Gurfinkel, E., Fromell, G. J., Goodman, S. G., Fox, K. A. A., & Califf, R. M. (2000) · American Heart Journal · doi:10.1067/mhj.2000.106915 · Cited by 36 · see citing works
Self-citationKrucoff, M. W., Johanson, P., Baeza, R., Crater, S. W., & Dellborg, M. (2004) · Circulation · doi:10.1161/01.cir.0000150401.54856.d3 · Cited by 28 · see citing works
Yan, A. T.-K., Yan, R. T., Tan, M., Senaratne, M., FITCHETT, D. H., Langer, A., & Goodman, S. G. (2007) · American Heart Journal · doi:10.1016/j.ahj.2007.02.003 · Cited by 23 · see citing works
Self-citationYan, A. T.-K., Steg, P. G., FitzGerald, G., Feldman, L. J., Eagle, K. A., Gore, J. M., Anderson, F. A., Lopez-Sendon, J. L., Gurfinkel, E., Brieger, D. B., et al. (2009) · International Journal of Cardiology · doi:10.1016/j.ijcard.2009.05.007 · Cited by 20 · see citing works
Self-citationSjauw, K. D., van der Horst, I. C. C., Nijsten, M. W. N., Nieuwland, W., & Zijlstra, F. (2006) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2005.12.034 · Cited by 20 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., Jaffe, A. S., Jneid, H., Kelly, R. F., Kontos, M. C., et al. (2014) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2014.09.017 · Cited by 3,595 · see citing works
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., Jaffe, A. S., Jneid, H., Kelly, R. F., Kontos, M. C., et al. (2014) · Circulation · doi:10.1161/cir.0000000000000134 · Cited by 1,059 · see citing works
Red Blood Cell Function and Dysfunction: Redox Regulation, Nitric Oxide Metabolism, Anemia
Kuhn, V., Diederich, L., Keller, T. C. S., Kramer, C. M., Lückstädt, W., Panknin, C., Suvorava, T., Isakson, B. E., Kelm, M., & Cortese-Krott, M. M. (2017) · Antioxidants & Redox Signaling · doi:10.1089/ars.2016.6954 · Cited by 469 · see citing works
Iron Deficiency Anemia—Bridging the Knowledge and Practice Gap
Shander, A., Goodnough, L. T., Javidroozi, M., Auerbach, M., Carson, J. L., Ershler, W. B., Ghiglione, M., Glaspy, J. A., & Lew, I. (2014) · Transfusion Medicine Reviews · doi:10.1016/j.tmrv.2014.05.001 · Cited by 122 · see citing works
Is anemia a new cardiovascular risk factor?
Kaiafa, G., Kanellos, I., Savopoulos, C., Kakaletsis, N., Giannakoulas, G., & Hatzitolios, A. I. (2015) · International Journal of Cardiology · doi:10.1016/j.ijcard.2015.03.159 · Cited by 92 · see citing works
Li, W., Liu, Q., & Tang, Y. (2017) · Scientific Reports · doi:10.1038/srep40426 · Cited by 79 · see citing works
Kunadian, V., Mehran, R., Lincoff, A. M., Feit, F., Manoukian, S. V., Hamon, M., Cox, D. A., Dangas, G., & Stone, G. W. (2014) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2014.09.023 · Cited by 67 · see citing works
Mirski, M. A., Frank, S. M., Kor, D. J., Vincent, J., & Holmes, D. R. (2015) · Critical Care · doi:10.1186/s13054-015-0912-y · Cited by 56 · see citing works
Value of Hematological and Coagulation Parameters as Prognostic Factors in Acute Coronary Syndromes
Babeş, E. E., Zaha, D. C., Ţiţ, D. M., Nechifor, A. C., BUNGAU, S. G., Andronie-Cioară, F. L., Behl, T., Stoicescu, M., Munteanu, M. A., Rus, M., et al. (2021) · Diagnostics · doi:10.3390/diagnostics11050850 · Cited by 37 · see citing works
Gong, I. Y., Yan, A. T.-K., Ko, D. T., Earle, C. C., Cheung, W. Y., Peacock, S. J., Hall, M., Gale, C. P., & Chan, K. (2017) · Cancer · doi:10.1002/cncr.31174 · Cited by 25 · see citing works
Self-citationGuerrero, C., Garay, A., Ariza‐Solé, A., Formiga, F., Raposeiras‐Roubín, S., Abu‐Assi, E., D’Ascenzo, F., Kinnaird, T., Manzano‐Fernández, S., Alegre, O., et al. (2018) · Thrombosis Research · doi:10.1016/j.thromres.2018.05.024 · Cited by 23 · see citing works
Impact of Anaemia on Mortality and its Causes in Elderly Patients with Acute Coronary Syndromes
Ariza‐Solé, A., Formiga, F., Salazar‐Mendiguchía, J., Garay, A., Lorente, V., Sánchez‐Salado, J. C., Sánchez-Elvira, G., Lara, J. G., & Cequier, A. R. (2014) · Heart Lung and Circulation · doi:10.1016/j.hlc.2014.12.004 · Cited by 22 · see citing works
Hwang, I., Lee, H., Yoon, Y. E., Choi, I.-S., Kim, H., Chang, H., Lee, J. Y., Choi, J. A., Kim, H. J., Cho, G., et al. (2019) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2019.09.018 · Cited by 21 · see citing works
Lee, S. H., Jeong, M. H., Han, K. R., Sim, D. S., Yoon, J., Youn, Y. J., Cho, B. R., Cha, K. S., Hyon, M. S., Rha, S., et al. (2016) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2016.02.030 · Cited by 11 · see citing works
Tang, C., Luo, E., Wang, D., Yan, G., Qiao, Y., Zhu, B., Liu, B., & Hou, J. (2019) · BioMed Research International · doi:10.1155/2019/8534752 · Cited by 11 · see citing works
Shedding blood: anemia and adverse events after percutaneous coronary intervention (PCI)
Galougahi, K. K., Karmpaliotis, D., Kirtane, A. J., & Ali, Z. A. (2016) · Journal of Thoracic Disease · doi:10.21037/jtd.2016.02.29 · Cited by 11 · see citing works
Jomaa, W., Ali, I. B., Hamdi, S., Azaiez, M. A., Hraïech, A. E., Hamda, K. B., & Maatouk, F. (2016) · Journal of the Saudi Heart Association · doi:10.1016/j.jsha.2016.10.003 · Cited by 10 · see citing works
A Prospective Study on Prevalence and Causes of Anaemia in Patients with Acute Coronary Syndrome
Penta, B. (2016) · JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH · doi:10.7860/jcdr/2016/19091.8106 · Cited by 9 · see citing works
Correia, L. C. L., Souza, A. C., Sabino, M., Brito, M., Maraux, M., Garcia, G., Esteves, J. P., & Noya-Rabelo, M. (2012) · Cardiology · doi:10.1159/000336954 · Cited by 8 · see citing works
Zhu, Z., & Zhou, X. (2023) · Acta cardiologica. Supplementum · doi:10.1080/00015385.2023.2289718 · Cited by 7 · see citing works
Amsterdam, E. A., WENGER, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., Jaffe, A. S., Jneid, H. M., Kelly, R. F., Kontos, M. C., et al. (2014) · Cited by 7 · see citing works
Stähli, B. E., Gebhard, C., Gick, M., Ferenc, M., Mashayekhi, K., Buettner, H. J., Neumann, F., & Toma, A. (2017) · Catheterization and Cardiovascular Interventions · doi:10.1002/ccd.27412 · Cited by 7 · see citing works
Jiang, L., Gao, Z., Song, Y., Xu, J., Tang, X., Wang, H., Liu, R., Jiang, P. X., Xu, B., & Yuan, J. (2018) · Journal of Interventional Cardiology · doi:10.1111/joic.12570 · Cited by 7 · see citing works
Puddu, P. E., Iannetta, L., Placanica, A., Cuturello, D., Schiariti, M. S., & Manfrini, O. (2016) · International Journal of Cardiology · doi:10.1016/j.ijcard.2016.07.207 · Cited by 6 · see citing works
Yaylak, B., Altıntaş, B., Özcan, K. S., Akdeniz, E., Avcı, İ. İ., Zeren, G., Şimşek, B., & Karabay, C. Y. (2018) · Advances in Interventional Cardiology · doi:10.5114/aic.2018.79868 · Cited by 6 · see citing works
Anemia and prognosis in acute coronary syndromes
Moura, B. (2012) · Revista Portuguesa de Cardiologia (English Edition) · doi:10.1016/j.repce.2011.12.009 · Cited by 5 · see citing works
Red Blood Cells as Redox Modulators in Hemolytic Anemia
Fibach, E., & Dana, M. (2019) · IntechOpen eBooks · doi:10.5772/intechopen.84498 · Cited by 5 · see citing works
Bhardwaj, B., Kolte, D. S., Zhao, Y., Alu, M. C., Zahr, F. E., Passeri, J. J., Inglessis, I., Vlahakes, G. J., Garcia, S. A., Cohen, D. J., et al. (2022) · Journal of the Society for Cardiovascular Angiography & Interventions · doi:10.1016/j.jscai.2022.100531 · Cited by 4 · see citing works
Ogiso, M., Yamaguchi, J., Otsuki, H., Arashi, H., Sekiguchi, H., Ogawa, H., & Hagiwara, N. (2021) · Heart and Vessels · doi:10.1007/s00380-021-01850-x · Cited by 4 · see citing works
Lu, Z., Ma, G., & Chen, L. (2020) · Mediators of Inflammation · doi:10.1155/2020/8143835 · Cited by 3 · see citing works
Anemia e prognóstico das síndromes coronárias agudas
Moura, B. (2012) · Revista Portuguesa de Cardiologia · doi:10.1016/j.repc.2011.12.003 · Cited by 3 · see citing works
Çiçek, Ö. F., Çetin, M., & Palice, A. (2026) · Diagnostics · doi:10.3390/diagnostics16020276 · Cited by 2 · see citing works
Arbel, Y., Milwidsky, A., Finkelstein, A., Halkin, A., Revivo, M., Berliner, S. A., Ellis, M. H., Herz, I., Keren, G., & Banai, S. (2015) · PubMed · Cited by 1 · see citing works
Separham, A., Seyedi, S. Z., & Sarvestani, A. H. (2020) · Multidisciplinary Cardiovascular Annals · doi:10.5812/mca.107077 · Cited by 1 · see citing works
Prognostic impact of anaemia in patients undergoing aortic valve replacement: a nationwide study
Brems, D. A., Petersen, J. K., Begun, X., Smerup, M., Butt, J. H., Køber, L., & Fosbøl, E. L. (2024) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcae057 · Cited by 1 · see citing works
Hemoglobin Levels, Nitric Oxide Bioavailability and Cardiovascular Outcomes
Andreotti, F., Pafundi, T., Coluzzi, G., & Maseri, A. (2011) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2010.12.028 · Cited by 1 · see citing works
(2010) · The American Journal of Cardiology · doi:10.1016/s0002-9149(10)02039-4
- Authors
- Rousseau, M., Yan, R. T., Tan, M., Lefkowitz, C. J., Casanova, A., Fitchett, D., Jolly, S. S., Langer, A., Goodman, S. G., & Yan, A. T.
- Affiliations
- St. Michael's Hospital (CA)
- Canadian Heart Research Centre (CA)
- University of Toronto (CA)
- Population Health Research Institute (CA)
- Corresponding author
- Yan, Andrew T.
- ORCID
- Venue
- The American Journal of Cardiology
- Publisher
- Elsevier BV
- Published
- 2010-11
- Volume
- 106
- Issue
- 10
- Pages
- 1417-1422
- ISSN
- 0002-9149 (ISSN-L)
- OpenAlex
- W1972706572
- Cited by
- 37
- References
- 30
- Citations by year
- 2026: 1 · 2024: 1 · 2023: 1 · 2022: 1 · 2021: 2 · 2020: 2 · 2019: 3 · 2018: 3 · 2017: 3 · 2016: 6 · 2015: 3 · 2014: 6 · 2012: 3
- FWCI
- 1.10
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The American Journal of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Heart and Stroke Foundation of Canada
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Health Sciences › Medicine › Oncology › Inflammatory Biomarkers in Disease Prognosis
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Keywords
- hemoglobin levels, anemia, recurrent myocardial ischemia, non-ST-elevation acute coronary syndrome, INTERACT trial, GRACE risk score
- MeSH terms
- Aged, Female, Hemoglobins, Humans, Male, Middle Aged, Prospective Studies, Recurrence, Electrocardiography, Ambulatory, Randomized Controlled Trials as Topic, Myocardial Ischemia, Acute Coronary Syndrome
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
