Use of preoperative erythropoietin‐stimulating agents is associated with decreased thrombotic adverse events compared to red blood cell transfusion in surgical patients with anaemia

Background and Objectives Preoperative red blood cell (RBC) transfusions increase post‐operative venous thromboembolic (VTE) events. Erythropoietin‐stimulating agents (ESAs) increase VTE risk in cancer patients; we aimed to assess ESA versus RBC‐associated VTE risks in a broad population of surgical patients. Materials and Methods We queried TriNetX Diamond Network from 2006 to 2023, comparing patients with anaemia within 3 months preoperatively who received preoperative ESAs with or without intravenous (IV) iron to patients who received preoperative RBCs. Sub‐analyses included (1) all surgeries and (2) cardiovascular surgeries. We propensity score matched for demographics, comorbidities, medical services, post‐treatment haemoglobin (g/dL) and, for all‐surgery comparisons, surgery type. Outcomes included 30‐day post‐operative mortality, VTE, pulmonary embolism (PE), disseminated intravascular coagulation (DIC) and haemoglobin. Results In our 19,548‐patient cohorts, compared with preoperative RBC transfusion, ESAs without IV iron were associated with lower mortality (relative risk [RR] = 0.51 [95% confidence interval (CI), 0.45–0.59]), VTE (RR = 0.57 [0.50–0.65]) and PE (RR = 0.67 [0.54–0.84]). Post‐operative haemoglobin was higher in the ESA without IV iron cohort compared with the transfusion cohort (10.0 ± 1.4 vs. 9.4 ± 1.8 g/dL, p = 0.002). Cardiac surgical patients receiving ESAs with or without IV iron had lower risk for post‐operative mortality, VTE and PE (p