When “Normal” Hemoglobin May Not Be Enough: Sex-Specific Anemia Thresholds and Outcomes in Cardiac Surgery
6 affiliations
- 1Department of Anesthesiology, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- 2Neuroscience Research Group—Perioperative Pathophysiology and Pain Unit, Bellvitge Biomedical Research Institute (IDIBELL), 08908 L’Hospitalet de Llobregat, Spain
- 3Perioperative Medicine Research Group, Hospital del Mar Research Institute, 08003 Barcelona, Spain
- 4Department of Anesthesia, Hospital del Mar, 08003 Barcelona, Spain
- 5Department of Anesthesiology, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- 6Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, 08907 L’Hospitalet de Llobregat, Spain
Abstract
Background/Objectives: Sex-specific anemia criteria classify women with hemoglobin (Hb) 12.0–12.9 g/dL as non-anemic. We assessed whether World Health Organization (WHO) criteria underrecognize red blood cell (RBC) transfusion risk compared with a uniform patient blood management (PBM) threshold of Hb <13.0 g/dL in elective open cardiac valve surgery (CVS). Methods: This nationwide retrospective cohort included adults undergoing elective open CVS in 40 Spanish centers (2016–2024), 32 of which reported preoperative Hb. Hb was modeled continuously and in three strata (<12.0, 12.0–12.9, ≥13.0 g/dL). The primary outcome was RBC transfusion; secondary outcomes were postoperative complications, length of stay, and in-hospital mortality within 30 days. Mixed-effects models adjusted for age, comorbidity burden, surgical complexity, valve position, year of surgery, and center. Results: Among 29,757 eligible patients, 20,017 had available Hb measurements; 9247 (46.2%) were women, including 2333 (25.2%) with Hb 12.0–12.9 g/dL. In this stratum, 68.0% of women and 52.7% of men received RBC transfusions. The adjusted between-sex probability difference was 15.1 percentage points (95% CI, 11.4–18.9; adjusted odds ratio, 1.85; 95% CI, 1.59–2.16). The categorical sex × Hb interaction was significant (p < 0.001), whereas the continuous interaction was not (p = 0.486). Sex did not significantly modify the Hb associations with complications or in-hospital mortality within 30 days. Conclusions: Women with Hb 12.0–12.9 g/dL had substantial transfusion risk despite being classified as non-anemic by the WHO criteria. Hb <13.0 g/dL may be a pragmatic sex-inclusive trigger for perioperative risk recognition and etiologic evaluation, not a proven therapeutic target.
Related
- Gestational Age– and Altitude-Specific Hemoglobin Thresholds and Candidate Windows for Preterm Birth
- Non-Cardiac Surgery After Left Ventricular Assist Device Implantation: Perioperative Management and Outcomes from a Single Center
- GLP-1 receptor agonists in elective spine surgery: a systematic review of fusion outcomes, perioperative safety, and procedure-specific risk
- Sex-specific impact of computed tomography-defined sarcopenia on postoperative complications following elective cardiac surgery in older patients.
- Association Between Preoperative Anemia and Postoperative Outcomes in Adults Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis
BibTeX
@article{mendez2026when,
title = {{When “Normal” Hemoglobin May Not Be Enough: Sex-Specific Anemia Thresholds and Outcomes in Cardiac Surgery}},
author = {Esther Méndez and Elvira Bisbe and Misericordia Basora and Adrián Vizoso and Albert García-Casanovas and Maria J. Colomina},
journal = {Journal of Clinical Medicine},
year = {2026},
month = nov,
doi = {10.3390/jcm15218632},
url = {https://www.mdpi.com/2077-0383/15/21/8632},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - When “Normal” Hemoglobin May Not Be Enough: Sex-Specific Anemia Thresholds and Outcomes in Cardiac Surgery
AU - Esther Méndez
AU - Elvira Bisbe
AU - Misericordia Basora
AU - Adrián Vizoso
AU - Albert García-Casanovas
AU - Maria J. Colomina
PY - 2026
DA - 2026/11/05
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15218632
UR - https://www.mdpi.com/2077-0383/15/21/8632
AB - Background/Objectives: Sex-specific anemia criteria classify women with hemoglobin (Hb) 12.0–12.9 g/dL as non-anemic. We assessed whether World Health Organization (WHO) criteria underrecognize red blood cell (RBC) transfusion risk compared with a uniform patient blood management (PBM) threshold of Hb <13.0 g/dL in elective open cardiac valve surgery (CVS). Methods: This nationwide retrospective cohort included adults undergoing elective open CVS in 40 Spanish centers (2016–2024), 32 of which reported preoperative Hb. Hb was modeled continuously and in three strata (<12.0, 12.0–12.9, ≥13.0 g/dL). The primary outcome was RBC transfusion; secondary outcomes were postoperative complications, length of stay, and in-hospital mortality within 30 days. Mixed-effects models adjusted for age, comorbidity burden, surgical complexity, valve position, year of surgery, and center. Results: Among 29,757 eligible patients, 20,017 had available Hb measurements; 9247 (46.2%) were women, including 2333 (25.2%) with Hb 12.0–12.9 g/dL. In this stratum, 68.0% of women and 52.7% of men received RBC transfusions. The adjusted between-sex probability difference was 15.1 percentage points (95% CI, 11.4–18.9; adjusted odds ratio, 1.85; 95% CI, 1.59–2.16). The categorical sex × Hb interaction was significant (p < 0.001), whereas the continuous interaction was not (p = 0.486). Sex did not significantly modify the Hb associations with complications or in-hospital mortality within 30 days. Conclusions: Women with Hb 12.0–12.9 g/dL had substantial transfusion risk despite being classified as non-anemic by the WHO criteria. Hb <13.0 g/dL may be a pragmatic sex-inclusive trigger for perioperative risk recognition and etiologic evaluation, not a proven therapeutic target.
SN - 2077-0383
ER -