Risk of transfusion associated circulatory overload after blood products transfusion in patients with hfref vs. hfpef: A real-world propensity-matched analysis

Abstract Background: Transfusion Associated Circulatory Overload (TACO) is a serious complication of blood products transfusion, particularly in patients with pre-existing heart failure. This study aimed to compare the short-term incidence of TACO defined as pulmonary edema within 24 hours following transfusion in adults with heart failure with reduced ejection fraction (HFrEF) versus those with preserved ejection fraction (HFpEF). Methods: We conducted a retrospective cohort analysis using the TriNetX U.S. Collaborative Network, a federated research platform comprising 69 healthcare organizations. Adult patients (≥18 years) with HFrEF or HFpEF who underwent blood products transfusion were identified using ICD-10 and CPT codes. Propensity score matching was applied 1:1 to balance demographics and comorbidities, resulting in two matched cohorts of 97,731 patients each. The primary outcome was a diagnosis of pulmonary edema- reflecting the incidence of TACO- within one day following transfusion. Kaplan-Meier survival analysis and Cox proportional hazards models were used to compare outcomes. Results: Pulmonary edema occurred in 5,638 patients (5.77%) in the HFrEF cohort compared to 4,364 patients (4.46%) in the HFpEF cohort. The risk of developing pulmonary edema was significantly higher in the HFrEF group (Hazard Ratio [HR] = 1.30; 95% CI: 1.25–1.35; p < 0.001). Kaplan-Meier analysis confirmed a lower short-term pulmonary edema–free survival in the HFrEF group (Log-rank p < 0.001). Conclusion: Among transfused patients with heart failure, those with reduced ejection fraction experienced a significantly higher risk of developing Transfusion Associated Circulatory Overload within one day compared to those with preserved ejection fraction. These findings highlight the importance of careful transfusion management in patients with HFrEF to mitigate the risk of acute volume overload and associated complications.