Clinical Features

Anemia is most often recognized by abnormal screening laboratory test results. Much less frequently, patients will present to their family physician with previously unrecognized anemia, complaining of fatigue, loss of stamina, shortness of breath, and rapid heart rate (particularly with physical exercise). In younger patients, if the anemia comes on gradually, several compensatory mechanisms help maintain tissue oxygenation. These include peripheral vasodilation, increased cardiac output, a change in the oxygen-hemoglobin dissociation curve that facilitates oxygen unloading in the tissues, and shunting of blood away from circulation-rich organs (e.g., gut, skin, kidney) to critical organs (e.g., heart, brain).

Physicians must recognize that the signs and symptoms of anemia will be determined in part by the acuteness of onset. Acute anemia is almost always caused by blood loss or hemolysis. If blood loss is mild, enhanced oxygen delivery is achieved through changes in the oxyhemoglobin dissociation curve and in hemodynamics. With acute blood loss, however, the changes in blood volume dominate the clinical picture, and Hct and Hb levels do not reflect the volume of blood lost for at least 48 hours. Signs of vascular instability appear with acute blood losses of 10% to 15% of the total blood volume. In such patients, management issues are related not to the anemia, but to hypotension and decreased organ perfusion. When more than 30% of the blood volume is lost suddenly, patients are unable to compensate with the usual mechanisms of vascular contraction and changes in regional or organ blood flow. The patient prefers to remain lying flat and will show postural hypotension and tachycardia if placed in an upright position. If the volume of blood loss is more than 40% (>2 L in average-sized adult), signs of shock are prominent, including confusion, air hunger, sweating, hypotension, and tachycardia. These patients have significant deficits in vital organ perfusion and require immediate volume replacement.

For the family physician, certain disorders are associated more often with anemia. These include chronic inflammatory states (e.g., infection, rheumatoid arthritis, cancer) associated with mild to moderate anemia, whereas lympho-proliferative disorders (e.g., chronic lymphocytic leukemia, other B-cell neoplasms) may be associated with immunemediated hemolysis.

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