Yet, considering the supporting evidence and the questions the panel focused on, I do challenge the strict transfusion triggers provided by the panel. First, in developing the guidelines, the panel focused more on blood transfusion and its related problems than on the problems associated with anemia. In any decision to transfuse, one must weigh the risks and benefits associated with transfusion against those associated with anemia. Although blood transfusions have been associated with adverse outcomes, anemia is also associated with increased mortality rates (2 - 4). Second, the quality of blood has improved over the years. In particular, it is likely (although not definitely proven) that leukoreduction has helped decrease some of the harmful effects of blood transfusion (5). Observational studies in Europe have suggested that transfusion has become safer over time. For example, blood transfusion was an independent risk factor for mortality in the ABC (Anemia and Blood Transfusion in Critical Care) study conducted in 1999 (6) but not in the SOAP (Sepsis Occurrence in Acutely Ill Patients) study conducted several years later (7), although similar statistical techniques (including multivariable analyses and propensity scoring) were used in the 2 studies. Third and most important, the studies evaluating liberal versus conservative blood transfusion practices have usually addressed the simple question of number of transfusions, without taking into account particular characteristics of the patient populations, especially the presence of coronary artery disease (CAD) and patient age.