Etiology of anemia in patients with advanced heart failure

Endocrine Challenges in Patients with Continuous-Flow Left Ventricular Assist Devices

Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.

Serum iron: a new predictor of adverse outcomes independently from serum hemoglobin levels in patients with acute decompensated heart failure

Iron is an essential trace element in the body. However, in heart failure (HF), iron is only recognized as the cause of anemia. Actually, iron itself affects myocardial exercise tolerance and cardiac function via mitochondrial function. Therefore, it is necessary to clarify the pathological significance of iron in acute HF, irrespective of concomitant anemia. We investigated the impact of serum iron level at discharge on the prognosis of 615 patients emergently admitted with acute decompensated HF (ADHF). Patients were divided into two groups according to the median level of serum iron (62 µg/dL). The endpoint was the composite outcome, which included all-cause mortality and readmission for HF. During the mean follow-up period of 32.1 months, there were 333 events. Kaplan-Meier analysis showed that the incidence of the composite outcome was significantly higher in the Low iron group (P < 0.0001). In the multivariate analysis adjusted with factors including hemoglobin and ferritin levels, low serum iron was an independent predictor for the composite outcome (hazard ratio, 1.500; 95% confidence interval, 1.128-1.976; P = 0.0044). Low serum iron was an independent predictor of poor prognosis in ADHF, irrespective of hemoglobin or ferritin level, providing a new concept that iron may play a role in the pathophysiology of ADHF via non-hematopoietic roles.

Prevalence and association of iron deficiency with anemia among patients with heart failure in the USA: NHANES 2017-2018

Background: Heart failure (HF) is a major debilitating disease. HF patients with iron deficiency(ID) have poorer outcomes and treatment significantly improves outcomes. We set out to update the national prevalence of ID in the USA and its association with anemia using data from NHANES 2017-2018. Methods: Diagnosis of HF was self-reported. ID was defined as serum ferritin levels <100 ng/mL or a ferritin level between 100 and 299 ng/mL with transferrin saturation <20%. Anemia was defined as a hemoglobin level of <13 g/dl and <12 g/dl for men and women, respectively. Differences in prevalence of ID across various groups were assessed using Chi-squared test for categorical variables and equality of means for continuous variables with p-values <0.05 considered statistically significant. Results: A total of 187 persons ≥20 years, corresponding to a 5.57million had HF. The prevalence of ID was 48.17% (95% CI 36.84-59.69) and the prevalence of anemia was 12.08%(95% CI 8.16-17.53). Diabetics (61.03%) were more likely to have ID compared to nondiabetics (35.38%), p 0.022. The prevalence of ID was similar in persons with anemia (47.45%) and persons without anemia (48.27%), p-value 0.983. The prevalence of ID has been constant for at least the past 20 years, making ID in HF an underdiagnose and/or undertreated condition among patients with HF and should be addressed. Conclusions: One in every two persons with HF has ID. Also, prevalence of ID was similar in patients with anemia and without anemia. Anemia should not be considered a prerequisite for screening for ID in patients with HF.

High soluble transferrin receptor in patients with heart failure: a measure of iron deficiency and a strong predictor of mortality

AIMS

Iron deficiency (ID) is frequent in heart failure (HF), linked with exercise intolerance and poor prognosis. Intravenous iron repletion improves clinical status in HF patients with left ventricular ejection fraction (LVEF) ≤45%. However, uncertainty exists about the accuracy of serum biomarkers in diagnosing ID. The aims of this study were (i) to identify the iron biomarker with the greatest accuracy for the diagnosis of ID in bone marrow in patients with ischaemic HF, and (ii) to establish the prevalence of ID using this biomarker and its prognostic value in HF patients.

METHODS AND RESULTS

Bone marrow was stained for iron in 30 patients with ischaemic HF with LVEF ≤45% and 10 healthy controls, and ID was diagnosed for 0-1 grades (Gale scale). A total of 791 patients with HF with LVEF ≤45% were prospectively followed up for 3 years. Serum ferritin, transferrin saturation, soluble transferrin receptor (sTfR) were assessed as iron biomarkers. Most patients with HF (n = 25, 83%) had ID in bone marrow, but none of the controls (P < 0.001). Serum sTfR had the best accuracy in predicting ID in bone marrow (area under the curve 0.920, 95% confidence interval 0.761-0.987, for cut-off 1.25 mg/L sensitivity 84%, specificity 100%). Serum sTfR was ≥1.25 mg/L in 47% of HF patients, in 56% and 46% of anaemics and non-anaemics, respectively (P < 0.05). The reclassification methods revealed that serum sTfR significantly added the prognostic value to the baseline prognostic model, and to the greater extent than plasma N-terminal pro B-type natriuretic peptide. Based on internal derivation and validation procedures, serum sTfR ≥1.41 mg/L was the optimal threshold for predicting 3-year mortality, independent of other established variables.

CONCLUSIONS

High serum sTfR accurately reflects depleted iron stores in bone marrow in patients with HF, and identifies those with a high 3-year mortality.

Accurate Noninvasive Assessment of Myocardial Iron Load in Advanced Heart Failure Patients

Background

Heart failure patients presenting with iron deficiency can benefit from systemic iron supplementation; however, there is the potential for iron overload to occur, which can seriously damage the heart. Therefore, myocardial iron (M-Iron) content should be precisely balanced, especially in already failing hearts. Unfortunately, the assessment of M-Iron via repeated heart biopsies or magnetic resonance imaging is unrealistic, and alternative serum markers must be found. This study is aimed at assessing M-Iron in patients with advanced heart failure (HF) and its association with a range of serum markers of iron metabolism.

Methods

Left ventricle (LV) myocardial biopsies and serum samples were collected from 33 consecutive HF patients (25 males) with LV dysfunction (LV ejection fraction 22 (11) %; NT-proBNP 5464 (3308) pg/ml) during heart transplantation. Myocardial ferritin (M-FR) and soluble transferrin receptor (M-sTfR1) were assessed by ELISA, and M-Iron was determined by Instrumental Neutron Activation Analysis in LV biopsies. Nonfailing hearts (n = 11) were used as control/reference tissue. Concentrations of serum iron-related proteins (FR and sTfR1) were assessed.

Results

LV M-Iron load was reduced in all HF patients and negatively associated with M-FR (r = -0.37, p = 0.05). Of the serum markers, sTfR1/logFR correlated with (r = -0.42; p = 0.04) and predicted (in a step-wise analysis, R ² = 0.18; p = 0.04) LV M-Iron. LV M-Iron load (μg/g) can be calculated using the following formula: 210.24-22.869 × sTfR1/logFR.

Conclusions

The sTfR1/logFR ratio can be used to predict LV M-Iron levels. Therefore, serum FR and sTfR1 levels could be used to indirectly assess LV M-Iron, thereby increasing the safety of iron repletion therapy in HF patients.

Correction of iron deficiency in hospitalized heart failure patients does not improve patient outcomes

Heart failure (HF) has an estimated prevalence of 1-2% in the world's population and up to 10% of patients age 65 and above. Iron deficiency (ID) in HF has been shown to be an independent contributor of increased mortality and poorer quality of life and has been associated with increased rates of hospitalization. Estimates are varied, but it is believed that as many as 30-83% of HF patients have ID, often without overt anemia, therefore making diagnosis more difficult. Well-established large studies have shown intravenous iron (IVFe) supplementation in HF patients is superior to an oral route, though these guidelines were developed for the chronic HF patients in the outpatient setting. For patients who are frequently hospitalized for HF, their inpatient stays may present an opportunity to diagnose ID. We previously showed that ID is underdiagnosed in the inpatient setting. To date, limited studies investigate long-term outcomes in hospitalized HF patients diagnosed with ID who are treated with IVFe compared to those who are not. In this retrospective analysis, we assessed 1-year readmission rates and mortality outcomes in patients who were diagnosed with ID while admitted for HF and subsequently received IVFe versus those who did not on their initial admission. These data suggest that there is no significant reduction in readmissions for HF or mortality between those patients who received IVFe and those who did not.

Iron deficiency and supplementation in heart failure and chronic kidney disease

Iron is a key element for normal cellular function and plays a role in many cellular processes including mitochondrial respiration. The role of iron deficiency (ID) in heart failure (HF) has been a subject of debate amid increasing advocacy for intravenous (IV) supplementation. Both the definition and the approach to treatment of ID in HF have been adapted from the experience in patients with chronic kidney disease (CKD). In this review, we highlight the differences in regulatory mechanisms as well as pathophysiology of ID in CKD and HF population both at the systemic and cellular levels. We will review the major clinical trials in HF patients that have shown symptomatic benefit from IV iron supplementation but without effect on clinical outcomes. Intravenous iron loading bypasses the mechanisms that tightly regulate iron uptake and can potentially cause myocardial and endothelial damage by releasing reactive oxygen species. By contrast, newer oral iron preparations do not have similar toxicity concerns and might have a role in heart failure.

Iron and cardiovascular diseases

Iron is a necessary element for life; however, excess iron leads to oxidative stress by the Fenton reaction. Iron deficiency is prevalent in patients with heart failure, while iron overload is associated in the pathogenesis of atherosclerosis. These findings suggest the "iron paradox" in cardiovascular diseases. Iron metabolism in cardiovascular diseases is complex, and the mechanisms regulating systemic and cellular iron metabolism in cardiovascular diseases remain completely unknown. In this review, we focus on the role of iron in cardiovascular diseases.

Comparative accuracy of ferritin, transferrin saturation and soluble transferrin receptor for the diagnosis of iron deficiency in inflammatory bowel disease

BACKGROUND

The diagnosis of iron deficiency is based on ferritin and transferrin saturation (TfS) in inflammatory bowel disease (IBD) patients, yet guideline thresholds are not evidence-based. Soluble transferrin receptor (sTfR) is one of the best noninvasive tests in patients with inflammation.

AIMS

To evaluate the accuracy of ferritin and/or TfS for diagnosing iron deficiency in IBD and identify the optimal thresholds of these parameters using sTfR as reference.

METHODS

Two hundred and two patients (2072 samples) receiving at least one infusion of biologic (vedolizumab or infliximab) were included.

RESULTS

In ulcerative colitis patients with C-reactive protein (CRP) <10 mg/L, optimal iron deficiency diagnostic performances were observed with ferritin and TfS thresholds of 65 µg/L (sensitivity of 0.78 and specificity of 0.76) and 16% (sensitivity of 0.79 and specificity of 0.90), respectively. For ulcerative colitis patients with CRP > 10 mg/L, the thresholds with the best diagnostic performance were 80 µg/L (sensitivity of 0.75 and a specificity of 0.82) for ferritin and 11% for TfS (sensitivity of 0.75 and a specificity of 0.82). There was no added value for combined ferritin and TfS. No ferritin or TfS threshold had good diagnostic performance in Crohn's disease patients (AUC for ferritin was 0.65 (95% CI 0.55-0.75) and the AUC for TfS was 0.70 (95% CI 0.61-0.78).

CONCLUSION

Ferritin and TfS are reliable parameters for iron deficiency diagnosis only in ulcerative colitis patients, at thresholds different from current guidelines. In Crohn's disease patients, sTfR should be used given the poor diagnostic performance of ferritin and TfS.

The effect of iron deficiency on cardiac resynchronization therapy: results from the RIDE-CRT Study

Aims

Cardiac resynchronization therapy (CRT) improves functional status, induces reverse left ventricular remodelling, and reduces hospitalization and mortality in patients with symptomatic heart failure, left ventricular systolic dysfunction, and QRS prolongation. However, the impact of iron deficiency on CRT response remains largely unclear. The purpose of the study was to assess the effect of functional and absolute iron deficiency on reverse cardiac remodelling, clinical response, and outcome after CRT implantation.

Methods and results

The relation of iron deficiency and cardiac resynchronization therapy response (RIDE‐CRT) study is a prospective observational study. We enrolled 77 consecutive CRT recipients (mean age 71.3 ± 10.2 years) with short‐term follow‐up of 3.3 ± 1.9 months and long‐term follow‐up of 13.0 ± 3.2 months. Primary endpoints were reverse cardiac remodelling on echocardiography and clinical CRT response, assessed by change in New York Heart Association classification. Echocardiographic CRT response was defined as relative improvement of left ventricular ejection fraction ≥ 20% or left ventricular global longitudinal strain ≥ 20%. Secondary endpoints were hospitalization for heart failure and all‐cause mortality (mean follow‐up of 29.0 ± 8.4 months). At multivariate analysis, iron deficiency was identified as independent predictor of echocardiographic (hazard ratio 4.97; 95% confidence interval 1.15–21.51; P = 0.03) and clinical non‐response to CRT (hazard ratio 4.79; 95% confidence interval 1.30–17.72, P = 0.02). We found a significant linear‐by‐linear association between CRT response and type of iron deficiency (P = 0.004 for left ventricular ejection fraction improvement, P = 0.02 for left ventricular global longitudinal strain improvement, and P = 0.003 for New York Heart Association response). Iron deficiency was also significantly associated with an increase in all‐cause mortality (P = 0.045) but not with heart failure hospitalization.

Conclusions

Iron deficiency is a negative predictor of effective CRT therapy as assessed by reverse cardiac remodelling and clinical response. Assessment of iron substitution might be a relevant treatment target to increase CRT response and outcome in chronic heart failure patients.

The association of anemia as a risk of heart failure

AIM

The present study was conducted to assess the presence of anemia in patients with advanced heart failure (HF) and compared the clinical characteristics of patients with anemia and without anemia.

METHODOLOGY

The present study was conducted on 102 patients (60 males, 42 females) with advanced HF admitted in hospital. In all, general physical and clinical examinations were performed. All were subjected to complete blood count (CBC), hematocrit, and assessment of urea, creatinine, sodium, potassium, and brain natriuretic peptide (BNP). The levels of serum iron, ferritin, iron saturation, and iron-binding capacity were also evaluated. The causes of HF were assessed.

RESULTS

Mean age was 48.2 ± 5.7 and 42.2 ± 6.2 years in males and females patients, respectively. Left ventricular ejection fraction (LVEF) was 0.26 ± 0.8 in males and 0.24 ± 0.5 in females. 71.5% males and 76.3% females were on inotropic support. The etiology of HF was ischemia in 29% males and 27% females, high blood pressure in 15% males and 12% females, obesity in 18% males and 19% females, valvular heart disease in 7% males and 5% females, diabetes in 11% males and 6% females, and idiopathy in 20% males and 31% females. There was a significant difference in mean age, initial HB, final HB, hypertension, creatinine, BNP, and initial hematocrit level in patients with anemia and without anemia (P < 0.05). Deaths in hospital were also significant (P < 0.05).

CONCLUSION

Anemia was seen in one-third of the patients with HF. Anemia was an independent marker with poor prognosis. Anemic patients were older than non-anemic patients.

[Position Paper. The role of iron deficiency in patients with chronic heart failure and current corrective approaches]

.

Methylmalonic acid and vitamin B12 in patients with heart failure

OBJECTIVE

Vitamin B12 deficiency among patients with heart failure (HF) may have been underestimated. High serum levels of methylmalonic acid (MMA) have been identified in several studies as an early indicator of vitamin B12 deficiency. Furthermore, MMA seems to constitute a biomarker of oxidative stress and mitochondrial dysfunction. There are scarce data regarding vitamin B12 and MMA in patients with HF. The aim of this study was to investigate vitamin B12 and MMA serum levels in patients with HF.

METHODS

One hundred five consecutive patients admitted to our hospital with symptoms and signs of acute decompensated HF were included in the study. Demographic and clinical characteristics as well as comorbidities and medical treatment before hospital admission were recorded. Transthoracic echocardiography was performed in all patients. Blood samples were collected during the first 24 hours of hospitalization and measured for complete blood count, biochemical profile, vitamin B12, N-terminal prohormone of brain natriuretic peptide, and MMA levels. Finally, 51 healthy individuals constituted the control group.

RESULTS

A total of 43.8% of patients with HF had elevated MMA levels, but only 10.5% had overt vitamin B12 deficiency, defined as serum cobalamin levels below 189 pg/ml. Mean MMA level was higher in patients with HF than in controls (33.0 ± 9.6 vs. 19.3 ± 6.3 ng/ml; p < 0.001). This difference remained significant when adjusted for age, sex, vitamin B12, and folate serum levels and kidney function (B = 14.7 (9.6-19.7); p < 0.001). MMA levels were higher in patients with acutely decompensated chronic HF than in those with newly diagnosed acute HF (34.7 ± 10.5 vs. 30.7 ± 7.8 ng/ml; p = 0.036). Correlation analysis revealed significantly negative correlation between MMA and vitamin B12 levels only in patients without comorbidities.

CONCLUSION

Patients with HF have elevated MMA levels, independent of age, gender, HF category, or comorbidities, possibly indicating subclinical vitamin B12 deficiency. Further research is needed to investigate subclinical vitamin B12 deficiency in patients with HF and/or to clarify whether MMA constitutes a biomarker of oxidative stress.

Iron Deficiency in Acute Decompensated Heart Failure

The aim of this study was to characterize iron deficiency (ID) in acutely decompensated heart failure (ADHF) and identify whether ID is associated with dyspnea class, length of stay (LOS), biomarker levels, and echocardiographic indices of diastolic function in patients with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). Consecutive patients admitted with ADHF at a single tertiary center were included. Demographic information, pathology investigations, and metrics regarding hospital stay and readmission were recorded. Patients were classified as having 'absolute' ID if they had a ferritin level <100 ng/mL; or 'functional' ID if they had a ferritin 100-200 ng/mL and a transferrin saturation <20%. Of 503 patients that were recruited, 270 (55%) had HFpEF, 160 (33%) had HFREF, and 57 (12%) had heart failure with mid-range ejection fraction. ID was present in 54% of patients with HFrEF and 56% of patients with HFpEF. In the HFpEF group, ID was associated with a LOS of 11 ± 7.7 vs. 9 ± 6 days in iron replete patients, p = 0.036, and remained an independent predictor of increased LOS in a multivariate linear regression incorporating comorbidities, age, and ID status. This study corroborates a high prevalence of ID in both HFrEF and HFpEF, and further shows that in patients with HFpEF there is a prolongation of LOS not seen in HFrEF which may indicate a more prominent role for ID in HFpEF.

Immunity, Inflammation and Heart Failure: Their Role on Cardiac Function and Iron Status

Aims: Heart failure is a clinical syndrome characterized by subclinical systemic inflammation and immune system activation associated with iron deficiency. No data exist on the various activations of immune-mediated mechanisms of inflammation in heart failure patients with reduced/preserved ejection fraction. We aimed to (1) investigate possible differences in inflammatory parameters and oxidative stress, and (2) detect a different iron status between groups.

Materials and Methods: We enrolled 50 consecutive Caucasian outpatients with heart failure. All patients underwent echocardiographic measurements, laboratory determinations, evaluation of iron status and Toll-like receptors, and NF-κB expression in peripheral blood mononuclear cells, as well as pro-inflammatory cytokines. All statistical calculations were made using SPSS for Mac version 21.0.

Results: Patients with reduced ejection fraction showed significantly lower hemoglobin levels (12.3 ± 1.4 vs. 13.6 ± 1.4 g/dl), serum iron (61.4 ± 18.3 vs. 93.7 ± 33.7 mcg/dl), transferrin iron binding capacity (20.7 ± 8.4 vs. 31.1 ± 15.6 %), and e-GFR values (78.1 ± 36.1 vs. 118.1 ± 33.9 ml/min/1.73 m²) in comparison to patients with preserved ejection fraction, while unsaturated iron binding capacity (272.6 ± 74.9 vs. 221.7 ± 61.4 mcg/dl), hepcidin (4.61 ± 0.89 vs. 3.28 ± 0.69 ng/ml), and creatinine (1.34 ± 0.55 vs. 1.03 ± 0.25 mg/dl) were significantly higher in the same group. When considering inflammatory parameters, patients with reduced ejection fraction showed significantly higher expression of both Toll-like receptors-2 (1.90 ± 0.97 vs. 1.25 ± 0.76 MFI) and Toll-like receptors-4 (4.54 ± 1.32 vs. 3.38 ± 1.62 MFI), respectively, as well as a significantly higher activity of NF-κB (2.67 ± 0.60 vs. 1.07 ± 0.30). Furthermore, pro-inflammatory cytokines, interleukin-1, and interleukin-6, was significantly higher in patients with reduced ejection fraction, while the protective cytokine interleukin-10 was significantly lower in the same group. Correlational analyses demonstrated a significant and inverse relationship between left ventricular function and inflammatory parameters in patients with reduced ejection fraction, as well as a direct correlation between ferritin and inflammatory parameters.

Conclusions: Our data demonstrate a different immune-mediated inflammatory burden in heart failure patients with reduced or preserved ejection fraction, as well as significant differences in iron status. These data contribute to further elucidate pathophysiologic mechanisms leading to cardiac dysfunction.

Inhibition of the renin-angiotensin system in the cardiorenal syndrome with anaemia: a double-edged sword

: The term 'cardiorenal syndrome' (CRS) was introduced to describe problems related to the simultaneous existence of heart and renal insufficiency. The prevalence of anaemia in CRS is high and increases the risk of hospitalizations and death. Renin-angiotensin system (RAS) inhibition is the cornerstone therapy in cardiovascular and renal medicine. As angiotensin II regulates both glomerular filtration rate (GFR) and erythropoiesis, RAS inhibition can further deteriorate renal function and lower hematocrit or cause anaemia in patients with heart failure. The aim of this review is to explore the relationship among CRS, anemia and administration of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) and summarize the evidence suggesting that RAS inhibition may be considered an iatrogenic cause of deterioration of CRS with anemia. It should be emphasized however, that RAS inhibition reduces mortality in both groups with and without worsening of renal function, and therefore, no patient with CRS should be denied an ACEi or ARB trial without careful evaluation.

The Burden of Iron Deficiency in Heart Failure: Therapeutic Approach

Heart failure (HF) is highlighted by its burdening symptom-limited exercise capacity and recurrent hospitalizations. Despite substantial advances regarding disease-modifying drugs in HF with reduced ejection fraction, additional therapeutic strategies to improve quality of life are invaluable. Currently, iron deficiency (ID) is overwhelmingly recognized in over 30% to 50% of patients with stable chronic HF, which worsens prognosis. The established pathophysiological mechanisms of progressive HF may be intertwined with increasing myocardial iron scarcity, wherein one begets the other. Most importantly, ID constitutes a novel target for symptom relief in carefully selected patients. In this regard, intravenous iron may be a safe and efficacious intervention, potentially reducing HF hospitalizations. We discuss the evidence and gaps in knowledge concerning iron therapy in HF and propose a practical, comprehensive, clinically oriented algorithm for timely adequate iron replenishment in different clinical scenarios. Finally, we further debate imperative decision-making before intervention and the drawbacks of such a strategy.

Effects of 6-months of oral ferrous and ferric supplement therapy in patients who were hospitalized for decompensated chronic heart failure

Objective

Anemia is common in patients with chronic heart failure (CHF). This study aimed to examine the frequency of iron deficiency anemia in patients with CHF. We investigated the effects of oral ferrous or ferric supplementation on prognosis of CHF and quality of life.

Methods

A total of 201 patients with chronic decompensated heart failure were enrolled in a 6-month prospective study. Patients were randomly assigned to two groups. Patients in group I (n = 100) received ferrous fumarate and those in group II (n = 101) received ferric hydroxide polymaltose complex. Quality of life was measured by the 6-minute walking test (6MWT).

Results

A total of 49% of the patients had iron-dependent anemia in group I and 53.3% were anemic in group II. In group I, the number of anemic patients was significantly lower at 6 months after admission compared with at initial admission (49% versus 45%). Significant improvements were observed in hemoglobin values, the 6MWT distance, and New York Heart Association class after 6 months in both groups.

Conclusions

Iron deficiency is a significant comorbidity in CHF, even without anemia. Iron should be replaced orally or intravenously because it significantly improves the quality of life of patients.

[Anaemia and iron deficiency in chronic heart failure patients]

Tis review focused on prevalence of anemia and iron defciency (ID) in CHF and their effect on the course and prognosis of this condition. Based on evaluation of numerous laboratory data defnitions of anemia and ID were suggested. Specifcally, a diagnostic value of measuring serum iron, serum ferritin, transferrin saturation, total iron-binding capacity, and concentration of soluble transferrin receptors was discussed. Te review highlighted the importance of measuring bone marrow iron, which is rarely used in everyday clinical practice even though this test is considered a «gold standard» of ID diagnosis. Te review provided an insight into pathogenetic mechanisms of ID in CHF including insufcient iron supply, role of inflammation, erythropoietin, RAS, and effects of some pharmacological therapies. Te authors described physiological consequences of ID and anemia, activation of hemodynamic and non-hemodynamic compensatory mechanisms, which develop in response to anemia and not infrequently aggravate CHF. Special atention was paid to current approaches to treatment of anemia and ID in CHF, including a discussion of efcacy and safety of oral and intravenous dosage forms of iron and hemopoiesis stimulators.

Definition of Iron Deficiency Based on the Gold Standard of Bone Marrow Iron Staining in Heart Failure Patients

BACKGROUND

The most commonly used definition of iron deficiency (ID; ferritin <100 ng/mL or ferritin 100-300 ng/mL and transferrin saturation [TSAT] <20%) has not been validated in patients with heart failure (HF). We aimed to define and validate the biomarker-based definition of ID in HF, using bone marrow iron staining as the gold standard. Second, we aimed to assess the prognostic value of the optimized definition.

METHODS AND RESULTS

Bone marrow aspiration with iron staining was performed in 42 patients with HF and a reduced left ventricular ejection fraction (≤45%) undergoing median sternotomy for coronary artery bypass grafting. Patients were mostly male (76%) with mild-to-moderate HF and a mean age of 68±10 years. Bone marrow ID was found in 17 (40%) of the HF patients. The most commonly used definition of ID had a sensitivity of 82% and a specificity of 72%. A definition solely based on TSAT ≤19.8% or serum iron ≤13 µmol/L had a sensitivity of 94% and specificity of 84% and 88%, respectively (P<0.05 compared with the former definition). Subsequently, we assessed the incidence of all-cause mortality in 387 consecutive outpatient HF patients (left ventricular ejection fraction ≤45%). In these patients, TSAT ≤19.8% and serum iron ≤13 µmol/L, and not ferritin, were independently associated with mortality.

CONCLUSIONS

A TSAT ≤19.8% or a serum iron ≤13 µmol/L shows the best performance in selecting patients with ID and identifies HF patients at the highest risk of death. Our findings validate the currently used TSAT cutoff of <20% for the identification of ID in HF patients, but question the diagnostic value of ferritin.

Dynamic iron status after acute heart failure

BACKGROUND

Iron deficiency (ID) is common in heart failure (HF), and is associated with unfavourable clinical outcomes. Although it is recommended to screen for ID in HF, there is no clear consensus on the optimal timing of its assessment.

AIM

To analyse changes in iron status during a short-term follow-up in patients admitted for acute HF.

METHODS

Iron status (serum ferritin concentration and transferrin saturation) was determined in 110 consecutive patients (median age: 81 years) admitted to a referral centre for acute HF, at three timepoints (admission, discharge and 1 month after discharge). ID was defined according to the guidelines.

RESULTS

The prevalence rates of ID at admission, discharge and 1 month were, respectively, 75% (95% confidence interval [CI] 67-83%), 61% (95% CI: 52-70%), and 70% (95% CI: 61-79%) (P=0.008). Changes in prevalence were significant between admission and discharge (P=0.0018). Despite a similar ID prevalence at admission and 1 month (P=0.34), iron status changed in 25% of patients. Between admission and discharge, variation in C-reactive protein correlated significantly with that of ferritin (ρ=0.30; P=0.001). Advanced age, anaemia, low ferritin concentration and low creatinine clearance were associated with the persistence of ID from admission to 1 month.

CONCLUSIONS

Iron status is dynamic in patients admitted for acute HF. Although ID was as frequent at admission as at 1 month after discharge, iron status varied in 25% of patients.

Management of Iron Deficiency in Heart Failure

Anemia is a common finding in patients with heart failure (HF). The cause for anemia is multifactorial, with iron deficiency being the most common cause. Anemia with HF is an established predictor of morbidity and mortality. Iron deficiency in systolic HF, even without anemia, has been associated with increased mortality, increased hospitalizations, and decreased functional capacity and quality of life measures. Data from several randomized controlled trials and meta-analyses of iron deficiency and systolic HF show a beneficial effect for intravenous (IV) iron in terms of quality of life and functional capacity (improvements in 6-min walk test, and improvements in New York Heart Association functional class), as well as decreased hospitalizations for HF and reduction in cardiovascular mortality rates. Limited evidence exists for a beneficial effect of IV iron in diastolic dysfunction. Patients with symptomatic systolic HF should undergo an anemia diagnostic work-up. When iron deficiency (defined as ferritin <100 ng/mL or serum ferritin 100-299 ng/mL and transferrin saturation <20%) is present, current evidence supports treating HF patients with iron deficiency with IV iron.

Iron deficiency in heart failure

: Due to aging of the patients with heart failure, comorbidities are an emerging problem and, among them, iron deficiency is an important therapeutic target, independently of concomitant hemoglobin level. Iron deficiency affects up to 50% of heart failure patients, and it has been largely established its association with poor quality of life, impaired exercise tolerance and higher mortality. Randomized controlled trials (RCTs) and meta-analyses have demonstrated that intravenous iron supplementation in heart failure patients with iron deficiency positively affects symptoms, quality of life, exercise tolerance (as measured by VO2 peak and 6MWT), with a global trend to reduction of hospitalization rates. Current European Society of Cardiology Guidelines for heart failure recommend a diagnostic work-up for iron deficiency in all heart failure patients and intravenous iron supplementation with ferric carboxymaltose for symptomatic patients with iron deficiency, defined by ferritin level less than 100 μg/l or by ferritin 100-300 μg/l with TSAT less than 20%. On-going studies will provide new evidence for a better treatment of this important comorbidity of heart failure patients.

Prevalence, risk factors, and significance of iron deficiency and anemia in nonischemic heart failure patients with reduced ejection fraction from a Himachal Pradesh heart failure registry

BACKGROUND

The study aimed to estimate the prevalence, risk determinants, and its clinical significance of iron deficiency and anemia in patients of nonischemic heart failure with reduced ejection fraction (HFrEF).

METHODS

Serum ferritin, transferrin saturation, and the hemoglobin (Hb) levels were measured in 226 consecutive patients with HFrEF diagnosed based on the left ventricular ejection fraction ≤ 45% and absence of coronary artery luminal narrowing of more than 50%, in a prospective tertiary care hospital-based heart failure registry. Patients with the New York Heart Association functional class III/IV were classified as patients with advanced heart failure. Multivariable logistic regression modeling was performed to assess the risk determinants of iron deficiency and anemia and their clinical significance as the risk factors for advanced heart failure. Odds ratio with 95% confidence interval (CI) was reported as the estimates of the strength of association between exposure and outcome variables.

RESULTS

Iron deficiency and anemia were prevalent in 58.8% (52.2%-65.1%) and 35.8% (29.8%-42.3%) of patients, respectively. Female gender [OR 3.5 (95% CI 1.9-6.5)], history of bleeding [OR 11.7 (95% CI 1.4-101.2)], and vegetarian diet [OR 2.5 (95% CI 1.4-4.6)] were significantly associated with iron deficiency, while diabetes [OR 3.0 (95% CI 1.40-6.5)], estimated glomerular filtration rate [OR 0.98 (95% CI 0.97-0.99)], history of bleeding [OR 13.0 (95% CI 2.3-70.9)], and female gender [OR 2.9 (95% CI 1.5-5.7)] had significant association with anemia. The Hb level (OR 0.82 (95% CI 0.70-0.96) and transferrin saturation (OR 0.98 (95% CI 0.96-0.99)] had a significant inverse association with symptoms of advanced heart failure.

CONCLUSION

Iron deficiency and anemia are common comorbidities associated with HFrEF. Low Hb and transferrin saturation are significantly associated with advanced heart failure. The findings have important implications in the management of heart failure.

Screening, diagnosis and treatment of iron deficiency in chronic heart failure: putting the 2016 European Society of Cardiology heart failure guidelines into clinical practice

Iron deficiency is common in patients with chronic heart failure (CHF) and is associated with reduced exercise performance, impaired health-related quality of life and an increased risk of mortality, irrespective of whether or not anaemia is present. Iron deficiency is a serious but treatable condition. Several randomized controlled clinical trials have demonstrated the ability of intravenous (IV) iron, primarily IV ferric carboxymaltose (FCM), to correct iron deficiency in patients with heart failure with reduced ejection fraction (HFrEF), resulting in improvements in exercise performance, CHF symptoms and health-related quality of life. The importance of addressing the issue of iron deficiency in patients with CHF is reflected in the 2016 European Society of Cardiology (ESC) heart failure guidelines, which recognize iron deficiency as an important co-morbidity, independent of anaemia. These guidelines recommend that all newly diagnosed heart failure patients are routinely tested for iron deficiency and that IV FCM should be considered as a treatment option in symptomatic patients with HFrEF and iron deficiency (serum ferritin < 100 µg/L, or ferritin 100-299 µg/L and transferrin saturation < 20%). Despite these specific recommendations, there is still a lack of practical, easy-to-follow advice on how to diagnose and treat iron deficiency in clinical practice. This article is intended to complement the current 2016 ESC heart failure guidelines by providing practical guidance to all health care professionals relating to the procedures for screening, diagnosis and treatment of iron deficiency in patients with CHF.

Usefulness of Oral Ferric Citrate in Patients With Iron-Deficiency Anemia and Chronic Kidney Disease With or Without Heart Failure

Patients with chronic inflammatory conditions including chronic kidney disease (CKD) and heart failure (HF) are undertreated with iron-deficiency anemia (IDA). Progressive inflammation and reduced iron transport associated with CKD and HF may reduce the efficacy of oral iron therapy. Oral ferric citrate improves anemia markers in CKD, but its effects in patients with CKD and concomitant HF have not been described. Patients with CKD not on dialysis and IDA from a phase 2 and 3 trial were treated with ferric citrate (n = 190) or placebo (n = 188); patients with HF were identified from medical histories. Hemoglobin response was defined as a ≥10.0-g/L increase in hemoglobin. Changes in hemoglobin, transferrin saturation, ferritin, and serum phosphate from baseline to week 12 and the incidence of adverse events potentially related to HF were evaluated. HF was reported in 22% (n = 81) of patients. The proportion of patients with hemoglobin response to ferric citrate treatment did not significantly differ in patients with and without HF (43% vs 49%, respectively; p = 0.47); changes from baseline in hemoglobin, iron parameters, and serum phosphate were similar. Adverse events potentially related to HF were noted more frequently in patients with HF (ferric citrate, 23%; placebo, 17%) versus those without HF (ferric citrate, 12%; placebo, 11%). In conclusion, these results indicate a potential role for ferric citrate in the treatment of IDA in patients with CKD not on dialysis and concomitant HF.

Erythropoietin response to anaemia in heart failure

Background

Despite multiple factors correlating with the high prevalence of anaemia in heart failure, the prevailing mechanisms have yet to be established. The purpose of this study is to systematically review the literature and determine whether low circulating haemoglobin is primarily underlain by erythropoietin resistance or defective production in heart failure.

Design and methods

We conducted a systematic search of MEDLINE since its inception until May 2017 for articles reporting erythropoietin and haemoglobin concentrations in heart failure patients not treated with erythropoietin-stimulating agents. The primary outcome was the mean difference in observed/predicted (O/P) erythropoietin ratio between heart failure patients and normal reference values. Meta-regression analyses assessed the influence of potential moderating factors.

Results

Forty-one studies were included after systematic review, comprising a total of 3137 stable heart failure patients with mean age and left ventricular ejection fraction ranging from 52 years to 80 years and 21% to 59%. The O/P erythropoietin ratio was below reference values in 24 of 25 studies in anaemic heart failure patients ( n = 1094, range = 0.49–1.05), whereas only one out of 16 studies in non-anaemic heart failure patients presented a low O/P erythropoietin ratio ( n = 2043, range = 0.91–1.97). In studies comparing anaemic versus non-anaemic heart failure patients ( n = 1531), the mean O/P erythropoietin ratio was consistently reduced in anaemic heart failure patients (mean difference = –0.68, 95% confidence interval = −0.78, −0.57; p < 0.001). In meta-regression, the O/P erythropoietin ratio was negatively associated with age, female sex, left ventricular ejection fraction, inflammation and disease severity.

Conclusion

Anaemia in heart failure is overwhelmingly characterized by impaired erythropoietin production, which is exacerbated with age, female sex, left ventricular ejection fraction, inflammation and disease severity.

Elevated levels of vitamin B12 in chronic stable heart failure: a marker for subclinical liver damage and impaired prognosis

Background

Elevated vitamin B12 is a sign for liver damage, but its significance in chronic stable heart failure (HF) is less known. The present study investigated the clinical correlates and prognostic significance of vitamin B12 levels in stable systolic HF.

Methods

A total of 129 consecutive patients with HF and 50 control subjects were enrolled. Data regarding demographics, clinical signs, therapeutic and conventional echocardiographic measurements were recorded for all patients. Right-sided HF was defined as the presence of at least one of the typical symptoms (ankle swelling) or specific signs (jugular venous distention or abdominojugular reflux) of right HF. Cox proportional hazards regression analyses were performed to determine the independent prognostic determinants of mortality.

Results

Baseline B12 levels in HF patients (n=129) with and without right sided HF were significantly higher compared to healthy controls (n=50): Median 311 pg/mL and 235 pg/mL vs 198 pg/mL, respectively (P=0.005). Folic acid levels were similar between the study groups. Age, ejection fraction, left atrial size, estimated glomerular filtration rate, and direct and indirect bilirubin levels were significantly correlated to serum B12 level in univariate analysis. In multivariate analysis, independent correlates of B12 were direct bilirubin (R=0.51, P<0.001) and age (R=0.19, P=0.028). Patients with HF were followed-up for a median period of 32 months. Median B12 levels were significantly higher in patients who subsequently died (n=35) compared to survivors, but folic acid was not different between the two groups. ROC analysis showed that B12 values ≥270 pg/mL had 80% sensitivity and 58% specificity for predicting all-cause mortality (area under the curve=0.672, 95% CI=0.562−0.781; P=0.003). However, in Cox regression analysis, only left atrial diameter, level of direct bilirubin, and the presence of abdominojugular reflux were independent predictors of death.

Conclusion

Increased B12 in stable HF patients is associated with increased direct bilirubin due to right HF, indicating a cardiohepatic syndrome, but neither B12 nor folic acid are independently associated with mortality.

Iron deficiency in chronic and acute heart failure: A contemporary review on intertwined conditions

Iron Deficiency (ID) is increasingly recognized as a prevalent comorbid condition in Heart Failure (HF). Despite this, the pathophysiological mechanisms for progressive ID in either chronic or acute HF are still poorly understood. Beyond the traditional factors for iron deficit in the general population, we ought to review the specificities of such paucity in the HF patient, particularly focusing on the interplay between heightened inflammation, overactivity of the sympathetic nervous system and the so-called cardio-renal-anaemia-ID syndrome. Currently, ID constitutes not only an independent prognostic marker but also a novel safe therapeutic target. Particularly, in selected stable HF patients with reduced left ventricular ejection fraction, intravenous (IV) iron improves symptomatic burden and reduces hospitalizations due to worsening HF. On this topic, the main trials of IV iron with either iron sucrose (Toblli et al., FERRIC-HF and IRON-HF) or ferric carboxymaltose (FAIR-HF, CONFIRM-HF and EFFECT-HF) will be summarized and discussed. Finally, we debate the gaps in knowledge of ID in special populations, namely the unreliability of routine plasmatic surrogate markers to assess iron status in acute and advanced HF, the challenging patient with both HF and Chronic Kidney Disease, as well as efficacy and safety concerns in these settings and the potential role of iron correction in cardiac resynchronization therapy candidates.

Red blood cell transfusion after a global strategy for early detection and treatment of iron deficiency anemia: three-year results of a prospective observational study

BACKGROUND

Anemia is the main indication for red blood cell (RBC) transfusion and iron deficiency is the most prevalent, preventable, and treatable cause of anemia worldwide. We aimed to assess the impact of iron deficiency anemia (IDA) on RBC transfusion by means of a program for prevention, early detection, and treatment.

STUDY DESIGN AND METHODS

A prospective observational study was conducted starting in 2014 after an intervention in clinical practice in Melilla, a peripheral city isolated by 207 km sea distance to nearest continental Spain. Recommendations were proposed for first-step diagnosis of iron deficiency in the laboratory, oral iron prevention and treatment in primary care, and intravenous iron complexes and RBC transfusion for hospital management. Reduction in RBC use for years 2014 to 2016 was the primary outcome, with the period 2010 to 2013 considered as baseline performance for statistical analysis.

RESULTS

Compared to baseline, there was a significant (p < 0.05) increase in mean (±SD) yearly reference population (79,748 ± 3265 vs. 85,376 ± 781), ferritin assays (6980 ± 997 vs. 11,794 ± 1567), admissions (6768 ± 239 vs. 7629 ± 191), and subjects exposed to iron therapy (3975 ± 0.0 vs. 4667 ± 21 for oral, 54 ± 7 vs. 257 ± 109 for sucrose, and 128 ± 9 vs.176 ± 15 for carboxymaltose iron). Mean yearly number of RBC units transfused decreased (1622 ± 112 vs. 1434 ± 44; p = 0.043), with a mean reduction of 11.6% from baseline, or 21.4% when estimated by units transfused per 1000 admissions.

CONCLUSIONS

Management of IDA is a target to avoid RBC transfusion, and awareness of this health problem should be among the first pillars for any patient blood management program.

Determination of Non-Transferrin Bound Iron, Transferrin Bound Iron, Drug Bound Iron and Total Iron in Serum in a Rats after IV Administration of Sodium Ferric Gluconate Complex by Simple Ultrafiltration Inductively Coupled Plasma Mass Spectrometric Detection

A rapid, sensitive and specific ultrafiltration inductively-coupled plasma mass spectrometry (UF-ICP-MSICP-MS) method was developed and validated for the quantification of non-transferrin bound iron (NTBI), transferrin bound iron (TBI), drug bound iron (DI) and total iron (TI) in the same rat serum sample after intravenous (IV) administration of iron gluconate nanoparticles in sucrose solution (Ferrlecit^®). Ultrafiltration with a 30 kDa molecular cut-off filter was used for sample cleanup. Different elution solvents were used to separate each form of iron from sample serum. Isolated fractions were subjected to inductively-coupled mass spectrometric analysis after microwave digestion in 4% nitric acid. The reproducibility of the method was evaluated by precision and accuracy. The calibration curve demonstrated linearity from 5-500 ng/mL with a regression (r²) of more than 0.998. This method was effectively implemented to quantify rat pharmacokinetic study samples after intravenous administration of Ferrlecit^®. The method was successfully applied to a pharmacokinetic (PK) study of Ferrlecit in rats. The colloidal iron followed first order kinetics with half-life of 2.2 h and reached background or pre-dose levels after 12 h post-dosing. The drug shown a clearance of 0.31 mL/min/kg and volume of distribution of 0.05 L/kg. 19.4 ± 2.4 mL/h/kg.

Iron Laboratory Studies in Pediatric Patients With Heart Failure from Dilated Cardiomyopathy

Iron deficiency (FeD), with or without anemia, in adults with heart failure (HF) is associated with poor outcomes, which can be improved with replacement therapy. A similar therapeutic opportunity may exist for children; however, iron laboratory measurements and FeD have not been described in pediatric patients with HF. A single-center, retrospective study was conducted on 28 patients <21 years old with a diagnosis of dilated cardiomyopathy and HF who had iron laboratories (serum iron, iron saturation, and ferritin) performed. The mean (standard deviation) age at time of laboratory collection was 10.3 (5.5) years. Twenty-seven patients (96.4%) met the criteria for FeD. Serum iron and iron saturation were significantly associated with inpatient hospitalization, being on inotropic medications, or having stage D HF. Low-serum iron was associated with a higher left ventricular end-diastolic dimension and left ventricular end-systolic dimension z-score by echocardiography ((β -2.58, 95% confidence interval [CI] -4.76, -0.40, p = 0.02) and (β -2.43, 95% CI -4.70, -0.17, p = 0.04)), respectively. Low ferritin was associated with higher mortality (relative risk 0.29, 95% CI 0.12, 0.70, p = 0.006). In conclusion, FeD was common in this pediatric cohort with more advanced HF. Iron profile abnormalities were associated with worse HF severity and outcomes including mortality.

Anemia and Iron Deficiency in Heart Failure — Clinical Update

Iron deficiency and anemia affect approximately half of the chronic heart failure patients and they are associated with increased hospitalization rate, lower functional capacity, lower quality of life, and higher mortality. The exact mechanism of iron deficiency in heart failure patients is still not fully understood. Current guidelines recommend ferritin as the most accurate serum biomarker for the diagnosis of iron deficiency. The use of erythropoiesis-stimulating agents is no longer recommended because of the lack of improvement on mortality or hospital readmission rate, and it was associated with a higher rate of thromboembolic events. Intravenous iron replacement therapy is safe and generally well tolerated, with fewer side effects compared to oral administration. Large randomized studies with ferric carboxymaltose demonstrated its effectiveness and superiority to oral administration, and it was associated with a decreased rate of hospitalization rate and worsening heart failure, and improvement of functional capacity and quality of life. Intravenous iron supplementation for chronic heart failure is strongly recommended by European guidelines. Further studies are needed for a better knowledge of this complex pathology and determination of the long-term safety and effectiveness of iron administration in chronic heart failure patients. .

Iron deficiency in heart failure: Efficacy and safety of intravenous iron therapy

AIM

To discuss the pathophysiology of iron metabolism in chronic heart failure (CHF) and the current knowledge of the efficacy of intravenous (IV) iron therapy in patients with CHF and identify points of controversy as well as highlight areas for future research.

DISCUSSION

Iron deficiency is a recognized complication of many chronic conditions. Numerous studies have reported that iron deficiency is highly prevalent in patients with CHF and is associated with exercise intolerance, reduced quality of life, and increased risk of hospitalization and mortality. Several small studies have demonstrated IV iron to be associated with improvements in symptoms, exercise capacity, quality of life, renal function, New York Heart Association (NYHA) functional class and left ventricular ejection fraction (LVEF), and reduction in NT-pro-brain natriuretic peptide (NT-proBNP) in patients with CHF and iron deficiency. Two larger-scale trials confirming these results (FAIR-HF and CONFIRM-HF) have led to guideline recommendations that IV iron therapy should be considered in patients with CHF with reduced ejection fraction and iron deficiency (serum ferritin <100 μg/L, or ferritin between 100 and 299 μg/L with transferrin saturation <20%) to provide symptomatic relief and improve exercise capacity and quality of life.

CONCLUSION

Intravenous iron therapy improves symptoms, exercise capacity, and quality of life, at least in the short-to-intermediate time. However, there are still currently no standardized criteria used to define iron deficiency and the underlying mechanism of iron deficiency in CHF remains incompletely understood. Further work is required to improve the ability to identify iron deficiency in patients with CHF and evaluate the effect of iron repletion on hard endpoints including hospitalization and mortality.

Anemia in severe heart failure patients: does it predict prognosis?

Background

Anemia is highly prevalent in heart failure (HF) patients. However, the prevalence, clinical impact and prognostic factor of anemia in heart failure patients is widely varies. The aim of this study was to evaluate the prevalence of anemia in patients with HF, to compare baseline clinical characteristic and outcomes of severe HF patients with and without anemia admitted to Gondar University Referral Hospital (GURH), Gondar, Ethiopia.

Method

A retrospective cohort study was conducted and we assessed medical records of heart failure patients who were admitted Gondar University Referral Hospital in the period between December 02, 2010 and November 30, 2016. Kaplan Meier curve was used to analyze the survival status and log rank test was used to compare the curves. Multivariate Cox regression was used to analyze independent predictors of mortality in all HF patients. P value less than 0.05 was considered statistically significant.

Result

Three hundred and seventy patients participated in the study. The prevalence of anemia in the study cohorts was 41.90% and majority of the participants were females (64.59%). There was a significant difference in the level of hemoglobin, creatinine, and sodium among anemic and non-anemic patients. Anemic patients with HF tend to take angiotensin converting enzyme inhibitors (ACEI) less frequently. Kaplan Meier survival curves and Log rank test (P = 0.042) showed a significant difference in the prognosis of HF patients with anemia and non – anemic. More significant difference was observed (Log rank test, P = 0.001) in the study participants based on hemoglobin level. Furthermore, multivariate Cox regression showed: advanced age, levels of lower sodium and higher creatinine, and absences of medications like ACEI and Spironolactone independently predicted overall mortality.

Conclusion

HF patients with anemia tend to be older age, had lower hemoglobin and sodium level and higher creatinine value. Moreover, there was a significant difference in the prognosis between study cohorts, as anemic pateints tend to have a worse survival status . Even though, anemia is a significant risk marker, it is not an independent predictor of mortality in the current study.

Anemia is a mortality prognostic factor in patients initially hospitalized for acute heart failure

Anemia is a risk factor related to morbidity and mortality in patients with chronic heart failure (HF). Less is known about its influence in patients in an early stage of HF. Our aim is to investigate the prognostic role of anemia in patients initially hospitalized for acute HF. We reviewed all consecutive patients admitted within a 18-month period with a main diagnosis of acute HF. We collected demographic, clinical and treatment data. Anemia is defined as Hemoglobin <12/13 g/dL upon admission in female/male patients, respectively. 719 patients were included (55.5% female), with a mean age of 78.7 ± 9 years. Anemia was present in 59.6% of patients upon admission, with a mean Hb of 10.4 ± 1.4 g/dL. Multivariate analysis confirms the relationship between the presence of anemia and older age, a previous diagnostic history of diabetes, and the presence of chronic kidney disease. In-hospital mortality is similar for anemic and non-anemic patients (6.8 vs 3.8%, p = n.s.) However, the difference is significant when one-year mortality is evaluated (31% in anemic patients vs 19% in non-anemic patients, p < 0.001). Cox regression analysis confirms the association between anemia and higher risk of one-year mortality, as well as with older age and a higher Charlson comorbidity index. Our study confirms that the presence of anemia is an independent factor for mid-term (1-year) mortality even in patients experiencing a first admission due to acute HF.

Pathophysiology of cardiorenal syndrome in patients with heart failure: potential therapeutic targets

Despite the development of pharmacological inventions and new nonpharmacological techniques to prevent and treat heart failure (HF), the mortality rate in patients with symptomatic HF remains high. To conquer these difficulties, the pathophysiology of HF should be considered within a wide range of views. Given the diverse mechanisms of HF pathophysiology, renal and cardiac functions have close and complementary interconnections. Recent studies have suggested that communication between the kidney and heart through bidirectional pathways causes significant pathological changes. This review summarizes the pathophysiology of cardiorenal syndrome (CRS) from three different viewpoints, namely, underlying chronic kidney disease, worsening renal function during hospitalization due to HF, and resistance to diuretics. We also summarize the presently available data on the pathophysiology of CRS, identify the challenges associated with some clinical approaches, and explore the potential therapeutic target for CRS.

Oral Iron Therapy for Heart Failure With Reduced Ejection Fraction: Design and Rationale for Oral Iron Repletion Effects on Oxygen Uptake in Heart Failure

: Iron deficiency is present in ≈50% of patients with heart failure and is an independent predictor of mortality. Despite growing recognition of the functional and prognostic significance of iron deficiency, randomized multicenter trials exploring the use of oral iron supplementation in heart failure, a therapy that is inexpensive, readily available, and safe, have not been performed. Moreover, patient characteristics that influence responsiveness to oral iron in patients with heart failure have not been defined. Although results of intravenous iron repletion trials have been promising, regularly treating patients with intravenous iron products is both expensive and poses logistical challenges for outpatients. Herein, we describe the rationale for the Oral Iron Repletion effects on Oxygen Uptake in Heart Failure (IRONOUT HF) trial. This National Institute of Health-sponsored trial will investigate oral iron polysaccharide compared with matching placebo with the primary end point of change in exercise capacity as measured by peak oxygen consumption at baseline and at 16 weeks.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02188784.

Prevalence of Erythrocyte Changes in Patients with Heart Failure

Heart failure (HF) is one of the most common causes of hospitalization in patients over the age of 65. Purpose The objective of our study was to assess the prevalence of anemia and characterize the morphology of red blood cells in patients admitted for HF decompensation. Material and Methods We have included patients with decompensated HF with left ventricular ejection fraction (LVEF). ≤45% successively hospitalized at Filantropia Clinical Hospital Craiova. Results A total of 397 patients, including 204 males (51.39%) were included. The prevalence of anemia in our group was 38.54% (153 patients). The mean age of patients with heart failure and anemia was significantly higher compared to those with normal hemoglobin (75.05±7.16 years vs. 72.27±7.91 years, p=0.00047). The majority of anemias (68.62%) were normocytic normochromic, defined as mean corpuscular hemoglobin (MCV) value between 80 to 98fl and mean corpuscular hemoglobin concentration (MCH)>27pg. 20 patients (13.07%) had microcytic hypochromic anemia (MCV<80fL and MCH<27pg), in 16 patients (10.45%) was present normocytic hypochromic anemia (MCV 80-98fl and MCH<27pg) and 12 patients (7.48%) had macrocytic anemia (MCV>98fL and MCH>27pg), respectively. Conclusions Our study suggests that the prevalence of anemia in hospitalized patients for HF decompensation is high and normocytic normochromic anemia was the most common morphological type of anemia.