Anemia and chronic heart failure implications and treatment options

Rationale and design of a pilot randomized controlled trial to assess the role of intravenous ferric carboxymaltose in Asian patients with heart failure (PRACTICE-ASIA-HF)

AIMS

Iron deficiency (ID) is highly prevalent in patients with heart failure (HF) worldwide regardless of haemoglobin levels. Results from therapeutic trials of intermittently dosed intravenous (i.v.) iron are promising in the ambulatory Caucasian population with HF with reduced left ventricular ejection fraction, although evidence is scarce in Asia. The Pilot Randomized Controlled Trial to Assess the Role of Intravenous Ferric Carboxymaltose in Asian Patients with Heart Failure aims to assess the effect of single-dose i.v. ferric carboxymaltose (FCM) in a multi-ethnic Asian population with HF and ID.

METHODS AND RESULTS

This is an open-label, randomized, placebo-controlled trial recruiting stabilized inpatients with decompensated HF (regardless of left ventricular ejection fraction), ID [defined as serum ferritin <300 ng/mL if transferrin saturation <20%] and haemoglobin ≤14 g/dL. Patients from two tertiary institutions were randomized in a 1:1 ratio to receive a single dose of either i.v. FCM (Ferinject®) 1000 mg or i.v. normal saline. The primary endpoint is the change in 6-min walk distance at Weeks 4 and 12, and secondary endpoints are changes at Weeks 4 and 12 in (i) quality of life as measured by the Kansas City Cardiomyopathy Questionnaire and Visual Analogue Scale scores and (ii) New York Heart Association functional class.

CONCLUSIONS

Preliminary efficacy data on i.v. FCM therapy in Asian HF are expected from this pilot study to support larger-scale multicentre therapeutic i.v. FCM trials within Asia.

Anemia and its association with clinical outcome in heart failure patients undergoing cardiac resynchronization therapy

PURPOSE

Although a substantial proportion of patients with heart failure (HF) have anemia, there is a paucity of data evaluating the impact of anemia on clinical outcome in CRT patients. Our goal was to examine the ability of baseline hemoglobin (Hb) level and change in Hb level over time to predict clinical 2-year outcome and echocardiographic response to CRT.

METHODS

Three hundred consecutive CRT patients (median 72 years [interquartile range (IQR) 16 years], 19% female) with baseline and follow-up hematological profiles available were examined. Baseline anemia was defined as Hb <12 g/dL in women and <13 g/dL in men, and patients were grouped into equal quartiles based on change in Hb. Two-year clinical outcome was determined using a composite endpoint that included HF hospitalization, left ventricular assist device (LVAD) placement, heart transplantation, and all-cause mortality. Echocardiographic reverse remodeling was examined at 6-month follow-up.

RESULTS

One hundred fifty-one anemic patients were compared to 149 non-anemic patients. Changes in left ventricular dimensions and ejection fraction were similar for both groups. Univariate predictors of 2-year clinical outcome included baseline creatinine level, diuretic usage, and anemia; in multivariable regression, baseline anemia was an independent predictor for outcome (hazard ratio [HR] 1.79, 95% confidence interval [CI] [1.22-2.63], p = 0.003). The quartile with the most negative change in Hb concentration over time (≤-1.00 g/dL) had poorer event-free 2-year survival (HR 1.84, CI [1.13-3.00], p = 0.014).

CONCLUSIONS

Baseline anemia and early postimplantation decline in Hb levels are associated with a worse 2-year prognosis in CRT patients, even though the magnitude of left ventricular reverse remodeling is similar compared to non-anemic patients.

Increased risk of stroke with darbepoetin alfa in anaemic heart failure patients with diabetes and chronic kidney disease

AIMS

The use of an erythropoesis-stimulating agent, darbepoetin alfa (DA), to treat anaemia in patients with diabetes mellitus and chronic kidney disease was associated with a heightened risk of stroke and neutral efficacy in the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT), despite epidemiological data suggesting the contrary. However, this association has not been evaluated in another randomized, placebo-controlled trial.

METHODS AND RESULTS

Reduction of Events by Darbepoetin Alfa in Heart Failure (RED-HF) was a randomized placebo-controlled trial of DA in 2278 patients with systolic heart failure and anaemia, enrolled from 2006 to 2012 and followed for a median of 28 months. Within RED-HF, 816 patients had diabetes mellitus and chronic kidney disease [estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m(2) ] and met inclusion criteria for TREAT. TREAT-like RED-HF patient data were analysed alone and combined at the patient level with the 4038 TREAT patients. In RED-HF, the annualized event rate of stroke was 2.3 in patients on DA and 1.1 in patients randomized to placebo (P = 0.051). Analysis of the combined group (n = 4854) confirmed a nearly two-fold increase in stroke risk [hazard ratio (HR) 1.94, 95% confidence interval (CI) 1.43-2.63] and an overall neutral effect on mortality (HR 1.00, 95% CI 0.89-1.12) of raising haemoglobin with DA.

CONCLUSION

The placebo-controlled cohort of heart failure patients with anaemia, diabetes mellitus, and chronic kidney disease from RED-HF provides confirmation of the increased stroke risk associated with DA use identified in TREAT.

AHEAD score--Long-term risk classification in acute heart failure

BACKGROUND

The role of co-morbidities in the prognosis of patients hospitalized for AHF was examined using the AHEAD (A--atrial fibrillation, H--haemoglobin<130 g/l for men and 120 g/l for women (anaemia), E--elderly (age>70years), A--abnormal renal parameters (creatinine>130 μmol/l), D--diabetes mellitus) scoring system.

METHODS

AHEAD--multicentre prospective Czech registry of AHF patients; GREAT registry--international cohort of AHF patients. Data from 5846 consecutive patients hospitalized for AHF (AHEAD registry; derivation cohort) were analysed to build the AHEAD score. Each risk factor of the AHEAD score was counted as 1 point. The model was validated externally using an international cohort of similar patients in the GREAT registry (6315).

RESULTS

Main outcome was one year all-cause mortality. The mean age of patients was 72±12 years, with 61.6% of patients aged >70 years; 43.4% were women. Atrial fibrillation was present in 30.7%, anaemia in 38.2%, creatinine>130 mmol/l (abnormal renal parameters) in 30.1%, and diabetes mellitus in 44.0%. The mean AHEAD score was 2.1. In patients with AHEAD scores of 0-5, the one-year mortality rates were 13.6%, 23.4%, 32.0%, 41.1%, 47.7%, and 58.2%, respectively (p<0.001), and the 90 month mortality rates were 35.1%, 57.3%, 73.5%, 84.8%, 88.0%, and 91.7%, respectively (p<0.001).

CONCLUSION

The AHEAD is a simple scoring system based on the analysis of co-morbidities for the estimation of the short and long term prognosis of patients hospitalized for AHF.

Relation of left ventricular ejection fraction and clinical features or co-morbidities to outcomes among patients hospitalized for acute heart failure syndromes

The aim of this study was to evaluate the heterogeneity of the association of a preserved or reduced ejection fraction (EF) with the increased risk of outcomes among patients with acute heart failure syndromes. Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry in Japan, 4,720 patients were evaluated to investigate the association of EF and clinical features or co-morbidities with all-cause mortality after admission. The median follow-up period after admission was 519 (388 to 781) days. The all-cause mortality rate did not differ between the reduced EF and preserved EF groups (24.9% and 24.5%, respectively). To evaluate the heterogeneity of the influence of a preserved or reduced EF on all-cause mortality, subgroup analyses were performed. As a result, there were significant interactions in the association of a preserved or reduced EF with all-cause mortality when the patients were stratified by an ischemic cause, a hypertensive cause, previous hospitalization for heart failure, diabetes mellitus, and anemia. The influence of a nonischemic cause, a hypertensive cause, or new-onset heart failure on the risk of all-cause mortality was significantly greater in patients with preserved EF than in those with reduced EF. In contrast, the influence of diabetes mellitus or anemia on the risk of all-cause mortality was significantly greater in patients with reduced EF than in those with preserved EF. In conclusion, the present analysis demonstrated that the association of a preserved or reduced EF with the clinical outcome differs markedly in relation to the clinical features or co-morbidities of these patients.

Mechanisms linking red blood cell disorders and cardiovascular diseases

The present paper aims to review the main pathophysiological links between red blood cell disorders and cardiovascular diseases, provides a brief description of the latest studies in this area, and considers implications for clinical practice and therapy. Anemia is associated with a special risk in proatherosclerotic conditions and heart disease and became a new therapeutic target. Guidelines must be updated for the management of patients with red blood cell disorders and cardiovascular diseases, and targets for hemoglobin level should be established. Risk scores in several cardiovascular diseases should include red blood cell count and RDW. Complete blood count and hemorheological parameters represent useful, inexpensive, widely available tools for the management and prognosis of patients with coronary heart disease, heart failure, hypertension, arrhythmias, and stroke. Hypoxia and iron accumulation cause the most important cardiovascular effects of sickle cell disease and thalassemia. Patients with congenital chronic hemolytic anemia undergoing splenectomy should be monitored, considering thromboembolic and cardiovascular risk.

RED BLOOD VALUES CHANGES IN CARDIOVASCULAR PATIENTS — EPIDEMIOLOGY, PROGNOSIS AND TREATMENT APPROACHES

The review highlights a significance of anemic syndrome in cardiovascular patients, which is certainly negatively related to life quality and prognosis of patients. The main causes for its development are discussed, of those the main are hemodilution, inflammatory cytokines, iron deficiency. Also anemia correction is discussed and the main trials of this field are mentioned. The U-shaped relation is discussed for hemoglobin concentration and cardiovascular morbidity and mortality which reflect that higher levels of hemoglobin and hematocrit are associated with poorer outcome. There is lack of information on the prevalence and influence of hemoconcentration on prognosis in cardiological patients, as the data available is usually controversial. The conclusion is made that at the moment the problem of target hemoglobin and hematocrit levels definition for anemia treatment in cardiological patients, as also the data on the hemoconcentration influence of course and prognosis of cardiovascular diseases remains open. 

Noncardiac comorbidities in heart failure with reduced versus preserved ejection fraction

Heart failure patients are classified by ejection fraction (EF) into distinct groups: heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Although patients with heart failure commonly have multiple comorbidities that complicate management and may adversely affect outcomes, their role in the HFpEF and HFrEF groups is not well-characterized. This review summarizes the role of noncardiac comorbidities in patients with HFpEF versus HFrEF, emphasizing prevalence, underlying pathophysiologic mechanisms, and outcomes. Pulmonary disease, diabetes mellitus, anemia, and obesity tend to be more prevalent in HFpEF patients, but renal disease and sleep-disordered breathing burdens are similar. These comorbidities similarly increase morbidity and mortality risk in HFpEF and HFrEF patients. Common pathophysiologic mechanisms include systemic and endomyocardial inflammation with fibrosis. We also discuss implications for clinical care and future HF clinical trial design. The basis for this review was discussions between scientists, clinical trialists, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum.

Diagnosis and treatment of iron deficiency in patients with heart failure: expert position paper from French cardiologists

The prevalence of iron deficiency is high -even in the absence of anaemia- in patients with chronic heart failure (HF). Although iron deficiency is easily diagnosed with two biomarkers (serum ferritin and transferrin saturation), it is underdiagnosed in patients with HF. Iron is not only necessary for red blood cells, but also for cells in tissues with high-energy demands (heart, muscle, brain). Even before the onset of anaemia, HF patients with iron deficiency have decreased physical and cognitive performances and a poorer quality of life. Moreover, iron deficiency is a risk factor, independent of anaemia, of unfavourable outcome (death or heart transplantation) in patients with chronic HF. Several randomized controlled studies have shown improvement in exercise capacity, New York Heart Association functional class and quality of life after correction of iron deficiency. The results of these clinical trials, which are supported by European guidelines, suggest considering iron deficiency in HF as a possible therapeutic target.

Associations of anemia and renal dysfunction with outcomes among patients hospitalized for acute decompensated heart failure with preserved or reduced ejection fraction

BACKGROUND AND OBJECTIVES

The relationship among anemia, renal dysfunction, left ventricular ejection fraction, and outcomes of patients hospitalized for acute decompensated heart failure is unclear. The aim of this study was to evaluate the association between cardiorenal anemia syndrome and postdischarge outcomes in patients hospitalized for heart failure with a preserved or reduced ejection fraction.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Of 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes Registry between April 1, 2007 and December 31, 2011, 4393 patients were evaluated to investigate the association among anemia, renal dysfunction, preserved or reduced ejection fraction, and the primary end point (mortality and readmission for heart failure since discharge). The patients were divided into four groups on the basis of eGFR and hemoglobin at discharge. The median follow-up period after discharge was 432 (range=253-659) days.

RESULTS

The primary end point was reached in 37.6% and 34.8% of the preserved and reduced ejection fraction groups, respectively. After adjustment for multiple comorbidities, there was no significant association of either renal dysfunction or anemia alone with the primary end point in patients with preserved ejection fraction, but the combination of renal dysfunction and anemia was associated with a significantly higher risk than that without either condition (hazard ratio, 1.54; 95% confidence interval, 1.12 to 2.12; P<0.01). In patients with reduced ejection fraction, adjusted analysis showed that a significantly higher risk of the primary end point was associated with renal dysfunction alone (hazard ratio, 1.65; 95% confidence interval, 1.21 to 2.25; P=0.002) and also, renal dysfunction plus anemia relative to the risk without either condition (hazard ratio, 2.19; 95% confidence interval, 1.62 to 2.96; P<0.001).

CONCLUSIONS

The findings show that renal dysfunction combined with anemia is associated with an increased risk of adverse postdischarge outcomes in patients with preserved ejection fraction, whereas renal dysfunction is an independent predictor of the risk of adverse outcomes in patients with reduced ejection fraction, regardless of anemia.

The role of erythropoietin stimulating agents in anemic patients with heart failure: solved and unresolved questions

Anemia is a common finding in congestive heart failure (CHF) and is associated with an increased mortality and morbidity. Several conditions can cause depression of erythroid progenitor cells: reduction of iron absorption and reuptake, decreased bone marrow activity, reduced endogenous erythropoietin production, and chronic inflammatory state. Anemia's etiology in CHF is complex and partially understood; it involves several systems including impaired hemodynamic condition, reduced kidney and bone perfusion, increased inflammatory activity, and neurohormonal overdrive. The use of erythropoiesis stimulating agents (ESAs) such as erythropoietin and its derivatives is recently debated; the last interventional trial seems to demonstrate a neutral or negative effect in the active arm with darbepoetin treatment. The current data is opposite to many single blind studies and previous meta-analysis showing an improvement in quality of life, New York Heart Association class, and exercise tolerance using ESA therapy. These contrasting data raise several concerns regarding the target of hemoglobin levels needing intervention, the exact anemia classification and categorization, and the standardization of hematocrit cutoffs. Some cardiac and systemic conditions (ie, hypertension, atrial fibrillation, prothrombotic status) may predispose to adverse events, and ESA administration should be avoided. To prevent the negative effects, high-dosage and chronic administration should be avoided. Clarification of these items could probably identify patients that may benefit from additional iron or ESA treatment. In this review, we discuss the interventional trials made in anemic heart failure patients, the underlying mechanism of anemia in CHF, and the potential role of ESA in this setting.

High prevalence of iron deficiency in patients with acute decompensated heart failure

AIMS

Limited data are available on iron parameters in patients hospitalized for decompensation of chronic heart failure.

METHODS AND RESULTS

Iron parameters of patients hospitalized for decompensation of chronic heart failure were prospectively assessed during the 72 h after hospital admission. Iron deficiency was defined according to the 2012 European Society of Cardiology Guidelines. Overall, 411 men (75 ± 12  years; 75% NYHA functional classes III/IV) and 421 women (81 ± 11 years; 71% NYHA classes III/IV) were evaluated. The prevalence of iron deficiency was 69% in men and 75% in women (including 41% and 49% with absolute iron deficiency, respectively). The prevalence of anaemia in men (<13 g/dL) was 68% and in women (<12 g/dL) it was 52%. Among non-anaemic patients, the prevalence of iron deficiency was 57% in men and 79% in women. Only 9% of patients received iron supplementation at the time of admission (oral, 9%; intravenous, 0.2%). Multivariate analysis showed that anaemia and antiplatelet treatment in men, and diabetes and low C-reactive protein in women, were independently associated with iron deficiency.

CONCLUSIONS

Iron deficiency is very common in patients admitted for acute decompensated heart failure, even among non-anaemic patients. Given the benefit of iron therapy in chronic heart failure, our results emphasize the need to assess iron status not only in chronic heart failure patients, but even more so in those admitted for worsening heart failure, regardless of gender, heart failure severity, or haemoglobin level. Initiating iron therapy in hospitalized heart failure patients needs to be investigated.

Adaptive servo-ventilation therapy improves long-term prognosis in heart failure patients with anemia and sleep-disordered breathing

Sleep disordered breathing (SDB) and anemia influences the progression of chronic heart failure (CHF). Adaptive servo-ventilation (ASV) is an effective therapeutic device for treatment of CHF, however, the impacts of ASV on CHF patients with or without anemia remain unclear.A total of 139 patients with CHF and SDB were divided into two groups: those treated with ASV (n = 53) and without ASV (n = 86). All patients were prospectively followed after discharge with the endpoints of cardiac death or progressive heart failure requiring rehospitalization. There were 65 patients (47%) with anemia among all subjects. The apnea hypopnea index was improved, and plasma BNP and high sensitive C-reactive protein levels were decreased in both groups with and without anemia by ASV therapy. The Kaplan-Meier survival curve demonstrated that the cardiac event-free rate in patients with ASV was significantly higher than in those without ASV in the anemia group (P = 0.008). However, in the non-anemia group, the cardiac event-free rate was similarly high in patients both with and without ASV (P = 0.664). Multivariate Cox proportional hazard analysis demonstrated that ASV use was an independent predictor of cardiac events in the anemia group (P = 0.0308), but not in the non-anemia group.ASV treatment for CHF and SDB has more favorable impacts in patients with anemia than in those without anemia.

Clinical profile and prognostic value of anemia at the time of admission and discharge among patients hospitalized for heart failure with reduced ejection fraction: findings from the EVEREST trial

BACKGROUND

Anemia has been associated with worse outcomes in patients with chronic heart failure (HF). We aimed to characterize the clinical profile and postdischarge outcomes of hospitalized HF patients with anemia at admission or discharge.

METHODS AND RESULTS

An analysis was performed on 3731 (90%) of 4133 hospitalized HF patients with ejection fraction ≤40% enrolled in the Efficacy of Vasopressin Antagonist in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial with baseline hemoglobin data, comparing the clinical characteristics and outcomes (all-cause mortality and cardiovascular mortality or HF hospitalization) of patients with and without anemia (hemoglobin <12 g/dL for women and <13 g/dL for men) on admission or discharge/day 7. Overall, 1277 patients (34%) were anemic at baseline, which persisted through discharge in 73% and resolved in 27%; 6% of patients without baseline anemia developed anemia by discharge or day 7. Patients with anemia were older, with lower blood pressure, and higher creatinine and natriuretic peptide levels compared with those without anemia (all P<0.05). After risk adjustment, anemia at discharge, but not admission, was independently associated with increased all-cause mortality (hazard ratio, 1.30; 95% confidence interval, 1.05-1.60; P=0.015; and hazard ratio, 0.94; 95% confidence interval, 0.76-1.15; P=0.53, respectively) and cardiovascular mortality plus HF hospitalization early postdischarge (≤100 days; hazard ratio 1.73; 95% confidence interval, 1.37-2.18; P<0.001; and hazard ratio, 0.92; 95% confidence interval, 0.73-1.16; P=0.47, respectively). Neither baseline nor discharge anemia was associated with long-term cardiovascular mortality plus HF hospitalization (>100 days) on adjusted analysis (both P>0.1).

CONCLUSIONS

Among hospitalized HF patients with reduced ejection fraction, modest anemia at discharge but not baseline was associated with increased all-cause mortality and short-term cardiovascular mortality plus HF hospitalization.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00071331.

Epidemiology and outcomes associated with anemia during long-term support with continuous-flow left ventricular assist devices

BACKGROUND

The purpose of this study was to define the prevalence and clinical ramifications of anemia in patients implanted with a continuous-flow left ventricular assist device (CF-LVAD).

METHODS AND RESULTS

Patients implanted with a CF-LVAD from January 1, 2008, to April 30, 2012, were included in this retrospective cohort study. The primary outcome was the prevalence of anemia throughout the 1st year of device support. Secondary end points included the impact of anemia on rates of readmission to hospital and mortality. Ninety-one patients were included; the prevalence of anemia 360 days after implantation was significantly reduced compared with baseline (61.4% vs 79.1%, respectively; P = .032); 65.4% of anemic patients and 34.6% of nonanemic patients were readmitted at least once (P = .067). The median number of readmissions in the anemic compared with the nonanemic group was 4 (interquartile range [IQR] 2-6) versus 1.5 (IQR 1-3), respectively (P < .001). Furthermore, among those who experienced >3 readmissions during the 1st year, 19 were anemic compared with 1 patient who was not anemic (P < .001).

CONCLUSIONS

Anemia remains a prevalent condition while on CF-LVAD support and is associated with a significant increase in the number of hospital readmissions.

Clinical outcomes of erythropoietin use in heart failure patients with anemia of chronic kidney disease

BACKGROUND

Anemia and chronic kidney disease are common disorders in heart failure (HF) patients and are associated with increased morbidity and mortality. This study assessed clinical outcomes associated with erythropoietin (EPO) treatment in this cardiorenal anemia syndrome (CRAS) population.

METHODS AND RESULTS

This was a retrospective cohort study of Veterans Affairs patients with CRAS from January 2003 to December 2006. The primary outcome was a composite of death, acute coronary syndrome (ACS), HF, and stroke. Multiple Cox regression modeling was used to evaluate the outcome in patients prescribed (n = 213) and not prescribed EPO (n = 1845). Adjusted incidence of mortality was statistically significantly higher in EPO than in non-EPO users (33.8% vs 19.7%; hazard ratio 1.40, 95% confidence interval 1.06-1.85; P = .02). The unadjusted composite of cardiovascular events/death was higher in the EPO group, but not statistically significant when adjusted for confounders (P = .12). Crude ACS events were documented in 18.8% and 10.8% patients (P = .001), and stroke events occurred in 22.5% and 18.3% patients (P = .14) in EPO and non-EPO groups, respectively.

CONCLUSIONS

We found that in CRAS patients, EPO use was associated with increased risk of mortality and a trend toward increased cardiovascular events. Therefore, clinicians considering EPO use in CRAS patients should assess whether any potential benefits outweigh the risks of use.

The relationship of initial transferrin saturation to cardiovascular parameters and outcomes in patients initiating dialysis

BACKGROUND

The prognostic importance of anemia for cardiovascular (CV) events and mortality has been extensively investigated. However, little is known about the impact of transferrin saturation (TSAT), a marker reflecting the availability of iron for erythropoiesis, on clinical outcome in dialysis patients.

METHODS

A total of 879 anemic incident dialysis patients were recruited from the Clinical Research Center for End-Stage Renal Disease in Korea and were divided into 3 groups according to baseline TSAT of ≤20%, 20-40%, and >40%.

RESULTS

There were no differences in hemoglobin levels and the proportion of patients on erythropoiesis-stimulating agents or iron supplements among the 3 groups. During a mean follow-up duration of 19.3 months, 51 (5.8%) patients died. CV composite (11.71 vs. 5.55 events/100 patient-years, P = 0.001) and all-cause mortality rates (5.38 vs. 2.31 events/100 patient-years, P = 0.016) were significantly higher in patients with TSAT ≤20% compared to those with TSAT 20-40% (reference group). Cox regression analysis revealed that patients with TSAT ≤20% had 1.62- and 2.19-fold higher risks for CV composite outcome (P = 0.046) and all-cause mortality (P = 0.030). Moreover, TSAT ≤20% was significantly associated with left ventricular hypertrophy [odds ratio (OR)  = 1.46], high-sensitivity C-reactive protein ≥3 mg/dL (OR = 2.09), N-terminal pro B-type natriuretic peptide ≥10000 pg/mL (OR  = 2.04), and troponin-T≥0.1 ng/mL (OR  = 2.02), on logistic regression analysis.

CONCLUSIONS

Low TSAT was a significant independent risk factor for adverse clinical outcome in incident dialysis patients with anemia, which may be partly attributed to cardiac dysfunction and inflammation.

A systematic analysis of global anemia burden from 1990 to 2010

Previous studies of anemia epidemiology have been geographically limited with little detail about severity or etiology. Using publicly available data, we estimated mild, moderate, and severe anemia from 1990 to 2010 for 187 countries, both sexes, and 20 age groups. We then performed cause-specific attribution to 17 conditions using data from the Global Burden of Diseases, Injuries and Risk Factors (GBD) 2010 Study. Global anemia prevalence in 2010 was 32.9%, causing 68.36 (95% uncertainty interval [UI], 40.98 to 107.54) million years lived with disability (8.8% of total for all conditions [95% UI, 6.3% to 11.7%]). Prevalence dropped for both sexes from 1990 to 2010, although more for males. Prevalence in females was higher in most regions and age groups. South Asia and Central, West, and East sub-Saharan Africa had the highest burden, while East, Southeast, and South Asia saw the greatest reductions. Iron-deficiency anemia was the top cause globally, although 10 different conditions were among the top 3 in regional rankings. Malaria, schistosomiasis, and chronic kidney disease-related anemia were the only conditions to increase in prevalence. Hemoglobinopathies made significant contributions in most populations. Burden was highest in children under age 5, the only age groups with negative trends from 1990 to 2010.

Endothelial nitric oxide synthase in red blood cells: key to a new erythrocrine function?

Red blood cells (RBC) have been considered almost exclusively as a transporter of metabolic gases and nutrients for the tissues. It is an accepted dogma that RBCs take up and inactivate endothelium-derived NO via rapid reaction with oxyhemoglobin to form methemoglobin and nitrate, thereby limiting NO available for vasodilatation. Yet it has also been shown that RBCs not only act as "NO sinks", but exert an erythrocrine function - i.e an endocrine function of RBC - by synthesizing, transporting and releasing NO metabolic products and ATP, thereby potentially controlling systemic NO bioavailability and vascular tone. Recent work from our and others laboratory demonstrated that human RBCs carry an active type 3, endothelial NO synthase (eNOS), constitutively producing NO under normoxic conditions, the activity of which is compromised in patients with coronary artery disease. In this review we aim to discuss the potential role of red cell eNOS in RBC signaling and function, and to critically revise evidence to this date showing a role of non-endothelial circulating eNOS in cardiovascular pathophysiology.

Red blood cell distribution width is longitudinally associated with mortality and anemia in heart failure patients

BACKGROUND

Red blood cell distribution width (RDW) has been found to be an independent predictor for adverse outcome in patients with heart failure (HF), but there are no data on the association of longitudinal RDW with all-cause mortality and occurrence of anemia.

METHODS AND RESULTS

1,702 patients discharged from a previous admission for acute HF (AHF) were included. RDW was measured during the available longitudinal history of the patient. Joint modeling and Multistate Markov were used for the analysis. The median RDW at baseline was 15.0% (IQR: 14.0-16.5), and 45.6% of patients had anemia. At a median follow-up of 1.5 years (IQR: 0.45-3.25), 713 patients died. The last RDW-trajectory value and cumulative RDW-trajectory mean were predictive of mortality (HR, 1.18; 95% CI: 1.12-1.24; and HR, 1.12; 95% CI: 1.08-1.16, respectively; P<0.001 for both). This effect, however, varied according the anemia status (P for interaction<0.001), being more pronounced in absence of anemia [HR=1.31 (95% CI: 1.22-1.42) and HR=1.48 (95% CI: 1.33-1.64)] compared to those with anemia [HR=1.08 (95% CI: 1.04-1.13), 1.12 (95% CI: 1.06-1.18)]. Longitudinal RDW (per 1% increasing) was also independently associated with incident anemia [HR=1.10 (95% CI: 1.03-1.18) P=0.002].

CONCLUSIONS

Following an admission for AHF, higher longitudinal RDW values over time were associated to an increased risk for both developing anemia and dying. The effect on mortality was more pronounced among non-anemic patients.  

Exercise performance of chronic heart failure patients in the early period of support by an axial-flow left ventricular assist device as destination therapy

Axial-flow left ventricular assist devices (LVADs) are increasingly used as destination therapy in end-stage chronic heart failure (CHF), as they improve survival and quality of life. Their effect on exercise tolerance in the early phase after implantation is still unclear. The aim of this study was to evaluate the effect of LVADs on the exercise capacity of a group of CHF patients within 2 months after initiation of circulatory support. Cardiopulmonary exercise test data were collected for 26 consecutive LVAD-implanted CHF patients within 2 months of initiation of assistance; the reference group consisted of 30 CHF patients not supported by LVAD who were evaluated after an episode of acute heart failure. Both LVAD and reference groups showed poor physical performance; LVAD patients achieved lower workload (LVAD: 36.3 ± 9.0 W, reference: 56.6 ± 18.2 W, P < 0.001) but reached a similar peak oxygen uptake (peak VO2 ; LVAD: 12.5 ± 3.0 mL/kg/min, reference: 13.6 ± 2.9 mL/kg/min, P = ns) and similar percentages of predicted peak VO2 (LVAD: 48.8 ± 13.9%, reference: 54.2 ± 15.3%, P = ns). While the values of the O2 uptake efficiency slope were 12% poorer in LVAD patients than in reference patients (1124.2 ± 226.3 vs. 1280.2 ± 391.1; P = ns), the kinetics of VO2 recovery after exercise were slightly better in LVAD patients (LVAD: 212.5 ± 62.5, reference: 261.1 ± 80.2 sec, P < 0.05). In the first 2 months after initiation of circulatory support, axial-flow LVAD patients are able to sustain a low-intensity workload; though some cardiopulmonary exercise test parameters suggest persistence of a marked physical deconditioning, their cardiorespiratory performance is similar to that of less compromised CHF patients, possibly due to positive hemodynamic effects beginning to be produced by the assist device.

Anemia, heart failure and evidence-based clinical management

Anemia is a prevalent comorbidity and marker of a poorer prognosis in patients with heart failure (HF). Its clinical relevance, as well as its pathophysiology and the clinical management of these patients are important subjects in the specialized literature. In the present review, we describe the current concepts on the pathophysiology of anemia in HF, its diagnostic criteria, and the recommendations for iron supplementation. Also, we make a critical analysis of the major studies showing evidences on the benefits of this supplementation. The four main components of anemia are addressed: chronic disease, dilutional, "renal" and malabsorption. In patients with HF, the diagnostic criteria are the same as those used in the general population: serum ferritin levels lower than 30 mcg/L in patients without kidney diseases and lower than 100 mcg/L or serum ferritin levels between 100-299 mcg/L with transferring saturation lower than 20% in patients with chronic kidney diseases. Finally, the therapeutic possibilities for anemia in this specific patient population are discussed.

[Heart failure and anemia]

Chronic heart failure has an age-dependent prevalence of 2% and is therefore one of the most frequent diseases in western societies. A reduced hemoglobin concentration according to the definition of the World Health Organization is a common comorbidity affecting more than half of all heart failure patients. Elderly patients, patients suffering from renal impairment and women are more likely to develop anemia but a definitive etiology of anemia is only identified in the minority of cases. Anemia is associated with a poor clinical status and a greater risk of hospitalization and is a predictive factor for increased mortality. The incidence of anemia appears to increase with a poorer functional class. Intravenous iron therapy improves the exercise capacity in patients with systolic heart failure and iron deficiency and is currently being recommended for patients with persistent symptoms despite optimal medical and device therapy. However, erythropoietin-stimulating agents as a treatment for anemia in chronic heart failure have failed to improve clinical outcome in a large randomized trial. In patients with heart failure but with maintained ejection fraction, anemia is also associated with a poor prognosis. Specific therapeutic recommendations for these patients are still not available.

Functional iron deficiency and diastolic function in heart failure with preserved ejection fraction

BACKGROUND

Functional iron deficiency (FID) is an independent risk factor for poor outcome in advanced heart failure with reduced EF, but its role in heart failure with preserved EF (HFPEF) remains unclear. We aimed to investigate the impact of FID on cardiac performance determined by pressure-volume loop analysis in HFPEF.

METHODS

26 HFPEF patients who showed an increase in LV stiffness by pressure-volume (PV) loop analysis obtained by conductance-catheterization, performed exercise testing, echocardiographic examination including tissue Doppler and determination of iron metabolism: serum iron, ferritin and transferrin saturation. HFPEF patients who provided ferritin <100 μg/l or ferritin of 100-299 μg/l in combination with transferrin saturation <20% were defined as having FID. In 14 patients the expression of transferrin receptor was determined from available endomyocardial biopsies.

RESULTS

Fifteen out of 26 HFPEF patients showed FID without anemia. Compared to control subjects and HFPEF patients without FID, HFPEF patients with FID showed an up-regulation of the myocardial transferrin receptor expression (p<0.05). No differences between HFPEF patients with and without iron deficiency were found in heart dimensions, systolic and diastolic function obtained by PV-loop and echocardiography analysis. According to the linear regression analysis, LV stiffness was correlated with peak oxygen uptake (r=-0.636, p<0.001) but not with the ferritin level or transferrin saturation. No relation was found between FID and exercise capacity. The association of LV stiffness with exercise performance was independent from the level of iron deficiency.

CONCLUSION

In non-anemic HFPEF patients, cardiac dysfunction and impaired exercise capacity occur independently of FID.

Association of anemia with the risk of cardiovascular adverse events in overweight/obese patients

OBJECTIVE

Anemia is associated with increased cardiovascular risks. Obesity may cause anemia in several ways, for example, by low-grade inflammation and relative iron deficit. The outcomes associated with anemia in overweight/obese patients at high cardiovascular risk are however not known. Therefore, we investigated the cardiovascular prognosis in overweight/obese subjects with anemia.

METHODS

A total of 9,687 overweight/obese cardiovascular high-risk patients from the Sibutramine Cardiovascular OUTcomes trial were studied. Patients were stratified after baseline hemoglobin level and followed for the risks of primary event (comprising nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death) and all-cause mortality. Risk estimates (hazard ratios (HR) with 95% confidence intervals (CI)) were calculated using Cox regression models.

RESULTS

Anemia was unadjusted associated with increased risk for the primary event, HR 1.73 (CI 1.37-2.18) and HR 2.02 (CI 1.34-3.06) for patients with mild or moderate-to-severe anemia, respectively, compared with patients without anemia. Adjusted for several confounders, anemia remained of prognostic importance. Increased risk of the primary events appeared to be driven by risk of cardiovascular death, adjusted HR 1.82 (CI 1.33-2.51) for mild anemia and adjusted HR 1.65 (CI 0.90-3.04) for moderate-to-severe anemia, and all-cause mortality, adjusted HR 1.50 (CI 1.17-1.93) for mild and adjusted HR 1.61 (CI 1.04-2.51) for moderate-to-severe anemia. While adding serum creatinine to the models, the increased risk of mild anemia was still a significant predictor for mortality (cardiovascular and all-cause), whereas moderate-to-severe anemia was not. For the primary events, anemia was no longer of independent prognostic importance when including serum creatinine.

CONCLUSION

Anemia is associated with an increased risk of long-term adverse cardiovascular events and deaths among overweight/obese cardiovascular high-risk patients. The increased risk appeared to be driven by the risk of cardiovascular death and all-cause mortality, and renal impairments seemed to have a role in the increased risk.

Noncardiac comorbidities and acute heart failure patients

The acute heart failure (AHF) population is a heterogeneous group with multiple interrelated noncardiovascular comorbidities. Chronic obstructive pulmonary disease, renal disease, diabetes, sleep apnea, and anemia affect the clinical characteristics and outcomes of patients with AHF and complicate inpatient management. This article summarizes the impact of these noncardiovascular comorbidities in patients with AHF. In some circumstances, careful attention to the diagnosis and management of these conditions in patients with AHF may help to improve patient outcomes.

Cardiorenal anemia syndrome as a prognosticator for death in heart failure

Anemia and chronic kidney disease are common in patients with heart failure (HF) and are associated with adverse outcomes. We analyzed the effect of cardiorenal anemia (CRA) syndrome, defined as anemia (hemoglobin <130 g/L for men, <120 g/L for women) and stage 3 or greater chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m(2)), in outpatients with HF. Consecutive patients with HF were prospectively enrolled from 2000 to 2005 (n = 748). The baseline clinical characteristics, pathology test results, and medication use were compared between those with and without CRA syndrome. The primary end point was all-cause mortality. The mean follow-up was 2.5 ± 1.6 years, with a left ventricular ejection fraction <45% present in 70% of patients. Angiotensin-converting enzyme inhibitors, β blockers, and spironolactone were used in 87%, 67%, and 37%, respectively. CRA syndrome was present in 224 patients (30%). These patients had greater all-cause mortality (51% vs 26%, p <0.001), older age (mean 77 ± 8 vs 67 ± 14 years, p <0.001), and greater rates of diabetes mellitus (35% vs 23%, p <0.001) and ischemic heart disease (50% vs 35%, p <0.001). The independent predictors of mortality were CRA syndrome (hazard ratio 2.0, 95% confidence interval 1.4 to 2.8, p <0.001), left ventricular systolic dysfunction per grade (hazard ratio 1.5, 95% confidence interval 1.3 to 1.8, p <0.001), the absence of a β blocker (hazard ratio 1.6, 95% confidence interval 1.1 to 2.2, p = 0.005), New York Heart Association class per class (hazard ratio 1.5, 95% confidence interval 1.2 to 1.9, p <0.01), and age per decade (hazard ratio 1.6, 95% confidence interval 1.4 to 2.0, p <0.001). In conclusion, CRA syndrome was common in patients with HF and was an independent predictor of all-cause mortality. Consideration should be given to identifying CRA syndrome and modifying reversible factors.

The cardiorenal syndrome in heart failure: cardiac? renal? syndrome?

There has been increasing interest on the so-called cardiorenal syndrome (CRS), defined as a complex pathophysiological disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other. In this review, we contend that there is lack of evidence warranting the adoption of a specific clinical construct such as the CRS within the heart failure (HF) syndrome by demonstrating that: (a) the approaches and tools regarding the definition of kidney involvement in HF are suboptimal; (b) development of renal failure in HF is often confounded by age, hypertension, and diabetes; (c) worsening of renal function (WRF) in HF may be largely independent of alterations in cardiac function; (d) the bidirectional association between HF and renal failure is not unique and represents one of the several such associations encountered in HF; and (e) inflammation is a common denominator for HF and associated noncardiac morbidities. Based on these arguments, we believe that dissecting one of the multiple bidirectional associations in HF and constructing the so-called cardiorenal syndrome is not justified pathophysiologically. Fully understanding of all morbid associations and not only the cardiorenal is of great significance for the clinician who is caring for the patient with HF.

The relationship between Type D personality, affective symptoms and hemoglobin levels in chronic heart failure

BACKGROUND

Anemia is associated with poor prognosis in heart failure (HF) patients. Contributors to the risk of anemia in HF include hemodilution, renal dysfunction and inflammation. Hemoglobin levels may also be negatively affected by alterations in stress regulatory systems. Therefore, psychological distress characterized by such alterations may adversely affect hemoglobin in HF. The association between hemoglobin and Type D personality and affective symptomatology in the context of HF is poorly understood.

AIM

To examine the relationship between Type D personality and affective symptomatology with hemoglobin levels at inclusion and 12-month follow-up, controlling for relevant clinical factors.

METHODS

Plasma levels of hemoglobin and creatinine were assessed in 264 HF patients at inclusion and at 12-month follow-up. Type D personality and affective symptomatology were assessed at inclusion.

RESULTS

At inclusion, hemoglobin levels were similar for Type D and non-Type D HF patients (p = .23), and were moderately associated with affective symptomatology (r = -.14, p = .02). Multivariable regression showed that Type D personality (β = -.15; p = .02), was independently associated with future hemoglobin levels, while controlling for renal dysfunction, gender, NYHA class, time since diagnosis, BMI, the use of angiotensin-related medication, and levels of affective symptomatology. Change in renal function was associated with Type D personality (β = .20) and hemoglobin at 12 months (β = -.25). Sobel mediation analysis showed significant partial mediation of the Type D - hemoglobin association by renal function deterioration (p = .01). Anemia prevalence increased over time, especially in Type D patients. Female gender, poorer baseline renal function, deterioration of renal function and a longer HF history predicted the observed increase in anemia prevalence over time, while higher baseline hemoglobin was protective.

CONCLUSION

Type D personality, but not affective symptomatology, was associated with reduced future hemoglobin levels, independent of clinical factors. The relation between Type D personality and future hemoglobin levels was mediated by renal function deterioration.

Baseline characteristics of patients in the Reduction of Events with Darbepoetin alfa in Heart Failure trial (RED-HF)

AIMS

This report describes the baseline characteristics of patients in the Reduction of Events with Darbepoetin alfa in Heart Failure trial (RED-HF) which is testing the hypothesis that anaemia correction with darbepoetin alfa will reduce the composite endpoint of death from any cause or hospital admission for worsening heart failure, and improve other outcomes.

METHODS AND RESULTS

Key demographic, clinical, and laboratory findings, along with baseline treatment, are reported and compared with those of patients in other recent clinical trials in heart failure. Compared with other recent trials, RED-HF enrolled more elderly [mean age 70 (SD 11.4) years], female (41%), and black (9%) patients. RED-HF patients more often had diabetes (46%) and renal impairment (72% had an estimated glomerular filtration rate < 60 mL/min/1.73 m2). Patients in RED-HF had heart failure of longer duration [5.3 (5.4) years], worse NYHA class (35% II, 63% III, and 2% IV), and more signs of congestion. Mean EF was 30% (6.8%). RED-HF patients were well treated at randomization, and pharmacological therapy at baseline was broadly similar to that of other recent trials, taking account of study-specific inclusion/exclusion criteria. Median (interquartile range) haemoglobin at baseline was 112 (106-117) g/L.

CONCLUSION

The anaemic patients enrolled in RED-HF were older, moderately to markedly symptomatic, and had extensive co-morbidity.

Anemia associated with chronic heart failure: current concepts

Anemia is a frequent comorbidity of heart failure and is associated with poor outcomes. Anemia in heart failure is considered to develop due to a complex interaction of iron deficiency, kidney disease, and cytokine production, although micronutrient insufficiency and blood loss may contribute. Currently, treatment of anemia of heart failure lacks clear targets and specific therapy is not defined. Intravenous iron use has been shown to benefit anemic as well as nonanemic patients with heart failure. Treatment with erythropoietin-stimulating agents has been considered alone or in combination with iron, but robust evidence to dictate clear guidelines is not currently available. Available and emerging new agents in the treatment of anemia of heart failure will need to be tested in randomized, controlled studies.

Anemia in heart failure: association of hepcidin levels to iron deficiency in stable outpatients

BACKGROUND

Anemia is a prevalent condition in heart failure with multiple potential causes. The complex interaction between iron stores, hepcidin, inflammation and anemia is poorly comprehended. We tested the hypothesis that, in stable heart failure patients with anemia, hepcidin is associated with iron deficiency status irrespective of inflammation.

METHODS AND RESULTS

Stable systolic heart failure outpatients with and without anemia underwent a complete iron panel, erythropoietin, hepcidin and tumor necrosis factor (TNF)-α assessment. Sixty outpatients were studied. Anemic patients (n = 38, mean hemoglobin 11.4 ± 1 g/dl) were older (69.6 ± 9.6 vs. 58 ± 10.8 years old, p < 0.01) compared with nonanemic patients (n = 22, mean hemoglobin 13.8 ± 1.1 g/dl). Iron deficiency was present in 42% of patients with anemia. TNF-α and hepcidin were 29 and 21% higher in patients with anemia, respectively, compared to nonanemic patients; however, no correlations were found between hepcidin and TNF-α levels. Hepcidin levels in the lower tertile (<31.7 ng/ml) were strongly associated with iron deficiency (OR 16.5, 95% CI 2.2-121.2; p < 0.01).

CONCLUSION

In stable heart failure patients with anemia, hepcidin levels may be more importantly regulated by patients' iron stores than by inflammation.

Comorbidity and ventricular and vascular structure and function in heart failure with preserved ejection fraction: a community-based study

BACKGROUND

Patients with heart failure and preserved ejection fraction (HFpEF) display increased adiposity and multiple comorbidities, factors that in themselves may influence cardiovascular structure and function. This has sparked debate as to whether HFpEF represents a distinct disease or an amalgamation of comorbidities. We hypothesized that fundamental cardiovascular structural and functional alterations are characteristic of HFpEF, even after accounting for body size and comorbidities.

METHODS AND RESULTS

Comorbidity-adjusted cardiovascular structural and functional parameters scaled to independently generated and age-appropriate allometric powers were compared in community-based cohorts of HFpEF patients (n=386) and age/sex-matched healthy n=193 and hypertensive, n=386 controls. Within HFpEF patients, body size and concomitant comorbidity-adjusted cardiovascular structural and functional parameters and survival were compared in those with and without individual comorbidities. Among HFpEF patients, comorbidities (obesity, anemia, diabetes mellitus, and renal dysfunction) were each associated with unique clinical, structural, functional, and prognostic profiles. However, after accounting for age, sex, body size, and comorbidities, greater concentric hypertrophy, atrial enlargement and systolic, diastolic, and vascular dysfunction were consistently observed in HFpEF compared with age/sex-matched normotensive and hypertensive.

CONCLUSIONS

Comorbidities influence ventricular-vascular properties and outcomes in HFpEF, yet fundamental disease-specific changes in cardiovascular structure and function underlie this disorder. These data support the search for mechanistically targeted therapies in this disease.