Retrospective analysis into differences in heart failure patients with and without iron deficiency or anaemia

Outcomes and complications of heart failure with iron deficiency anemia: a nationwide analysis

INTRODUCTION

Heart failure is a pressing public health concern, affecting millions in the United States and projected to rise significantly by 2030. Iron deficiency, prevalent in nearly half of ambulatory heart failure patients, contributes to anemia and diminishes patient outcomes. In this study, we aim to evaluate the impact of iron deficiency anemia on acute heart failure hospitalizations outcomes.

METHODS

Utilizing the 2019 National Inpatient Sample (NIS) database, a retrospective observational study assessed 112,864 adult patients hospitalized with heart failure and 7,865 cases also had a concomitant diagnosis of iron deficiency anemia (IDA).

RESULTS

Among 112,864 heart failure hospitalizations in 2019, approximately 7% had concomitant iron deficiency anemia (IDA). Heart failure patients with IDA exhibited distinct demographic characteristics, with females comprising 51.1% (p < 0.01) and higher rates of complicated hypertension (p < 0.01), complicated diabetes (p < 0.01), and peripheral vascular disease (p < 0.01). Adjusted mean LOS for patients with IDA was significantly longer at 1.31 days (95% CI 0.71-1.47; p < 0.01), persisting in both HFpEF and HFrEF subgroups. While total hospital charges were comparable in HFpEF, HFrEF patients with IDA incurred significantly higher charges ($13427.32, 95% CI: 1463.35-$25391.29, p = 0.03) than those without IDA. Complications such as atrial fibrillation and acute kidney injury were notably more prevalent in HFpEF and HFrEF patients with IDA.

CONCLUSION

The study highlighted that iron deficiency in heart failure patients leads to extended hospital stays, increased costs, and heightened risks of specific complications, particularly in HFrEF. Our study emphasized the implications of IDA in patients with heart failure ranging from prolonged hospitalizations and increased costs. Addressing iron deficiency is crucial, given its substantial impact on heart failure hospitalizations and outcomes, emphasizing the need for proactive diagnosis and management.

Iron Deficiency Among Hospitalized Patients With Congestive Heart Failure

INTRODUCTION

Studies have demonstrated the efficacy of intravenous (IV) iron when administered to patients with congestive heart failure (CHF) and iron deficiency (ID). We aimed to better understand the adherence of treatment for ID among a population with CHF, with particular interest in high-risk groups not often studied due to inadequate recruitment.

METHODS

A retrospective chart review at our institution was conducted from January 1, 2012, to July 7, 2021. Analysis included hospitalized patients with CHF and ID and dividing these patients into two time periods based on changes in iron treatment patterns and treatment between sexes.

RESULTS

Four thousand eight hundred thirteen patients were included in this study. During the "early era," 7.0% of patients with CHF and ID received IV iron compared with 20.9% of "late-era" patients. Female patients with ID were statistically less likely to receive IV iron when compared with male patients, both unadjusted (0.66, confidence interval [CI] 0.55-0.79, p < .0001) and adjusted (0.72, CI 0.59-0.87, p < .0001) for covariates.

CONCLUSION

This study illustrates improved adherence to treatment for ID among hospitalized population with CHF and ID over time but persistent undertreatment remains. Future studies will need to identify the barriers to treating female patients with CHF and ID to reduce these disparities.

The complementary roles of iron and estrogen in menopausal differences in cardiometabolic outcomes

Biological hormonal changes are frequently cited as an explanatory factor of sex and menopause differences in cardiometabolic diseases (CMD) and its associated risk factors. However, iron metabolism which varies between sexes and among women of different reproductive stages could also play a role. Recent evidence suggest that iron may contribute to CMD risk by modulating oxidative stress pathways and inflammatory responses, offering insights into the mechanistic interplay between iron and CMD development. In the current review, we provide a critical appraisal of the existing evidence on sex and menopausal differences in CMD, discuss the pitfall of current estrogen hypothesis as sole explanation, and the emerging role of iron in CMD as complementary pathway. Prior to menopause, body iron stores are lower in females as compared to males, but the increase during and after menopause, is tandem with an increased CMD risk. Importantly, basic science experiments show that an increased iron status is related to the development of type 2 diabetes (T2D), and different cardiovascular diseases (CVD). While epidemiological studies have consistently reported associations between heme iron intake and some iron biomarkers such as ferritin and transferrin saturation with the risk of T2D, the evidence regarding their connection to CVD remains controversial. We delve into the factors contributing to this inconsistency, and the limitation of relying on observational evidence, as it does not necessarily imply causation. In conclusion, we provide recommendations for future studies on evaluating the potential role of iron in elucidating the sex and menopausal differences observed in CMD.

Global Comparison of Readmission Rates for Patients With Heart Failure

BACKGROUND

Heart failure (HF) readmission rates are low in some jurisdictions. However, international comparisons are lacking and could serve as a foundation for identifying regional patient management strategies that could be shared to improve outcomes.

OBJECTIVES

This study sought to summarize 30-day and 1-year all-cause readmission and mortality rates of hospitalized HF patients across countries and to explore potential differences in rates globally.

METHODS

We performed a systematic review and meta-analysis using MEDLINE, Embase, and CENTRAL for observational reports on hospitalized adult HF patients at risk for readmission or mortality published between January 2010 and March 2021. We conducted a meta-analysis of proportions using a random-effects model, and sources of heterogeneity were evaluated with meta-regression.

RESULTS

In total, 24 papers reporting on 30-day and 23 papers on 1-year readmission were included. Of the 1.5 million individuals at risk, 13.2% (95% CI: 10.5%-16.1%) were readmitted within 30 days and 35.7% (95% CI: 27.1%-44.9%) within 1 year. A total of 33 papers reported on 30-day and 45 papers on 1-year mortality. Of the 1.5 million individuals hospitalized for HF, 7.6% (95% CI: 6.1%-9.3%) died within 30 days and 23.3% (95% CI: 20.8%-25.9%) died within 1 year. Substantial variation in risk across countries was unexplained by countries' gross domestic product, proportion of gross domestic product spent on health care, and Gini coefficient.

CONCLUSIONS

Globally, hospitalized HF patients exhibit high rates of readmission and mortality, and the variability in readmission rates was not explained by health care expenditure, risk of mortality, or comorbidities.

Mean corpuscular haemoglobin concentration and outcomes in heart failure with preserved ejection fraction

AIMS

This study aims to evaluate the prognostic value of mean corpuscular haemoglobin concentration (MCHC) on clinical outcomes in patients with heart failure with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

We analysed HFpEF participants from the Americas in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial with available baseline data (n = 1747). Patients were grouped into hypochromia or non-hypochromia group according to a MCHC cut-off level of 330 g/L. Cox proportional hazard model was used to explore the prognostic value of hypochromia on the long-term clinical outcomes (the primary endpoint [composite of cardiovascular mortality, HF hospitalization and aborted cardiac arrest], any-cause and HF hospitalization, all-cause and cardiovascular mortality). Patients were further stratified according to baseline estimated glomerular filtration rate (eGFR) to explore the impact of renal dysfunction on the prognostic value of hypochromia. Baseline hypochromia was prevalent (n = 662, 37.9%) and strongly associated with worse clinical outcomes. In patients with worse renal function (eGFR < 60 mL/min per 1.73 m² ), hypochromia was independently associated with primary endpoint (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.23-1.98; P < 0.001), any-cause hospitalization (HR, 1.43; 95% CI, 1.20-1.71, P < 0.001) and HF hospitalization (HR, 1.40; 95% CI, 1.07-1.84; P = 0.015), whereas no significant association between hypochromia and these outcomes was found in patients with better renal function.

CONCLUSIONS

Among HFpEF patients, hypochromia (i.e. MCHC ≤ 330 g/L) is independently associated with adverse clinical outcomes, especially when in the presence of co-morbidity renal dysfunction.

Exercise Capacity, Iron Status, Body Composition, and Mediterranean Diet in Patients with Chronic Heart Failure

In addition to drug therapy, lifestyle modification, including physical activity, and nutrition management are an integral part of current guidelines for patients with chronic heart failure (CHF). However, evidence on which clinical parameters are most influenced by nutritional behaviour, exercise capacity, or iron status is scarce. For a multicenter intervention study, we included participants with diagnosed CHF (n = 165) as well as participants with elevated NT-proBNP values and risk factors for CHF (n = 74). Cardiorespiratory fitness was tested with a bicycle test, and adherence to the Mediterranean diet (MedDiet) was assessed with the MDS questionnaire. Our data strengthened previous results confirming that the higher a person's adherence to MedDiet, the higher the cardiorespiratory fitness and the lower the body fat. Furthermore, our results showed that anemia in patients with CHF has an impact in terms of cardiorespiratory fitness, and functional outcomes by questionnaire. Since our data revealed gaps in iron supply (37.9% with iron deficiency), malnutrition (only 7.8% with high adherence to MedDiet), and both symptomatic and non-symptomatic study participants failed to meet reference values for physical performance, we encourage the enforcement of the guidelines in the treatment of CHF more strongly.

Management of Iron Deficiency in Heart Failure: A Review of Evidence

ABSTRACT

Iron deficiency is common in patients with heart failure and has been associated with worse outcomes, including increases in mortality, disease progression, and hospitalizations. As such, several studies have evaluated the role of iron supplementation in mitigating these risks. Evidence for the role of intravenous iron in improving exercise capacity, quality of life, and hospitalizations is promising, although the benefits of oral iron remain less clear. This review will evaluate the literature surrounding iron supplementation in heart failure and provide practical recommendations for its management.

Iron Deficiency in Heart Failure: What Do We Know So Far?

Iron is vital for multiple biological processes in the human body. Heart failure (HF) patients are at a high risk of becoming iron deficient. Iron deficiency is a marker of severe HF and an ominous sign of poor outcomes. Iron deficiency can be absolute (low iron stores) or functional (improper functioning in the metabolic processes). The European Society of Cardiology recommends routine screening of iron stores in HF patients using ferritin and transferrin saturation. It advises iron replacement in deficient patients irrespective of the presence of anemia. Iron replacement improved HF symptoms, exercise capacity, and quality of life in deficient patients. It alleviates their disordered breathing during sleep. Therefore, the treatment of iron deficiency is an important target in managing HF. Oral iron is not effective in repleting iron stores in HF patients. Intravenous iron is an effective way to replenish iron stores in this cohort.

Appraising the Causal Association between Systemic Iron Status and Heart Failure Risk: A Mendelian Randomisation Study

Although observational studies have shown that abnormal systemic iron status is associated with an increased risk of heart failure (HF), it remains unclear whether this relationship represents true causality. We aimed to explore the causal relationship between iron status and HF risk. Two-sample Mendelian randomisation (MR) was applied to obtain a causal estimate. Genetic summary statistical data for the associations (p < 5 × 10−8) between single nucleotide polymorphisms (SNPs) and four iron status parameters were obtained from the Genetics of Iron Status Consortium in genome-wide association studies involving 48,972 subjects. Statistical data on the association of SNPs with HF were extracted from the UK biobank consortium (including 1088 HF cases and 360,106 controls). The results were further tested using MR based on the Bayesian model averaging (MR-BMA) and multivariate MR (MVMR). Of the twelve SNPs considered to be valid instrumental variables, three SNPs (rs1800562, rs855791, and rs1799945) were associated with all four iron biomarkers. Genetically predicted iron status biomarkers were not causally associated with HF risk (all p > 0.05). Sensitivity analysis did not show evidence of potential heterogeneity and horizontal pleiotropy. Convincing evidence to support a causal relationship between iron status and HF risk was not found. The strong relationship between abnormal iron status and HF risk may be explained by an indirect mechanism.

Management of iron deficiency in chronic heart failure

Iron deficiency is frequent in patients with chronic heart failure (CHF) with a prevalence of 50%, and its frequency varies depending on the study groups. The presence of iron deficiency limits erythropoiesis, leading to the development of anemia over time in patients with CHF, regardless of gender, race, and left ventricular ejection fraction (LVEF). Observational studies demonstrate a higher prevalence of iron deficiency in women and in patients with higher NYHA (New York Heart Association) functional class, decreased LVEF, increased brain natriuretic peptide (NT-proBNP), or increased high-sensitivity C-reactive protein. Iron deficiency and anemia in patients with CHF are independently associated with a decreased exercise capacity, hospitalizations for CHF, an increase in overall mortality and mortality from cardiovascular diseases. The clinical significance of iron deficiency requires the need to diagnose iron metabolism in all patients with CHF. Current guidelines for the diagnosis and treatment of CHF indicate the need to determine the level of ferritin and saturation of transferrin in all patients with a suspected diagnosis of heart failure. The use of oral iron therapy in patients with CHF demonstrates its low efficacy in correcting this condition according to the clinical trials. At the same time the use of intravenous iron therapy is safe and improves symptoms, exercise capacity and quality of life in patients with heart failure with reduced ejection fraction and iron deficiency, which has been shown both in international placebo-controlled trials and meta-analyses. The use of iron carboxymaltose should improve CHF symptoms, exercise capacity and quality of life in patients with CHF and LVEF45%. Intravenous iron therapy has also been shown to reduce readmissions for CHF in patients with an LVEF50% who have recently been hospitalized for worsening CHF.

A year in heart failure: an update of recent findings

Major changes have occurred in these last years in heart failure (HF) management. Landmark trials and the 2021 European Society of Cardiology guidelines for the diagnosis and treatment of HF have established four classes of drugs for treatment of HF with reduced ejection fraction: angiotensin-converting enzyme inhibitors or an angiotensin receptor-neprilysin inhibitor, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, namely, dapagliflozin or empagliflozin. These drugs consistently showed benefits on mortality, HF hospitalizations, and quality of life. Correction of iron deficiency is indicated to improve symptoms and reduce HF hospitalizations. AFFIRM-AHF showed 26% reduction in total HF hospitalizations with ferric carboxymaltose vs. placebo in patients hospitalized for acute HF (P = 0.013). The guanylate cyclase activator vericiguat and the myosin activator omecamtiv mecarbil improved outcomes in randomized placebo-controlled trials, and vericiguat is now approved for clinical practice. Treatment of HF with preserved ejection fraction (HFpEF) was a major unmet clinical need until this year when the results of EMPEROR-Preserved (EMPagliflozin outcomE tRial in Patients With chrOnic HFpEF) were issued. Compared with placebo, empagliflozin reduced by 21% (hazard ratio, 0.79; 95% confidence interval, 0.69 to 0.90; P < 0.001), the primary outcome of cardiovascular death or HF hospitalization. Advances in the treatment of specific phenotypes of HF, including atrial fibrillation, valvular heart disease, cardiomyopathies, cardiac amyloidosis, and cancer-related HF, also occurred. Coronavirus disease 2019 (COVID-19) pandemic still plays a major role in HF epidemiology and management. All these aspects are highlighted in this review.

The Prognostic Significance of Anemia in Patients With Heart Failure: A Meta-Analysis of Studies From the Last Decade

Background: Anemia is a commonly occurring comorbidity in patients with heart failure (HF). Although there are a few reports of a higher prevalence of mortality and hospitalization-related outcomes due to accompanying anemia, other studies suggest that anemia does not have an adverse impact on the prognostic outcomes of HF. Two meta-analyses in the past decade had reported the adverse impact of anemia on both mortality and hospitalization- related outcomes. However, only one of these studies had evaluated the outcome while using multivariable adjusted hazard ratios. Moreover, several studies since then reported the prognostic influence of anemia in HF. In this present study, we evaluate the prognostic impact of anemia on mortality and hospitalization outcomes in patients with HF.

Methods: We carried out a systematic search of the academic literature in the scientific databases EMBASE, CENTRAL, Scopus, PubMed, Cochrane, ISI Web of Science, clinicaltrial.gov, and MEDLINE based on the PRISMA guidelines. Meta-analysis was then performed to evaluate the effect (presented as risk ratio) of anemia on the overall mortality and hospitalization outcome in patients with HF.

Results: Out of 1,397 studies, 11 eligible studies were included with a total of 53,502 (20,615 Female, 32,887 Male) HF patients (mean age: 71.6 ± 8.3-years, Hemoglobin: 11.9 ± 1.5 g/dL). Among them, 19,794 patients suffered from anemia (Hb: 10.5 ± 1.6), and 33,708 patients did not have anemia (Hb: 13.2 ± 1.7 g/dL). A meta-analysis revealed a high-odds ratio (OR) for the overall mortality in patients with anemia (OR: 1.43, 95% CI: 1.29–1.84). A high-risk ratio was also reported for hospitalization as the outcome in patients with anemia (1.22, 1.0–1.58).

Conclusion: This systematic review and meta-analysis provide evidence of the high risk of mortality and hospitalization-related outcomes in patients with HF and anemia. The study confirms the findings of previously published meta-analyses suggesting anemia as an important and independent risk factor delineating the prognostic outcome of chronic HF.

Iron deficiency in heart failure

Iron deficiency is a major heart failure co‐morbidity present in about 50% of patients with stable heart failure irrespective of the left ventricular function. Along with compromise of daily activities, it also increases patient morbidity and mortality, which is independent of anaemia. Several trials have established parenteral iron supplementation as an important complimentary therapy to improve patient well‐being and physical performance. Intravenous iron preparations, in the first‐line ferric carboxymaltose, demonstrated in previous clinical trials superior clinical effect in comparison with oral iron preparations, improving New York Heart Association functional class, 6 min walk test distance, peak oxygen consumption, and quality of life in patients with chronic heart failure. Beneficial effect of iron deficiency treatment on morbidity and mortality of heart failure patients is waiting for conformation in ongoing trials. Although the current guidelines for treatment of chronic and acute heart failure acknowledge importance of iron deficiency correction and recommend intravenous iron supplementation for its treatment, iron deficiency remains frequently undertreated and insufficiently diagnosed in setting of the chronic heart failure. This paper highlights the current state of the art in the pathophysiology of iron deficiency, associations with heart failure trajectory and outcome, and an overview of current guideline‐suggested treatment options.

Health resource utilization and associated healthcare costs of biologic disease modifying antirheumatic drugs in German patients with psoriatic arthritis

OBJECTIVE

To investigate healthcare costs associated with biologic disease-modifying antirheumatic drugs (bDMARDs) in a German real-world cohort of adult biologic-naïve patients with psoriatic arthritis (PsA).

METHODS

Claims data from the InGef research database for patients with a PsA diagnosis and bDMARD claims record (index date) between January 1^st , 2014 and December 31^st , 2017; and no bDMARD prescription for 365 days before the index date, were retrospectively analyzed. Primary outcomes were determination of healthcare resource utilization (HRU) and associated annual healthcare costs for overall and individual bDMARDs in the 12-month pre- and post-index periods. These outcomes were compared between persistent and non-persistent groups. Non-persistence was defined as treatment gap or switch to bDMARD other than the index therapy.

RESULTS

Among 10,954 patients with a PsA diagnosis, 348 were eligible. Although mean (SD) post-index costs were significantly higher in the persistent group than the non-persistent group (€27,869 [8,001] vs. €21,897 [10,600]; P<0.001) due to higher bDMARD acquisition costs (€23,996 [4,818] vs. €16,427 [9,033]; P<0.001), persistence reduced inpatient treatment costs (-€760), outpatient treatment costs (-€192), other drug costs (-€724), and sick leave costs (-€601).

CONCLUSION

Although initiation of bDMARDs increased the total healthcare costs irrespective of persistence status, partial cost offsets were observed in the persistent patient population.

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.

Anaemia, iron deficiency and heart failure in 2020: facts and numbers

Anaemia is defined by WHO as Hb < 13.0 g/dL in male adults and <12.0 g/dL in female adults. It is a common comorbidity in patients of heart failure with both HFrEF and HFpEF. The incidence ranges between 30% and 50%, though in certain communities, it is likely to be higher still. Elderly age, severe heart failure, poor nutrition, and elevation of inflammatory markers are associated with a higher incidence of anaemia. However, the commonest contributing factor to anaemia in HF is iron deficiency. In a Canadian study of 12 065 patients, the incidence of absolute ID was 21% in anaemic patients. Many other western studies have also quoted incidences varying between 35% and 43%. The earlier attempts to improve outcomes by supplementation with Erythropoietic-stimulating factors were unsuccessful and resulted in a higher incidence of thrombotic events. Iron deficiency (ID) has emerged as an important factor in patients of HF, even in those without anaemia and worsens outcomes. It is defined as Ferritin levels below 100 mcg/L or 100-299 μg/L with transferrin saturation of <20%. Attempts to correct ID by oral supplementation have been unsuccessful as seen in IRON-HF and IRONOUT-HF trials. FAIR-HF and CONFIRM-HF conclusively established the role of IV Iron in improving exercise capacity and quality of life in patients with HFrEF. ESC guidelines have given a class IC indication for testing all heart failure patients for ID, and an IIaA recommendation for its correction by IV ferric carboxymaltose was found to be deficient. Ongoing trials will establish the role of IV iron in improving mortality and in HFpEF patients and in patients with acute heart failure.

Retrospective analysis into differences in heart failure patients with and without iron deficiency or anaemia

Aims

The aim of this study was to assess the burden of heart failure (HF) patients with/without iron deficiency/iron deficiency anaemia (ID/A) from the health insurance perspective.

Methods and results

We conducted a retrospective claims database analysis using the Institut für angewandte Gesundheitsforschung Berlin research database. The study period spanned from 1 January 2012 to 31 December 2014. HF patients were identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision, German Modification codes (I50.‐, I50.0‐, I50.00, I50.01, I50.1‐, I50.11, I50.12, I50.13, I50.14, I50.19, and I50.9). HF patients were stratified into HF patients without ID/A and HF patients with ID/A (D50.‐, D50.0, D50.8, D50.9, and E61.1). HF patients with ID/A were stratified into three subgroups: no iron treatment, oral iron treatment, and intravenous iron treatment. A matching approach was applied to compare outcomes for HF patients without ID/A vs. HF patient with untreated incident ID/A without iron treatment and for HF patients receiving no iron treatment vs. oral iron treatment vs. intravenous iron treatment. Matching parameters included exact age, sex, and New York Heart Association functional class. An optimization algorithm was used to balance total health care costs in the baseline period for the potential matched pairs without sample size reduction. In total, 172 394 (4537.4 per 100 000) HF patients were identified in the Institut für angewandte Gesundheitsforschung Berlin research database in 2013. Of these, 11.1% (19 070; 501.9 per 100 000) were diagnosed with ID/A and/or had a prescription for iron medication in 2013. The mean age of HF patients was 77.0 years (±12.0 years). Women were more frequently diagnosed with HF (54.6%). HF patients with untreated incident ID/A (1.77%) had a significantly higher all‐cause mortality than HF patients without ID/A (33.1% vs. 24.1%, P < 0.01). The analysis of health care utilization revealed significant differences in the rate of all‐cause hospitalization (72.9% vs. 50.5%, P < 0.01). The annual health care costs for HF patients with untreated incident ID/A amounted to €17 347 with incremental costs of €849 (P < 0.01) attributed to ID/A.

Conclusions

Heart failure is associated with a major burden for patients and the health care system in terms of health care resource utilization, costs, and mortality. Our findings suggest that there is an unmet need for treating more HF patients with ID/A with iron medication.