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Nielsen WH, Gustafsson F. Iron Deficiency in Patients with Left Ventricular Assist Devices. Card Fail Rev 2024; 10:e08. [PMID: 39144580 PMCID: PMC11322955 DOI: 10.15420/cfr.2023.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/18/2024] [Indexed: 08/16/2024] Open
Abstract
Iron deficiency is a common and independent predictor of adverse outcomes in patients with heart failure. The implications of iron deficiency in patients implanted with a left ventricular assist device (LVAD) are less established. This review recaps data on the prevalence, characteristics and impact of Iron deficiency in the LVAD population. A systematic search yielded eight studies involving 517 LVAD patients, with iron deficiency prevalence ranging from 40% to 82%. IV iron repletion was not associated with adverse events and effectively resolved iron deficiency in most patients. However, the effects of iron deficiency and iron repletion on post-implant survival and exercise capacity remain unknown. Although iron deficiency is highly prevalent in LVAD patients, its true prevalence and adverse effects may be misestimated due to inexact diagnostic criteria. Future randomised controlled trials on IV iron treatment in LVAD patients are warranted to clarify the significance of this common comorbidity.
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Affiliation(s)
- William Herrik Nielsen
- Department of Cardiology, Copenhagen University Hospital, RigshospitaletCopenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital, RigshospitaletCopenhagen, Denmark
- Department of Clinical Medicine, University of CopenhagenCopenhagen, Denmark
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2
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Martens P, Ives L, Nguyen C, Kwon D, Hanna M, Tang WHW. The Impact of Iron Deficiency on Disease Severity and Myocardial Function in Cardiac Amyloidosis. AMERICAN JOURNAL OF MEDICINE OPEN 2024; 11:100063. [PMID: 39034938 PMCID: PMC11256277 DOI: 10.1016/j.ajmo.2023.100063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/09/2023] [Indexed: 07/23/2024]
Abstract
Background Reduced cardiac energy is a hallmark feature of heart failure and is common in cardiac amyloidosis (CA) and can be aggravated by the presence of iron deficiency. Methods Retrospective analysis of a single tertiary care center CA registry. Prevalence of iron deficiency was determined based on two definitions: (1) Classic definition, ferritin < 100 µg/L irrespective of transferin saturation (TSAT) or ferritin between 100 and 300 µg/L with a TSAT < 20%, and (2) TSAT-based definition, TSAT < 20%. Results Out of a total of 393 CA patients who had a full set of iron indices (44% light chain [AL]-CA, 50% transthyretin [ATTR]-CA, remainder other or unspecified CA subtype), 56% had iron deficiency according to the classic definition and 58% according to the TSAT definition, with similar prevalence in AL-CA vs ATTR-CA (p = .135). Per both definitions 58% had anemia. Only the TSAT-based definition was associated with worse functional status (p = .039) and worse cardiac function. CA patients with a TSAT < 20% illustrated features of more pronounced right ventricular (RV) failure including lower TAPSE on echocardiography, lower RV ejection fraction and RV stroke volume index on CMR, increased right-sided filling pressures, lower pulmonary artery pulsatility index, and higher RAP/PCWP ratio by right heart catheterization. Neither the classic nor the TSAT-based definition was associated with a higher risk of all-cause mortality after covariate adjustment. Conclusion Iron deficiency is common in cardiac amyloidosis and, when identified with a TSAT < 20%, is associated with worse functional status and more pronounced RV disease, but not with a higher risk of all-cause mortality.
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Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Ziekenhuis Oost Limburg, Genk, Belgium
| | - Lauren Ives
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Nguyen
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah Kwon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Beghini A, Sammartino AM, Papp Z, von Haehling S, Biegus J, Ponikowski P, Adamo M, Falco L, Lombardi CM, Pagnesi M, Savarese G, Metra M, Tomasoni D. 2024 update in heart failure. ESC Heart Fail 2024. [PMID: 38806171 DOI: 10.1002/ehf2.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.
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Affiliation(s)
- Alberto Beghini
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gianluigi Savarese
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Santas E, Del Canto I, Cardells I, Miñana G, Llàcer P, Almenar L, Fácila L, Maceira AM, Sanchis J, Núñez J. Improvement in left atrial strain following ferric carboxymaltose in heart failure: an analysis of the Myocardial-IRON trial. ESC Heart Fail 2024; 11:1258-1262. [PMID: 38115745 DOI: 10.1002/ehf2.14630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS Iron deficiency (ID) is associated with an impaired cardiac function and remodelling in heart failure (HF). Treatment with ferric carboxymaltose (FCM) has been showed recently to improve biventricular systolic function and ventricular strain parameters in patients with HF with reduced ejection fraction and ID, but there is no evidence on the benefit of FCM on the left atrium (LA). In this study, we aimed to evaluate the effect of FCM on LA longitudinal strain (LA-LS). METHODS AND RESULTS This is a post hoc subanalysis of a double-blind, placebo-controlled, randomized clinical trial that enrolled 53 ambulatory patients with HF, left ventricular ejection fraction (LVEF) < 50%, and ID [Myocardial-IRON trial (NCT03398681)], treated with FCM or placebo. Cardiac magnetic resonance-featured tracking (CMR-FT) strain changes were evaluated before and 7 and 30 days after randomization using linear mixed regression analysis. The median age of the sample was 68 years (interquartile range: 64-76), and 20 (69%) were men. Mean ± standard deviation of LVEF was 39 ± 11%, and most (97%) were in stable New York Heart Association class II. At baseline, mean LA-LS was -8.9 ± 3.5%. At 30 days, and compared with placebo, LA-LS significantly improved in those allocated to FCM treatment arm (LA-LS = -12.0 ± 0.5 and -8.5 ± 0.6, respectively; - ∆ 3.55%, P < 0.001). CONCLUSIONS In patients with stable HF, LVEF < 50%, and ID, treatment with FCM was associated with short-term improvements in LA-LS assessed by CMR-FT. Future works should assess the potential benefit of iron repletion on LA function.
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Affiliation(s)
- Enrique Santas
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Irene Del Canto
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Ingrid Cardells
- Department of Cardiology, Hospital de Manises, Valencia, Spain
| | - Gema Miñana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Valencia, Spain
| | - Pau Llàcer
- Department of Internal Medicine, Hospital Ramón y Cajal, Madrid, Spain
| | - Luis Almenar
- Department of Cardiology, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - Lorenzo Fácila
- Department of Cardiology, Hospital General Universitario de Valencia, Valencia, Spain
| | - Alicia M Maceira
- Cardiovascular Imaging Unit, Ascires Biomedical Group, Valencia, Spain
| | - Juan Sanchis
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Valencia, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Valencia, Spain
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5
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Martens P, Augusto SN, Mullens W, Tang WHW. Meta-Analysis and Metaregression of the Treatment Effect of Intravenous Iron in Iron-Deficient Heart Failure. JACC. HEART FAILURE 2024; 12:525-536. [PMID: 38069996 DOI: 10.1016/j.jchf.2023.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Guidelines recommend that intravenous iron should be considered to improve symptoms of heart failure (HF) and reduce the risk for HF admissions in patients after acute HF. OBJECTIVES This study sought to analyze the effect of intravenous iron on cardiovascular (CV) death and HF admissions in a broad population of HF patients with iron deficiency and the relation with baseline transferrin saturation (TSAT). METHODS A systematic review of all published randomized controlled trials assessing the effect of intravenous iron in patients with iron deficiency and HF between January 1, 2000, and August 26, 2023, was performed. The overall treatment effect was estimated using a fixed effect model for: 1) CV death; 2) CV death and HF admission; 3) first HF admission; and 4) total HF admissions. Metaregression through a mixed effect model was used to explore the impact of baseline TSAT in case of heterogeneity among trial results. RESULTS A total of 14 randomized controlled trials were identified in the systematic review and retained in the meta-analysis. Aggregate-level data were included on 6,624 HF patients, 3,407 of whom were randomized to intravenous iron and 3,217 to placebo. Treatment with intravenous iron resulted in a lower risk for CV death (OR: 0.867 [95% CI: 0.755-0.955]; P = 0.0427), combined CV death and HF admission (OR: 0.838 [95% CI: 0.751-0.936]; P = 0.0015), first HF admission (OR: 0.855 [95% CI: 0.744-0.983]; P = 0.0281), and total HF admissions (rate ratio: 0.739 [95% CI: 0.661-0.827]; P < 0.0001). Significant heterogeneity among trial results was observed for first and total HF admissions. Metaregression suggested that some of the heterogeneity was related to the baseline TSAT of the enrolled population, with trials enrolling patients with lower TSAT exhibiting a large effect size on HF-related events. CONCLUSIONS The totality of data suggests that treatment with intravenous iron reduces both CV death and HF-related events in a broad population with HF. A lower baseline TSAT might be important for the effect on HF-related events.
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Affiliation(s)
- Pieter Martens
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium; Hasselt University, Diepenbeek/Hasselt, Belgium.
| | - Silvio Nunes Augusto
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium; Hasselt University, Diepenbeek/Hasselt, Belgium
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Mousavi-Aghdas SA, Farashi E, Naderi N. Iron Dyshomeostasis and Mitochondrial Function in the Failing Heart: A Review of the Literature. Am J Cardiovasc Drugs 2024; 24:19-37. [PMID: 38157159 DOI: 10.1007/s40256-023-00619-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Abstract
Cardiac contraction and relaxation require a substantial amount of energy provided by the mitochondria. The failing heart is adenosine triphosphate (ATP)- and creatine-depleted. Studies have found iron is involved in almost every aspect of mitochondrial function, and previous studies have shown myocardial iron deficiency in heart failure (HF). Many clinicians advocated intravenous iron repletion for HF patients meeting the conventional criteria for systemic iron deficiency. While clinical trials showed improved quality of life, iron repletion failed to significantly impact survival or significant cardiovascular adverse events. There is evidence that in HF, labile iron is trapped inside the mitochondria causing oxidative stress and lipid peroxidation. There is also compelling preclinical evidence demonstrating the detrimental effects of both iron overload and depletion on cardiomyocyte function. We reviewed the mechanisms governing myocardial and mitochondrial iron content. Mitochondrial dynamics (i.e., fusion, fission, mitophagy) and the role of iron were also investigated. Ferroptosis, as an important regulated cell death mechanism involved in cardiomyocyte loss, was reviewed along with agents used to manipulate it. The membrane stability and iron content of mitochondria can be altered by many agents. Some studies are showing promising improvement in the cardiomyocyte function after iron chelation by deferiprone; however, whether the in vitro and in vivo findings will be reflected on on clinical grounds is still unclear. Finally, we briefly reviewed the clinical trials on intravenous iron repletion. There is a need for more well-simulated animal studies to shed light on the safety and efficacy of chelation agents and pave the road for clinical studies.
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Affiliation(s)
- Seyed Ali Mousavi-Aghdas
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Rajaie Cardiovascular, Medical, and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Farashi
- Department of Cardiothoracic Surgery, Imam Reza Medical Research & Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Rajaie Cardiovascular, Medical, and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Naderi
- Department of Cardiothoracic Surgery, Imam Reza Medical Research & Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
- Rajaie Cardiovascular, Medical, and Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Augusto SN, Martens P. Heart Failure-Related Iron Deficiency Anemia Pathophysiology and Laboratory Diagnosis. Curr Heart Fail Rep 2023; 20:374-381. [PMID: 37632674 DOI: 10.1007/s11897-023-00623-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE OF REVIEW The goal of the current review is to give an overview regarding the pathophysiology of iron deficiency in heart failure and how different laboratory tests change in the setting of heart failure. RECENT FINDINGS Recent studies have questioned the current employed definition of iron deficiency in the field of heart failure, as patients with ferritin < 100ng/ml but TSAT > 20% have a better prognosis, no iron deficiency on bone marrow staining, and altered treatment response to ferric carboxymaltose. This review summarizes changes in iron parameters in the setting of heart failure and underscores the importance of a reduced bioavailability of iron documented by a low serum iron or TSAT, irrespective of the presence of anemia.
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Affiliation(s)
- Silvio Nunes Augusto
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pieter Martens
- Kauffman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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8
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Vinke JSJ, Gorter AR, Eisenga MF, Dam WA, van der Meer P, van den Born J, Bakker SJ, Hoes MF, de Borst MH. Iron deficiency is related to lower muscle mass in community-dwelling individuals and impairs myoblast proliferation. J Cachexia Sarcopenia Muscle 2023; 14:1865-1879. [PMID: 37386912 PMCID: PMC10401536 DOI: 10.1002/jcsm.13277] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Loss of muscle mass is linked with impaired quality of life and an increased risk of morbidity and premature mortality. Iron is essential for cellular processes such as energy metabolism, nucleotide synthesis and numerous enzymatic reactions. As the effects of iron deficiency (ID) on muscle mass and function are largely unknown, we aimed to assess the relation between ID and muscle mass in a large population-based cohort, and subsequently studied effects of ID on cultured skeletal myoblasts and differentiated myocytes. METHODS In a population-based cohort of 8592 adults, iron status was assessed by plasma ferritin and transferrin saturation, and muscle mass was estimated using 24-h urinary creatinine excretion rate (CER). The relationships of ferritin and transferrin saturation with CER were assessed by multivariable logistic regression. Furthermore, mouse C2C12 skeletal myoblasts and differentiated myocytes were subjected to deferoxamine with or without ferric citrate. Myoblast proliferation was measured with a colorimetric 5-bromo-2'-deoxy-uridine ELISA assay. Myocyte differentiation was assessed using Myh7-stainings. Myocyte energy metabolism, oxygen consumption rate and extracellular acidification rate were assessed using Seahorse mitochondrial flux analysis, and apoptosis rate with fluorescence-activated cell sorting. RNA sequencing (RNAseq) was used to identify ID-related gene and pathway enrichment in myoblasts and myocytes. RESULTS Participants in the lowest age- and sex-specific quintile of plasma ferritin (OR vs middle quintile 1.62, 95% CI 1.25-2.10, P < 0.001) or transferrin saturation (OR 1.34, 95% CI 1.03-1.75, P = 0.03) had a significantly higher risk of being in the lowest age- and sex-specific quintile of CER, independent of body mass index, estimated GFR, haemoglobin, hs-CRP, urinary urea excretion, alcohol consumption and smoking status. In C2C12 myoblasts, deferoxamine-induced ID reduced myoblast proliferation rate (P-trend <0.001) but did not affect differentiation. In myocytes, deferoxamine reduced myoglobin protein expression (-52%, P < 0.001) and tended to reduce mitochondrial oxygen consumption capacity (-28%, P = 0.10). Deferoxamine induced gene expression of cellular atrophy markers Trim63 (+20%, P = 0.002) and Fbxo32 (+27%, P = 0.048), which was reversed by ferric citrate (-31%, P = 0.04 and -26%, P = 0.004, respectively). RNAseq indicated that both in myoblasts and myocytes, ID predominantly affected genes involved in glycolytic energy metabolism, cell cycle regulation and apoptosis; co-treatment with ferric citrate reversed these effects. CONCLUSIONS In population-dwelling individuals, ID is related to lower muscle mass, independent of haemoglobin levels and potential confounders. ID impaired myoblast proliferation and aerobic glycolytic capacity, and induced markers of myocyte atrophy and apoptosis. These findings suggest that ID contributes to loss of muscle mass.
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Affiliation(s)
- Joanna Sophia J. Vinke
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Alan R. Gorter
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Michele F. Eisenga
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Wendy A. Dam
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Peter van der Meer
- Department of CardiologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Jacob van den Born
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Stephan J.L. Bakker
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Martijn F. Hoes
- Department of Clinical GeneticsMaastricht University Medical Center+MaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastrichtThe Netherlands
| | - Martin H. de Borst
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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9
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Shamsi A, Cannata A, Piper S, Bromage DI, McDonagh TA. Treatment of Iron Deficiency in Heart Failure. Curr Cardiol Rep 2023; 25:649-661. [PMID: 37329419 PMCID: PMC10307722 DOI: 10.1007/s11886-023-01889-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is commonly associated with iron deficiency (ID), defined as insufficient levels of iron to meet physiological demands. ID's association with anaemia is well understood but it is increasingly recognised as an important comorbidity in HF, even in the absence of anaemia. This review summarises contemporary evidence for the measurement and treatment of ID, in both HFrEF and HFpEF, and specific HF aetiologies, and highlights important gaps in the evidence-base. RECENT FINDINGS ID is common among patients with HF and associated with increased morbidity and mortality. Correcting ID in patients with HF can impact upon functional status, exercise tolerance, symptoms, and overall quality of life, irrespective of anaemia status. ID is a modifiable comorbidity in HF. Therefore, recognising and treating ID has emerging therapeutic potential and is important for all clinicians who care for patients with HF to understand the rationale and approach to treatment.
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Affiliation(s)
- Aamir Shamsi
- Department of Cardiology, King's College Hospital London, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Antonio Cannata
- Department of Cardiology, King's College Hospital London, Denmark Hill, Brixton, London, SE5 9RS, UK
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, 125 Coldharbour Lane, London, SE5 9NU, UK
| | - Susan Piper
- Department of Cardiology, King's College Hospital London, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Daniel I Bromage
- Department of Cardiology, King's College Hospital London, Denmark Hill, Brixton, London, SE5 9RS, UK
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, 125 Coldharbour Lane, London, SE5 9NU, UK
| | - Theresa A McDonagh
- Department of Cardiology, King's College Hospital London, Denmark Hill, Brixton, London, SE5 9RS, UK.
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, 125 Coldharbour Lane, London, SE5 9NU, UK.
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10
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Martens P, Yu S, Larive B, Borlaug BA, Erzurum SC, Farha S, Finet JE, Grunig G, Hemnes AR, Hill NS, Horn EM, Jacob M, Kwon DH, Park MM, Rischard FP, Rosenzweig EB, Wilcox JD, Tang WHW. Iron deficiency in pulmonary vascular disease: pathophysiological and clinical implications. Eur Heart J 2023; 44:1979-1991. [PMID: 36879444 PMCID: PMC10474927 DOI: 10.1093/eurheartj/ehad149] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
AIMS Iron deficiency is common in pulmonary hypertension, but its clinical significance and optimal definition remain unclear. METHODS AND RESULTS Phenotypic data for 1028 patients enrolled in the Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics study were analyzed. Iron deficiency was defined using the conventional heart failure definition and also based upon optimal cut-points associated with impaired peak oxygen consumption (peakVO2), 6-min walk test distance, and 36-Item Short Form Survey (SF-36) scores. The relationships between iron deficiency and cardiac and pulmonary vascular function and structure and outcomes were assessed. The heart failure definition of iron deficiency endorsed by pulmonary hypertension guidelines did not identify patients with reduced peakVO2, 6-min walk test, and SF-36 (P > 0.208 for all), but defining iron deficiency as transferrin saturation (TSAT) <21% did. Compared to those with TSAT ≥21%, patients with TSAT <21% demonstrated lower peakVO2 [absolute difference: -1.89 (-2.73 to -1.04) mL/kg/min], 6-min walk test distance [absolute difference: -34 (-51 to -17) m], and SF-36 physical component score [absolute difference: -2.5 (-1.3 to -3.8)] after adjusting for age, sex, and hemoglobin (all P < 0.001). Patients with a TSAT <21% had more right ventricular remodeling on cardiac magnetic resonance but similar pulmonary vascular resistance on catheterization. Transferrin saturation <21% was also associated with increased mortality risk (hazard ratio 1.63, 95% confidence interval 1.13-2.34; P = 0.009) after adjusting for sex, age, hemoglobin, and N-terminal pro-B-type natriuretic peptide. CONCLUSION The definition of iron deficiency in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) pulmonary hypertension guidelines does not identify patients with lower exercise capacity or functional status, while a definition of TSAT <21% identifies patients with lower exercise capacity, worse functional status, right heart remodeling, and adverse clinical outcomes.
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Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Shilin Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Samar Farha
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - J Emanuel Finet
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Gabriele Grunig
- Department of Medicine & Environmental Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Evelyn M Horn
- Perkin Heart Failure Center, Division of Cardiology, Weill Cornell Medicine, New York, NY, USA
| | - Miriam Jacob
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Deborah H Kwon
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Margaret M Park
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Franz P Rischard
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Arizona, Tucson, AZ, USA
| | - Erika B Rosenzweig
- Department of Pediatrics and Medicine, Columbia University, New York, NY, USA
| | - Jennifer D Wilcox
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Wai Hong Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
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11
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Vinke JS, Eisenga MF, Sanders JSF, Berger SP, Spikman JM, Abdulahad WH, Bakker SJ, Gaillard CAJM, van Zuilen AD, van der Meer P, de Borst MH. Effect of Intravenous Ferric Carboxymaltose on Exercise Capacity After Kidney Transplantation (EFFECT-KTx): rationale and study protocol for a double-blind, randomised, placebo-controlled trial. BMJ Open 2023; 13:e065423. [PMID: 36948568 PMCID: PMC10040026 DOI: 10.1136/bmjopen-2022-065423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Iron deficiency (ID) is common and has been associated with an excess mortality risk in kidney transplant recipients (KTRs). In patients with chronic heart failure and ID, intravenous iron improves exercise capacity and quality of life. Whether these beneficial effects also occur in KTRs is unknown. The main objective of this trial is to address whether intravenous iron improves exercise tolerance in iron-deficient KTRs. METHODS AND ANALYSIS The Effect of Ferric Carboxymaltose on Exercise Capacity after Kidney Transplantation study is a multicentre, double-blind, randomised, placebo-controlled clinical trial that will include 158 iron-deficient KTRs. ID is defined as plasma ferritin <100 µg/L or plasma ferritin 100-299 µg/L with transferrin saturation <20%. Patients are randomised to receive 10 mL of ferric carboxymaltose (50 mg Fe3+/mL, intravenously) or placebo (0.9% sodium chloride solution) every 6 weeks, four dosages in total. The primary endpoint is change in exercise capacity, as quantified by the 6 min walk test, between the first study visit and the end of follow-up, 24 weeks later. Secondary endpoints include changes in haemoglobin levels and iron status, quality of life, systolic and diastolic heart function, skeletal muscle strength, bone and mineral parameters, neurocognitive function and safety endpoints. Tertiary (explorative) outcomes are changes in gut microbiota and lymphocyte proliferation and function. ETHICS AND DISSEMINATION The protocol of this study has been approved by the medical ethical committee of the University Medical Centre Groningen (METc 2018/482;) and is being conducted in accordance with the principles of the Declaration of Helsinki, the Standard Protocol Items: Recommendations for Interventional Trials checklist and the Good Clinical Practice guidelines provided by the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use. Study results will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03769441.
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Affiliation(s)
- Joanna Sj Vinke
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Michele F Eisenga
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan P Berger
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jacoba M Spikman
- Department of Neuropsychology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Wayel H Abdulahad
- Department of Immunology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan Jl Bakker
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Carlo A J M Gaillard
- Department of Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin H de Borst
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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12
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Martens P, Tang WHW. Iron Deficiency in Heart Failure and Pulmonary Hypertension. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022; 24:213-229. [PMID: 38994176 PMCID: PMC11238656 DOI: 10.1007/s11936-022-00971-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/24/2022]
Abstract
Purpose of review To describe the role of iron deficiency in both heart failure and pulmonary hypertension. Recent findings To role of iron deficiency in heart failure is well established and pathophysiologic overlap with pulmonary hypertension exists. Summary Iron deficiency is common co-morbidity in heart failure and pulmonary hypertension. The high prevalence is intertwined into the pathophysiology of these conditions (e.g., neurohormonal activation, inflammation). The presence of iron deficiency has a negative impact on cardiomyocytes and cardiac function, skeletal muscle function, and pulmonary vascular function. In heart failure data from over 2000 randomized patients with iron deficiency using a uniform diagnosis, have illustrated beneficial effects on functional status, quality of life, reverse cardiac remodeling, and heart failure admissions. While iron deficiency is recognized to be prevalent in pulmonary hypertension and associated with worse functional status, the absence of a uniform definition and the absence of large prospective randomized controlled trials with iron therapies limits the conclusions on the causal role of iron deficiency such as observed in heart failure.
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Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Kauffman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Kauffman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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13
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Tomasoni D, Adamo M, Metra M. June 2022 at a glance: prevention, outcomes and treatment. Eur J Heart Fail 2022; 24:913-915. [PMID: 35796283 DOI: 10.1002/ejhf.2232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/22/2021] [Accepted: 05/06/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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14
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Kvaslerud AB, Bardan S, Andresen K, Kløve SF, Fagerland MW, Edvardsen T, Gullestad L, Broch K. Intravenous iron supplement for iron deficiency in patients with severe aortic stenosis scheduled for TAVI Results of the IIISAS randomised trial. Eur J Heart Fail 2022; 24:1269-1279. [PMID: 35579454 PMCID: PMC9544901 DOI: 10.1002/ejhf.2557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 11/12/2022] Open
Abstract
Aims The aim of this trial was to evaluate whether intravenous iron could provide benefit beyond transcatheter aortic valve implantation (TAVI) in iron‐deficient patients with severe aortic stenosis. Methods and results In this randomised, placebo‐controlled, double‐blind, single‐centre trial, we enrolled patients with severe aortic stenosis and iron deficiency (defined as ferritin <100 µg/L, or 100–299 µg/L with a transferrin saturation <20%) who were evaluated for TAVI. Patients were randomly assigned (1:1) to receive intravenous ferric derisomaltose or placebo ∼3 months before TAVI. The primary endpoint was the between‐group, baseline‐adjusted 6‐min walk distance measured 3 months after TAVI. Secondary outcomes included quality of life, iron stores, hand grip strength, New York Heart Association (NYHA) class, and safety. Between January 2020 and September 2021, we randomised 74 patients to ferric derisomaltose and 75 patients to placebo. The modified intention‐to‐treat population comprised the 104 patients who completed the 6‐min walk test at baseline and 3 months after successful TAVI. Iron stores were restored in 76% of the patients allocated to iron and 13% of the patients allocated to placebo (p < 0.001). There was no difference in the baseline‐adjusted 6‐min walk distance between the two treatment arms (p = 0.82). The number of serious adverse events, quality of life, hand grip strength, and NYHA class did not differ between the treatment arms. Conclusion Treatment with intravenous iron did not provide clinical benefit beyond TAVI in iron‐deficient patients with severe aortic stenosis. Clinical Trial Registration: ClinicalTrials.gov NCT04206228.
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Affiliation(s)
- Anette B Kvaslerud
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for Cardiac Research and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Sara Bardan
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Andresen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Sophie Foss Kløve
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Thor Edvardsen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for Cardiac Research and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Kaspar Broch
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for Cardiac Research and Center for Heart Failure Research, University of Oslo, Oslo, Norway
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15
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Kalogeropoulos AP, Tam E. Intravenous iron in heart failure with reduced ejection fraction: just about right. Eur J Heart Fail 2022; 24:1114-1116. [PMID: 35481845 DOI: 10.1002/ejhf.2520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Edlira Tam
- Division of Cardiology, Department of Medicine, Stony Brook University, Stony Brook, NY, USA
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