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Lakhal-Littleton S, Cleland JGF. Iron deficiency and supplementation in heart failure. Nat Rev Cardiol 2024; 21:463-486. [PMID: 38326440 DOI: 10.1038/s41569-024-00988-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Non-anaemic iron deficiency (NAID) is a strategic target in cardiovascular medicine because of its association with a range of adverse effects in various conditions. Endeavours to tackle NAID in heart failure have yielded mixed results, exposing knowledge gaps in how best to define 'iron deficiency' and the handling of iron therapies by the body. To address these gaps, we harness the latest understanding of the mechanisms of iron homeostasis outside the erythron and integrate clinical and preclinical lines of evidence. The emerging picture is that current definitions of iron deficiency do not assimilate the multiple influences at play in patients with heart failure and, consequently, fail to identify those with a truly unmet need for iron. Additionally, current iron supplementation therapies benefit only certain patients with heart failure, reflecting differences in the nature of the unmet need for iron and the modifying effects of anaemia and inflammation on the handling of iron therapies by the body. Building on these insights, we identify untapped opportunities in the management of NAID, including the refinement of current approaches and the development of novel strategies. Lessons learned from NAID in cardiovascular disease could ultimately translate into benefits for patients with other chronic conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cancer.
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Affiliation(s)
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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2
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Nakao M, Nagai T, Anzai T. Iron supplementation is a residual piece of management in Asian patients with heart failure? Int J Cardiol 2024; 406:132014. [PMID: 38582240 DOI: 10.1016/j.ijcard.2024.132014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Sim DKL, Mittal S, Zhang J, Hung CL, Azman WAW, Choi JO, Yingchoncharoen T, De Lara ACF, Ito H, Ashraf T, Yiu KH, Krittayaphong R. Expert recommendations for the management of iron deficiency in patients with heart failure in Asia. Int J Cardiol 2024; 403:131890. [PMID: 38382854 DOI: 10.1016/j.ijcard.2024.131890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/31/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Iron deficiency is a common comorbidity in heart failure (HF) and is independently associated with a worse quality-of-life and exercise capacity, as well as increased risk of hospitalization, regardless of anemia status. Although international guidelines have provided recommendations for the management of iron deficiency in patients with HF, guidelines in Asia are less established, and practical use of guidelines for management of iron deficiency is limited in the region. METHODS A panel comprising cardiologists from China, Hong Kong, India, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, and Thailand convened to share insights and provide guidance for the optimal management of iron deficiency in patients with HF, tailored for the Asian community. RESULTS Expert opinions were provided for the screening, diagnosis, treatment and monitoring of iron deficiency in patients with HF. It was recommended that all patients with HF with reduced ejection fraction should be screened for iron deficiency, and iron-deficient patients should be treated with intravenous iron. Monitoring of iron levels in patients with HF should be carried out once or twice yearly. Barriers to the management of iron deficiency in patients with HF in the region include low awareness of iron deficiency amongst general physicians, lack of reimbursement for screening and treatment, and lack of proper facilities for administration of intravenous iron. CONCLUSIONS These recommendations provide a structured approach to the management of iron deficiency in patients with HF in Asia.
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Affiliation(s)
| | - Sanjay Mittal
- Department of Clinical and Preventive Cardiology, Heart Institute, Mendanta - The Medicity, India
| | - Jian Zhang
- Heart Failure Centre, Fuwai Hospital, China
| | - Chung-Lieh Hung
- Institute of Biomedical Sciences, MacKay Medical College, New Taipei, Taiwan; Division of Cardiology, Department of Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | | | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Republic of Korea
| | | | - Aileen Cynthia F De Lara
- Department of Medical Education and Research, Faculty of Medicine and Surgery, University of Santo Tomas, Philippines
| | - Hiroshi Ito
- Department of General Internal Medicine, Kawasaki Medical School, Japan
| | - Tariq Ashraf
- National Institute of Cardiovascular Disease, Pakistan
| | - Kai-Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, China
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Siriraj Hospital, Mahidol University, Thailand
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Yang Q, Dong T, Lyu D, Xue D, Zhuang R, Ma L, Zhang L. Anemia in Heart Failure: A Perspective from 20-Year Bibliometric Analysis. Int J Gen Med 2024; 17:1845-1860. [PMID: 38711826 PMCID: PMC11073182 DOI: 10.2147/ijgm.s456558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024] Open
Abstract
Background & Objective Anemia in patients with heart failure (HF) is a growing concern. However, there has no bibliometric analysis in this area up to now. The aim of this study is to explore the status and trends in the field of anemia in HF through the bibliometric analysis, and to provide an outlook on future research. Methods We retrieved publications from the Web of Science Core Collection database, and the following data analysis and visualization tools were utilized to perform data processing, statistical computing and graphics generation: VOSviewer (v.1.6.18), CiteSpace (v.6.2 R5), Scimago Graphica (v.1.0.36), Biblimatrix and Microsoft Excel. Results We identified a total of 3490 publications from 2004 to 2023. The publications in the field of anemia in HF are growing steadily. The United States, the United Kingdom, and Italy were the leading countries in this area. Stefan D Anker, as the most influential author, held the most total citations and publications. Harvard University was the most productive institution in this area. The European Journal of Heart Failure had published the most papers. Through the analysis of co-citations, 14 major clusters based on cluster labels were identified. Keyword analysis showed that mortality, outcome, prevalence, and risk were the most frequent keywords, and the potential research hotspots in the future will be intravenous iron and iron deficiency. Conclusion This study provides a comprehensive analysis of countries, authors, institutions, journals, co-cited references, and keywords in the field of anemia in HF through bibliometric analysis and data visualization. The status, hotspots and future trends in this field offer a reference for in-depth research. Further studies are necessary in the future to broaden the spectrum of research in this field, to evaluate comprehensive approaches to treating anemia in patients with HF, and to find rational targets for the management of anemia.
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Affiliation(s)
- Qiwen Yang
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Tairan Dong
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Diyang Lyu
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Donghua Xue
- Graduate School, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Rui Zhuang
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Liyong Ma
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Lijing Zhang
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, People’s Republic of China
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5
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Ahanchi NS, Khatami F, Llanaj E, Quezada-Pinedo HG, Dizdari H, Bano A, Glisic M, Eisenga MF, Vidal PM, Muka T. The complementary roles of iron and estrogen in menopausal differences in cardiometabolic outcomes. Clin Nutr 2024; 43:1136-1150. [PMID: 38593499 DOI: 10.1016/j.clnu.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/25/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland; Department of Internal Medicine, Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland; Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Erand Llanaj
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hugo G Quezada-Pinedo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Pediatrics Erasmus MC-Sophia Children's Hospital University, Rotterdam, the Netherlands
| | - Helga Dizdari
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Arjola Bano
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marija Glisic
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland
| | - Michele F Eisenga
- Division of Nephrology, Department of Internal Medicine, University of Groningen, Groningen, Netherlands
| | - Pedro-Marques Vidal
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Gale SE, Willeford A, Sandquist K, Watson K. Intravenous iron in patients with iron deficiency and heart failure: a review of modern evidence. Curr Opin Cardiol 2024; 39:178-187. [PMID: 38353280 DOI: 10.1097/hco.0000000000001121] [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] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Iron deficiency is common in patients with heart failure, affecting up to half of ambulatory patients and an even greater percentage of patients admitted for acute decompensation. Iron deficiency in this population is also associated with poor outcomes, including worse quality of life in addition to increased hospitalizations for heart failure and mortality. Evidence suggests that patients with iron deficiency in heart failure may benefit from repletion with IV iron. RECENT FINDINGS In this review, we outline the etiology and pathophysiology of iron deficiency in heart failure as well as various iron formulations available. We discuss evidence for intravenous iron repletion with a particular focus on recent studies that have evaluated its effects on hospitalizations and mortality. Finally, we discuss areas of uncertainty and future study and provide practical guidance for iron repletion. SUMMARY In summary, there is overwhelming evidence that intravenous iron repletion in patients with iron deficiency in heart failure is both beneficial and safe. However, further evidence is needed to better identify which patients would most benefit from iron repletion as well as the ideal repletion strategy.
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Affiliation(s)
- Stormi E Gale
- Novant Health Heart and Vascular Institute, Huntersville, North Carolina
| | - Andrew Willeford
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, California
| | | | - Kristin Watson
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Gewarges M, Mainland R, Wilkinson K, Sklar J, Gentilin A, McLean B, Hajjaj OI, Worme M, Lalonde S, Patel R, Lin Y, Callum J, Poon S. Increasing rates of screening and treatment of iron deficiency in ambulatory patients with heart failure with reduced ejection fraction: a quality improvement cohort study. BMJ Open Qual 2024; 13:e002584. [PMID: 38395465 PMCID: PMC10895242 DOI: 10.1136/bmjoq-2023-002584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Iron deficiency anaemia (IDA) is common in patients with heart failure (HF) and is associated with advanced HF and increased mortality. Intravenous iron supplementation increases exercise tolerance, improves quality of life, and decreases symptoms among patients with HF with reduced ejection fraction (HFrEF) and iron deficiency. Despite this, many patients are not screened or treated for IDA. We aimed to increase rates of screening and treatment of IDA among HF patients through the introduction of curated materials to aid HF clinicians with appropriate screening and treatment. METHODS We conducted a retrospective chart review to identify the baseline number of HFrEF patients screened and treated for IDA at two ambulatory cardiology clinics in Toronto, Ontario. A quality improvement initiative was then introduced, which consisted of education and curated materials to aid clinicians in the screening and treatment of IDA among HFrEF patients. The proportion of patients screened and treated for IDA preintervention and postintervention were compared using χ2 tests of Independence. RESULTS In the preintervention cohort, 36.3% (n=45) of patients with anaemia were screened for IDA. Among those screened, 64.4% (n=29) had IDA. Only 17.2% (n=5) of these were treated with IV iron. After implementation of the quality improvement initiative, 90.9% (n=60) of patients with anaemia were screened for IDA (p<0.001) and 90.3% (n=28) of those with IDA were treated with IV iron (p<0.001). CONCLUSION The introduction of curated materials to aid clinicians was associated with increased rates of screening and treatment of IDA among ambulatory HFrEF patients. Further work is required to identify barriers and implement strategies to increase screening and treatment rates of IDA among HFrEF patients.
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Affiliation(s)
- Mena Gewarges
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Roslyn Mainland
- Division of General Internal Medicine, Queen's University, Kingston, Ontario, Canada
| | - Katherine Wilkinson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jaime Sklar
- Division of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Gentilin
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bianca McLean
- McMaster University Michael G DeGroote School of Medicine, Hamilton, Ontario, Canada
| | - Omar I Hajjaj
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Mali Worme
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Spencer Lalonde
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Raumil Patel
- Division of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Stephanie Poon
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Edwin G, Alphonce B, Meremo A, Meda JR. Prevalence, clinical correlates and outcomes of cardiorenal anemia syndrome among patients with heart failure attending tertiary referral hospital in Dodoma, Tanzania: A protocol of a prospective observational study. PLoS One 2024; 19:e0292764. [PMID: 38166104 PMCID: PMC10760854 DOI: 10.1371/journal.pone.0292764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/14/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Cardiorenal anemia syndrome (CRAS) is a common complication among patients with heart failure and is associated with poor clinical outcomes. However, there is a paucity of published data concerning CRAS, despite of significant increase in heart failure patients attending medical services in developing countries. This study aims to assess the prevalence, clinical correlates, and outcomes of CRAS among patients with heart failure attending the Benjamin Mkapa Hospital in Dodoma, Tanzania. METHODOLOGY A prospective observational study is ongoing at the Benjamin Mkapa Hospital in Dodoma, Tanzania. Currently, 92 patients have been recruited into this study and process is not yet completed. The socio-demographic data, clinical correlates, and prevalence of CRAS will be determined at baseline meanwhile, the outcomes of CRAS will be determined during a follow-up period of six months from the date of enrollment. CRAS is the primary outcome of the study. Data will be categorized into CRAS and non-CRAS during statistical analysis. Mean and standard deviation will be used for normally distributed continuous variables while median and interquartile range will be used for skewed data. Frequencies and percentages will summarize categorical variables. Clinical correlates and outcomes of CRAS will be analyzed and compared by using univariate and multivariate logistic regression and Cox proportional hazards models. A two-tailed p-value of less than 0.05 will indicate statistical significance.
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Affiliation(s)
- Gidion Edwin
- Department of Internal Medicine, The University Dodoma, Dodoma, Tanzania
- Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma, Tanzania
| | - Baraka Alphonce
- Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma, Tanzania
| | - Alfred Meremo
- Department of Internal Medicine, The University Dodoma, Dodoma, Tanzania
- Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma, Tanzania
- Department of Nephrology, The Benjamin Mkapa Hospital, Dodoma, Tanzania
| | - John Robson Meda
- Department of Internal Medicine, The University Dodoma, Dodoma, Tanzania
- Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma, Tanzania
- Department of Cardiology, The Benjamin Mkapa Hospital, Dodoma, Tanzania
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Uskach TM, Tereschenko SN. [The Effects of Therapy for Iron Deficiency in Patients With Different Etiologies of Heart Failure and Concomitant Diseases]. KARDIOLOGIIA 2023; 63:87-95. [PMID: 38088117 DOI: 10.18087/cardio.2023.11.n2604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023]
Abstract
Iron deficiency (ID) in patients with heart failure (HF) is a factor for unfavorable course and prognosis of the disease. The significance of ID in the diagnosis and treatment of HF has previously been demonstrated by multiple studies and meta-analyses. Therapy for ID in patients with HF is one of the most relevant and discussed issues. The use of intravenous iron medicinal products for the treatment of ID is currently being actively studied in patients of various categories; attempts are being made to specify the indications for use to produce the greatest effect on the prognosis and quality of life of HF patients.
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Affiliation(s)
- T M Uskach
- Chazov National Medical Research Center, Moscow; Russian Medical Academy of Continuous Professional Education, Moscow
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Begrambekova YL, Mareev YV, Mareev VY, Orlova YA, Kobalava ZD, Karapetyan LV, Galochkin SA, Kazakhmedov ER, Lapshin AA, Garganeeva AA, Kuzheleva EA, Efremushkina AA, Kiseleva EV, Barbarash OL, Pecherina TB, Galyavich AS, Galeeva ZM, Baleeva LV, Koziolova NA, Veclich AS, Duplyakov DV, Maksimova MN, Yakushin SS, Smirnova EA, Sedykh EV, Shaposhnik II, Makarova NA, Zemlyanukhina AA, Skibitsky VV, Fendrikova AV, Skibitsky AV, Spiropoulos NA, Seredenina EM, Eruslanova KA, Kotovskaya YV, Tkacheva ON, Fedin MA. Female and Male Phenotypes of Iron Deficiency in CHF. Additional analysis of the «The Prevalence of Iron Deficiency in Patients With Chronic Heart Failure in the Russian Federation (J-CHF-RF)» study. KARDIOLOGIIA 2023; 63:3-13. [PMID: 37815134 DOI: 10.18087/cardio.2023.9.n2413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/27/2023] [Indexed: 10/11/2023]
Abstract
Aim To evaluate the incidence of iron deficiency (ID) in men and women with chronic heart failure (CHF) and to compare clinical and functional indexes in patient with and without ID depending on the gender.Material and methods An additional analysis of the study "Prevalence of Iron Deficiency in Patients With Chronic Heart Failure in the Russian Federation (ID-CHF-RF)" was performed. The study included 498 (198 women, 300 men) patients with CHF, in whom, in addition to iron metabolism, the quality of life and exercise tolerance (ET) were studied. 97 % of patients were enrolled during their stay in a hospital. ID was defined in consistency with the European Society of Cardiology (ESC) Guidelines. Also, and additional analysis was performed according to ID criteria validated by the morphological picture of the bone marrow.Results ID was detected in 174 (87.9 %) women and 239 (79.8 %) men (p=0.028) according to the ESC criteria, and in 154 (77.8 %) women and 217 (72.3 %) men (p=0.208) according to the criteria validated by the morphological picture of the bone marrow. Men with ID were older and had more severe CHF. They more frequently had HF functional class (FC) III and IV (63.4 % vs. 43.3 % in men without ID); higher concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) and lower ET. HF FC III increased the probability of ID presence 3.4 times (p=0.02) and the probability of HF FC IV 13.7 times (p=0.003). This clinical picture was characteristic of men when either method of determining ID was used. In women, ID was not associated with more severe CHF.Conclusion Based on the presented analysis, it is possible to characterize the male and female ID phenotypes. The male ID phenotype is associated with more severe CHF, low ET, and poor quality of life. In females of the study cohort, ID was not associated with either the severity of CHF or with ET.
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Affiliation(s)
| | - Yu V Mareev
- National Medical Research Center for Therapy and Preventive Medicine
| | - V Yu Mareev
- Lomonosov Medical Research and Educational Center
| | - Ya A Orlova
- Lomonosov Medical Research and Educational Center
| | - Zh D Kobalava
- People's Friendship University of Russia; Vinogradov Municipal Clinical Hospital
| | - L V Karapetyan
- People's Friendship University of Russia; Vinogradov Municipal Clinical Hospital
| | - S A Galochkin
- People's Friendship University of Russia; Vinogradov Municipal Clinical Hospital
| | - E R Kazakhmedov
- People's Friendship University of Russia; Vinogradov Municipal Clinical Hospital
| | - A A Lapshin
- People's Friendship University of Russia; Vinogradov Municipal Clinical Hospital
| | - A A Garganeeva
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | - E A Kuzheleva
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | - A A Efremushkina
- Altai State Medical University; Altai Territorial Cardiological Dispensary
| | | | - O L Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - T B Pecherina
- Research Institute for Complex Issues of Cardiovascular Diseases
| | | | | | | | | | | | - D V Duplyakov
- Research Institute of Cardiology, Samara State Medical University; Polyakov Samara Regional Clinical Cardiological Dispensary
| | - M N Maksimova
- Polyakov Samara Regional Clinical Cardiological Dispensary
| | - S S Yakushin
- Pavlov Ryazan State Medical University; Ryazan Regional Clinical Cardiological Dispensary
| | - E A Smirnova
- Ryazan Regional Clinical Cardiological Dispensary
| | - E V Sedykh
- Pavlov Ryazan State Medical University; Ryazan Regional Clinical Cardiological Dispensary
| | | | | | | | | | | | | | | | | | | | | | - O N Tkacheva
- Russian Gerontological Research and Clinical Center
| | - M A Fedin
- Russian Gerontological Research and Clinical Center; Pirogov Russian National Research Medical University
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Bianchi VE, von Haehling S. The treatment of chronic anemia in heart failure: a global approach. Clin Res Cardiol 2023:10.1007/s00392-023-02275-4. [PMID: 37660308 DOI: 10.1007/s00392-023-02275-4] [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] [Received: 11/22/2022] [Accepted: 07/24/2023] [Indexed: 09/05/2023]
Abstract
Chronic anemia is an independent risk factor for mortality in patients with heart failure (HF). Restoring physiological hemoglobin (Hb) levels is essential to increase oxygen transport capacity to tissues and improve cell metabolism as well as physical and cardiac performance. Nutritional deficits and iron deficiency are the major causes of chronic anemia, but other etiologies include chronic kidney disease, inflammatory processes, and unexplained anemia. Hormonal therapy, including erythropoietin (EPO) and anabolic treatment in chronic anemia HF patients, may contribute to improving Hb levels and clinical outcomes. Although preliminary studies showed a beneficial effect of EPO therapy on cardiac efficiency and in HF, more recent studies have not confirmed this positive impact of EPO, alluding to its side effect profile. Physical exercise significantly increases Hb levels and the response of anemia to treatment. In malnourished patients and chronic inflammatory processes, low levels of anabolic hormones, such as testosterone and insulin-like growth factor-1, contribute to the development of chronic anemia. This paper aims to review the effect of nutrition, EPO, anabolic hormones, standard HF treatments, and exercise as regulatory mechanisms of chronic anemia and their cardiovascular consequences in patients with HF.
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Affiliation(s)
- Vittorio Emanuele Bianchi
- Department of Endocrinology and Metabolism, Clinical Center Stella Maris, Strada Rovereta, 42, 47891, Falciano, San Marino.
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
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Capone F, Cipriani A, Molinari L, Noale M, Gusella B, Lucente F, Savino S, Bertomoro A, Saller A, Giannini S, Vettor R. Ferric Carboxymaltose in Patients with Acute Decompensated Heart Failure and Iron Deficiency: A Real-Life Study. J Pers Med 2023; 13:1250. [PMID: 37623500 PMCID: PMC10455601 DOI: 10.3390/jpm13081250] [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: 07/04/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023] Open
Abstract
Background: The correction of iron deficiency (ID) with ferric carboxymaltose (FCM) is a recommended intervention in heart failure (HF) with reduced ejection fraction. Our aim is to evaluate, in a real-life setting, the clinical significance of ID screening and FCM treatment in acute decompensated HF (ADHF). Methods: In a cohort of ADHF patients, the prevalence of ID and FCM administration were investigated. Among the 104 patients admitted for ADHF, in n = 90 (median age 84, 53.5% with preserved left ventricular ejection fraction-LVEF), a complete iron status evaluation was obtained. ID was detected in n = 73 (81.1%), 55 of whom were treated with in-hospital FCM. The target dose was reached in n = 13. Results: No significant differences were detected in terms of age, sex, comorbidities, or LVEF between the FCM-supplemented and -unsupplemented patients. During a median follow-up of 427 days (IQR 405-466) among the FCM-supplemented patients, only 14.5% received FCM after discharge; the mortality and rehospitalizations among FCM-supplemented and -unsupplemented patients were similar (p = ns). In a follow-up evaluation, ID was still present in 75.0% of the FCM-supplemented patients and in 69.2% of the unsupplemented patients (p = ns). Conclusions: In this real-life ADHF cohort, FCM was administered at lower-than-prescribed doses, thus having no impact on ID correction. The significance of our findings is that only achieving the target dose of FCM and pursuing outpatient treatment can correct ID and produce long-term clinical benefits.
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Affiliation(s)
- Federico Capone
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, 35128 Padua, Italy
| | - Leonardo Molinari
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Marianna Noale
- National Research Council (CNR), Neuroscience Institute, Aging Branch, 35128 Padua, Italy
| | - Beatrice Gusella
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Fabrizio Lucente
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Sandro Savino
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Antonella Bertomoro
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Alois Saller
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Sandro Giannini
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Roberto Vettor
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
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Lindberg F, Lund LH, Benson L, Linde C, Orsini N, Carrero JJ, Savarese G. Iron deficiency in heart failure: screening, prevalence, incidence and outcome data from the Swedish Heart Failure Registry and the Stockholm CREAtinine Measurements collaborative project. Eur J Heart Fail 2023; 25:1270-1280. [PMID: 37114346 DOI: 10.1002/ejhf.2879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 04/29/2023] Open
Abstract
AIMS Iron deficiency (ID) is common in heart failure (HF) and linked with poor prognosis regardless of anaemia. We assessed temporal trends in ID testing, ID prevalence, ID incidence, iron need, and outcomes associated with ID in HF across the ejection fraction (EF) spectrum. METHODS AND RESULTS From the Swedish HF registry, we enrolled 15 197 patients from Region Stockholm with available EF and collected laboratory tests from routine practice. Iron screening improved since 2016 but remained <25% as of 2018. In 1486 patients with iron biomarkers at baseline, the prevalence of ID was 55% (HF with reduced EF 54%; mildly reduced EF 51%; preserved EF 61%). Iron need was ≥1500 mg in 72% of patients. ID was independently associated with higher risk for HF rehospitalizations (incidence rate ratio [IRR] 1.62, 95% confidence interval [CI] 1.13-2.31) and with cardiovascular (CV) death or repeated HF hospitalizations (IRR 1.63, 95% CI 1.15-2.30) regardless of EF (p-interaction 0.21 and 0.26, respectively), but not with all-cause death, CV death, or first HF hospitalization. Among 96 patients without ID at baseline and with follow-up iron biomarkers, 21% developed ID within 6 months. CONCLUSIONS Iron deficiency screening improved over time but is still limitedly implemented, despite being highly prevalent and incident, and independently associated with CV death or HF rehospitalizations regardless of EF. Most patients with ID had an iron need necessitating either repeated administrations of intravenous iron or a preparation permitting >1000 mg doses. These data highlight the need for improved screening for ID in HF.
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Affiliation(s)
- Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neurology Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neurology Theme, Karolinska University Hospital, Stockholm, Sweden
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14
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Sung HP, Hsu CY, Lee YH, Lin PL, Liao CT, Chung FP, Ko SL, Huang CY, Lin KC, Chang HY. Iron deficiency in Taiwanese patients with heart failure and reduced ejection fraction. J Chin Med Assoc 2023; 86:725-731. [PMID: 37314316 DOI: 10.1097/jcma.0000000000000949] [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] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Iron deficiency (ID) is a common comorbidity among patients with heart failure and reduced ejection fraction (HFrEF), and is associated with poorer outcomes independent of anemia. This study aimed to evaluate the prevalence and prognostic significance of ID in Taiwanese patients with HFrEF. METHODS We included HFrEF patients from two multicenter cohorts at different periods. The multivariate Cox regression analysis was applied to assess the risk of outcomes associated with ID, accounting for the varying risk of death. RESULTS Of the 3612 patients with HFrEF registered from 2013 to 2018, 665 patients (18.4%) had available baseline iron profile measurements. Of these, 290 patients (43.6%) were iron deficient; 20.2% had ID+/anemia+, 23.4% ID+/anemia-, 21.5% ID-/anemia+, and 34.9% ID-/anemia-. Regardless of anemia status, patients with coexisting ID had a higher risk than those without ID (all-cause mortality: 14.3 vs 9.5 per 100 patient-years, adjusted hazard ratio [HR] 1.33; 95% confidence interval [CI], 0.96-1.85; p = 0.091; cardiovascular mortality: 10.5 per 100 patient-years vs 6.1, adjusted HR 1.54 [95% CI, 1.03-2.30; p = 0.037]; cardiovascular mortality or first unplanned hospitalization for HF: 36.7 vs 19.7 per 100 patient-years, adjusted HR 1.57 [95% CI, 1.22-2.01; p < 0.001]). Among patients eligible for treatment in the IRONMAN trial design (43.9%), parenteral iron therapy was estimated to reduce heart failure hospitalizations and cardiovascular deaths by 13.7 per 100 patient-years. CONCLUSION Iron profiles were tested in less than one-fifth of the Taiwanese HFrEF cohort. ID was present in 43.6% of tested patients and was independently associated with poor prognosis in these patients.
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Affiliation(s)
- Hsiao-Ping Sung
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
- Institute of Hospital and Health Care Administration, Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chien-Yi Hsu
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Ying-Hsiang Lee
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan, ROC
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan, ROC
| | - Po-Lin Lin
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan, ROC
| | - Chia-Te Liao
- Division of Cardiology, Chi-Mei Medical Center, Tainan, Taiwan, ROC
| | - Fa-Po Chung
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shao-Lun Ko
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chun-Yao Huang
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Kuan-Chia Lin
- Institute of Hospital and Health Care Administration, Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hung-Yu Chang
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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15
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Gerhardt LMS, Kordsmeyer M, Sehner S, Güder G, Störk S, Edelmann F, Wachter R, Pankuweit S, Prettin C, Ertl G, Wanner C, Angermann CE. Prevalence and prognostic impact of chronic kidney disease and anaemia across ACC/AHA precursor and symptomatic heart failure stages. Clin Res Cardiol 2023; 112:868-879. [PMID: 35648270 PMCID: PMC10293329 DOI: 10.1007/s00392-022-02027-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The importance of chronic kidney disease (CKD) and anaemia has not been comprehensively studied in asymptomatic patients at risk for heart failure (HF) versus those with symptomatic HF. We analysed the prevalence, characteristics and prognostic impact of both conditions across American College of Cardiology/American Heart Association (ACC/AHA) precursor and HF stages A-D. METHODS AND RESULTS 2496 participants from three non-pharmacological German Competence Network HF studies were categorized by ACC/AHA stage; stage C patients were subdivided into C1 and C2 (corresponding to NYHA classes I/II and III, respectively). Overall, patient distribution was 8.1%/35.3%/32.9% and 23.7% in ACC/AHA stages A/B/C1 and C2/D, respectively. These subgroups were stratified by the absence ( - ) or presence ( +) of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2) and anaemia (haemoglobin in women/men < 12/ < 13 g/dL). The primary outcome was all-cause mortality at 5-year follow-up. Prevalence increased across stages A/B/C1 and C2/D (CKD: 22.3%/23.6%/31.6%/54.7%; anaemia: 3.0%/7.9%/21.7%/33.2%, respectively), with concordant decreases in median eGFR and haemoglobin (all p < 0.001). Across all stages, hazard ratios [95% confidence intervals] for all-cause mortality were 2.1 [1.8-2.6] for CKD + , 1.7 [1.4-2.0] for anaemia, and 3.6 [2.9-4.6] for CKD + /anaemia + (all p < 0.001). Population attributable fractions (PAFs) for 5-year mortality related to CKD and/or anaemia were similar across stages A/B, C1 and C2/D (up to 33.4%, 30.8% and 34.7%, respectively). CONCLUSIONS Prevalence and severity of CKD and anaemia increased across ACC/AHA stages. Both conditions were individually and additively associated with increased 5-year mortality risk, with similar PAFs in asymptomatic patients and those with symptomatic HF.
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Affiliation(s)
- Louisa M S Gerhardt
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Maren Kordsmeyer
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, St Josefs-Hospital Wiesbaden, Wiesbaden, Germany
| | - Susanne Sehner
- Medical Centre Hamburg-Eppendorf, Institute of Medical Biometry and Epidemiology, Hamburg, Germany
| | - Gülmisal Güder
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Frank Edelmann
- Department of Internal Medicine, Cardiology, Charité - Campus Virchow Klinikum, Universitätsmedizin Berlin, and German Centre for Cardiovascular Research, Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology and Pneumology, University Hospital Leipzig, Leipzig, Germany
| | - Sabine Pankuweit
- Department of Cardiology, Philips-University Marburg, Marburg, Germany
| | | | - Georg Ertl
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
| | - Christoph Wanner
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I (Nephrology), University Hospital Würzburg, Würzburg, Germany
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany.
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Vukadinović D, Abdin A, Emrich I, Schulze PC, von Haehling S, Böhm M. Efficacy and safety of intravenous iron repletion in patients with heart failure: a systematic review and meta-analysis. Clin Res Cardiol 2023; 112:954-966. [PMID: 37074386 PMCID: PMC10116902 DOI: 10.1007/s00392-023-02207-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/24/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION AFFIRM-AHF and IRONMAN demonstrated lower rates of the combined endpoint recurrent heart failure (HF) hospitalizations and cardiovascular death (CVD) using intravenous (IV) ferric carboxymaltose (FCM) and ferric derisomaltose (FDI), respectively in patients with HF and iron deficiency (ID) utilizing prespecified COVID-19 analyses. MATERIAL AND METHODS We meta-analyzed efficacy, between trial heterogeneity and data robustness for the primary endpoint and CVD in AFFIRM-AHF and IRONMAN. As sensitivity analysis, we analyzed data from all eligible exploratory trials investigating FCM/FDI in HF. RESULTS FCM/FDI reduced the primary endpoint (RR = 0.81, 95% CI 0.69-0.95, p = 0.01, I2 = 0%), with the number needed to treat (NNT) being 7. Power was 73% and findings were robust with fragility index (FI) of 94 and fragility quotient (FQ) of 0.041. Effects of FCM/FDI were neutral concerning CVD (OR = 0.88, 95% CI 0.71-1.09, p = 0.24, I2 = 0%). Power was 21% while findings were fragile with reverse FI of 14 and reversed FQ of 0.006. The sensitivity analysis from all eligible trials (n = 3258) confirmed positive effects of FCM/FDI on the primary endpoint (RR = 0.77, 95% CI 0.66-0.90, p = 0.0008, I2 = 0%), with NNT being 6. Power was 91% while findings were robust (FI of 147 and FQ of 0.045). Effect on CVD was neutral (RR = 0.87, 95% CI 0.71-1.07, p = 0.18, I2 = 0%). Power was 10% while findings were fragile (reverse FI of 7 and reverse FQ of 0.002). Rate of infections (OR = 0.85, 95% CI 0.71-1.02, p = 0.09, I2 = 0%), vascular disorder (OR = 0.84, 95% CI 0.57-1.25, p = 0.34, I2 = 0%) and general or injection-site related disorders (OR = 1.39, 95% CI 0.88-1.29, p = 0.16, I2 = 30%) were comparable between groups. There was no relevant heterogeneity (I2 > 50%) between the trials for any of the analyzed outcomes. CONCLUSIONS Use of FCM/FDI is safe and reduces the composite of recurrent HF hospitalizations and CVD, while effects on CVD alone are based on available level of data indeterminate. Findings concerning composite outcomes exhibit a high level of robustness without heterogeneity between trials with FCM and FDI.
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Affiliation(s)
- Davor Vukadinović
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany.
| | - Amr Abdin
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany
| | - Insa Emrich
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, Friedrich-Schiller-University, University Hospital Jena, Jena, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Georg-August-University, University Medical Centre, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Göttingen, Germany
| | - Michael Böhm
- Klinik Für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Universität Des Saarlandes, Kirrberger Strasse, 66421, Homburg/Saar, Germany
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17
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Liu F, Liu Y, Xu S, Wang Q, Xu F, Liu Y. Mendelian randomization study reveals a causal relationship between serum iron status and coronary heart disease and related cardiovascular diseases. Front Cardiovasc Med 2023; 10:1152201. [PMID: 37383700 PMCID: PMC10294586 DOI: 10.3389/fcvm.2023.1152201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/29/2023] [Indexed: 06/30/2023] Open
Abstract
Background Growing observational studies have shown that abnormal systemic iron status is associated with Coronary heart disease (CHD). However, these results from observational studies was not entirely consistent.It remains unclear whether this relationship represents causality.It is necessary to explore the causal relationship between iron status and CHD and related cardiovascular diseases (CVD). Objective We aimed to investigate the potential casual relationship between serum iron status and CHD and related CVD using a two-sample Mendelian randomization (MR) approach. Methods Genetic statistics for single nucleotide polymorphisms (SNPs) between four iron status parameters were identified in a large-scale genome-wide association study (GWAS) conducted by the Iron Status Genetics organization. Three independent single nucleotide polymorphisms (SNPs) (rs1800562, rs1799945, and rs855791) aligned with four iron status biomarkers were used as instrumental variables. CHD and related CVD genetic statistics We used publicly available summary-level GWAS data. Five different MR methods random effects inverse variance weighting (IVW), MR Egger, weighted median, weighted mode, and Wald ratio were used to explore the causal relationship between serum iron status and CHD and related CVD. Results In the MR analysis, we found that the causal effect of serum iron (OR = 0.995, 95% CI = 0.992-0.998, p = 0.002) was negatively associated with the odds of coronary atherosclerosis (AS). Transferrin saturation (TS) (OR = 0.885, 95% CI = 0.797-0.982, p = 0.02) was negatively associated with the odds of Myocardial infarction (MI). Conclusion This MR analysis provides evidence for a causal relationship between whole-body iron status and CHD development. Our study suggests that a high iron status may be associated with a reduced risk of developing CHD.
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Affiliation(s)
- Fenglan Liu
- The Second Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for TCM Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- School of Clinical Medicine, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yanfei Liu
- The Second Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for TCM Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shihan Xu
- The Second Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for TCM Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qing Wang
- The Second Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for TCM Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Fengqin Xu
- The Second Department of Geriatrics, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for TCM Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yue Liu
- National Clinical Research Center for TCM Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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18
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Filippatos G, Ponikowski P, Farmakis D, Anker SD, Butler J, Fabien V, Kirwan BA, Macdougall IC, Metra M, Rosano G, Ruschitzka F, van der Meer P, Wächter S, Jankowska EA. Association Between Hemoglobin Levels and Efficacy of Intravenous Ferric Carboxymaltose in Patients With Acute Heart Failure and Iron Deficiency: An AFFIRM-AHF Subgroup Analysis. Circulation 2023; 147:1640-1653. [PMID: 37051919 PMCID: PMC10487376 DOI: 10.1161/circulationaha.122.060757] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/15/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Iron deficiency, with or without anemia, is an adverse prognostic factor in heart failure (HF). In AFFIRM-AHF (a randomized, double-blind placebo-controlled trial comparing the effect of intravenous ferric carboxymaltose on hospitalizations and mortality in iron-deficient subjects admitted for acute heart failure), intravenous ferric carboxymaltose (FCM), although having no significant effect on the primary end point, reduced the risk of HF hospitalization (hHF) and improved quality of life versus placebo in iron-deficient patients stabilized after an acute HF (AHF) episode. These prespecified AFFIRM-AHF subanalyses explored the association between hemoglobin levels and FCM treatment effects. METHODS AFFIRM-AHF was a multicenter, double-blind, randomized, placebo-controlled trial of FCM in hospitalized AHF patients with iron deficiency. Patients were stratified by baseline hemoglobin level (<12 versus ≥12 g/dL). In each subgroup, the primary composite (total hHF and cardiovascular death) and secondary (total hHF; total cardiovascular hospitalizations and cardiovascular death; time to cardiovascular death, and time to first/days lost due to hHF or cardiovascular death) outcomes were assessed with FCM versus placebo at week 52. Sensitivity analyses using the World Health Organization anemia definition (hemoglobin level <12 g/dL [women] or <13 g/dL [men]) were performed, among others. RESULTS Of 1108 AFFIRM-AHF patients, 1107 were included in these subanalyses: 464 (FCM group, 228; placebo group, 236) had a hemoglobin level <12 g/dL, and 643 (FCM, 329; placebo, 314) had a hemoglobin level ≥12 g/dL. Patients with a hemoglobin level <12 g/dL were older (mean, 73.7 versus 69.1 years), with more frequent previous HF (75.0% versus 68.7%), serum ferritin <100 μg/L (75.4% versus 68.1%), and transferrin saturation <20% (87.9% versus 81.4%). For the primary outcome, annualized event rates per 100 patient-years with FCM versus placebo were 71.1 and 73.6 (rate ratio, 0.97 [95% CI, 0.66-1.41]), respectively, and 48.5 versus 72.9 (RR, 0.67 [95% CI, 0.48-0.93]) in the hemoglobin levels <12 and ≥12 g/dL subgroups, respectively. No significant interactions between hemoglobin subgroup and treatment effect were observed for primary (Pinteraction=0.15) or secondary outcomes. Changes from baseline in hemoglobin, serum ferritin and transferrin saturation were significantly greater with FCM versus placebo in both subgroups between weeks 6 and 52. Findings were similar using the World Health Organization definition for anemia. CONCLUSIONS The effects of intravenous FCM on outcomes in iron-deficient patients stabilized after an AHF episode, including improvements in iron parameters over time, did not differ between patients with hemoglobin levels <12 and ≥12 g/dL. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02937454.
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Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, Athens, Greece (G.F., D.F.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University; and Institute of Heart Diseases, University Hospital, Wroclaw, Poland (P.P., E.A.J.)
| | - Dimitrios Farmakis
- National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, Athens, Greece (G.F., D.F.)
| | - Stefan D. Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany (S.D.A.)
| | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | | | - Bridget-Anne Kirwan
- Department of Clinical Research, SOCAR Research SA, Nyon, Switzerland (B-A.K.)
- London School of Hygiene and Tropical Medicine, University College London, UK (B-A.K.)
| | - Iain C. Macdougall
- Department of Renal Medicine, King’s College Hospital, London, UK (I.C.M.)
| | - Marco Metra
- Department of Cardiology, University and Civil Hospital, Brescia, Italy (M.M.)
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy (G.R.)
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Switzerland (F.R.)
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, the Netherlands (P.v.d.M.)
| | | | - Ewa A. Jankowska
- Institute of Heart Diseases, Wroclaw Medical University; and Institute of Heart Diseases, University Hospital, Wroclaw, Poland (P.P., E.A.J.)
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19
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Rosano GMC, Kalantar‐Zadeh K, Jankowska EA. Hypophosphataemia risk associated with ferric carboxymaltose in heart failure: A pooled analysis of clinical trials. ESC Heart Fail 2023; 10:1294-1304. [PMID: 36722321 PMCID: PMC10053364 DOI: 10.1002/ehf2.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/30/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023] Open
Abstract
AIMS Iron deficiency is a common finding among patients with heart failure (HF) and is associated with adverse outcomes, including decreased quality of life, increased risk of hospitalization, and decreased survival. Intravenous ferric carboxymaltose (FCM) has been shown to improve outcomes among patients with HF and concomitant iron deficiency, but FCM is associated with an increased risk of hypophosphataemia. We aimed to better characterize this risk among HF populations. METHODS AND RESULTS This pooled analysis examined data from 41 studies of adults with iron deficiency across disease states and therapeutic areas. Among the 7931 patients treated with FCM available for analysis, 14% made up the HF subgroup. Additional subgroups included women's health (36%), non-dialysis-dependent chronic kidney disease (NDD-CKD; 27%), haemodialysis-dependent chronic kidney disease (HD-CKD; 1%), gastrointestinal (10%), neurology (3%), and other (10%). The incidence of post-baseline moderate or severe hypophosphataemia (i.e. serum phosphate [PO4 3- ] level <2.0 mg/dL) varied across the therapeutic areas, with the lowest incidences observed in the HD-CKD (0%), HF (8.1%), and NDD-CKD (12.8%) subgroups. The prevalence of moderate or severe hypophosphataemia among the women's health, other, gastrointestinal, and neurology subgroups was 30.1%, 40.6%, 51.0%, and 55.6%, respectively. In the HF subgroup, one patient (<0.1%) had a serum PO4 3- of <1.0 mg/dL recorded, compared with 4.8% and 4.0% of the subjects in the neurology and gastrointestinal groups, respectively. With the exception of the HD-CKD subgroup, mean serum PO4 3- levels decreased through weeks 2 to 4, and then returned toward baseline and plateaued by week 8. The strongest predictor of hypophosphataemia was preserved kidney function (estimated glomerular filtration rate: >60 mL/min/1.73 m2 vs. <30 mL/min/1.73 m2 ; odds ratio: 12.2). Among patients in the HF subgroup, the incidence of treatment-emergent adverse events potentially related to hypophosphataemia (e.g. cardiac failure, ventricular tachyarrhythmias, fatigue, muscle weakness, bone pain, neurological symptoms, and muscle pain) was lower among FCM-treated patients than among those receiving placebo, and lower among patients with a post-baseline PO4 3- <2 mg/dL vs. those not meeting such criteria. CONCLUSIONS The risk of laboratory-assessed hypophosphataemia in HF patients treated with FCM was lower than that seen in patients in other therapeutic areas treated with FCM, and clinical events associated with hypophosphataemia are uncommon with FCM therapy in this population. Appropriate monitoring, particularly soon after administration in the unlikely event of repeated dosing in HF patients, will allow for further refinement of management strategies. [Correction added on 24 February 2023, after first online publication: In the preceding sentence, "…administration, will allow…" has been corrected to "…administration in the unlikely event of repeated dosing in HF patients, will allow…" in this version.].
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Affiliation(s)
| | - Kamyar Kalantar‐Zadeh
- Division of Nephrology and Hypertension and Kidney TransplantationUniversity of CaliforniaIrvineCaliforniaUSA
| | - Ewa A. Jankowska
- Institute of Heart DiseasesWrocław Medical UniversityWrocławPoland
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20
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Dhaliwal S, Kalogeropoulos AP. Markers of Iron Metabolism and Outcomes in Patients with Heart Failure: A Systematic Review. Int J Mol Sci 2023; 24:ijms24065645. [PMID: 36982717 PMCID: PMC10059277 DOI: 10.3390/ijms24065645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Iron deficiency (ID) in conjunction with heart failure (HF) poses a challenge for clinicians and is associated with worse HF outcomes. Treatment of ID with IV iron supplementation for patients with HF has demonstrated benefits in quality of life (QoL) and HF-related hospitalizations. The aim of this systematic review was to summarize the evidence linking iron metabolism biomarkers with outcomes in patients with HF to assist in the optimal use of these biomarkers for patient selection. A systematic review of observational studies in English from 2010 to 2022 was conducted using PubMed, with keywords of “Heart Failure” and respective iron metabolism biomarkers (“Ferritin”, “Hepcidin”, “TSAT”, “Serum Iron”, and “Soluble Transferrin Receptor”). Studies pertaining to HF patients, with available quantitative data on serum iron metabolism biomarkers, and report of specific outcomes (mortality, hospitalization rates, functional capacity, QoL, and cardiovascular events) were included, irrespective of left ventricular ejection fraction (LVEF) or other HF characteristics. Clinical trials of iron supplementation and anemia treatment were removed. This systematic review was conducive to formal assessment of risk of bias via Newcastle-Ottawa Scale. Results were synthesized based on their respective adverse outcomes and iron metabolism biomarker(s). Initial and updated searches identified 508 unique titles once duplicates were removed. The final analysis included 26 studies: 58% focused on reduced LVEF; age range was 53–79 years; males composed 41–100% of the reported population. Statistically significant associations of ID were observed with all-cause mortality, HF hospitalization rates, functional capacity, and QoL. Increased risk for cerebrovascular events and acute renal injury have also been reported, but these findings were not consistent. Varying definitions of ID were utilized among the studies; however, most studies employed the current European Society of Cardiology criteria: serum ferritin < 100 ng/mL or the combination of ferritin between 100–299 ng/mL and transferrin saturation (TSAT) < 20%. Despite several iron metabolism biomarkers demonstrating strong association with several outcomes, TSAT better predicted all-cause mortality, as well as long-term risk for HF hospitalizations. Low ferritin was associated with short-term risk for HF hospitalizations, worsening functional capacity, poor QoL, and development of acute renal injury in acute HF. Elevated soluble transferrin receptor (sTfR) levels were associated with worse functional capacity and QoL. Finally, low serum iron was significantly associated with increased risk for cardiovascular events. Considering the lack of consistency among the iron metabolism biomarkers for association with adverse outcomes, it is important to incorporate additional biomarker data, beyond ferritin and TSAT, when assessing for ID in HF patients. These inconsistent associations question how best to define ID to ensure proper treatment. Further research, potentially tailored to specific HF phenotypes, is required to optimize patient selection for iron supplementation therapy and appropriate targets for iron stores replenishment.
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21
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Role of Iron Deficiency in Heart Failure-Clinical and Treatment Approach: An Overview. Diagnostics (Basel) 2023; 13:diagnostics13020304. [PMID: 36673114 PMCID: PMC9857585 DOI: 10.3390/diagnostics13020304] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The association of chronic heart failure (CHF) and iron deficiency (ID) with or without anemia is frequently encountered in current medical practice and has a negative prognostic impact, worsening patients' exercise capacity and increasing hospitalization costs. Moreover, anemia is common in patients with chronic kidney disease (CKD) and CHF, an association known as cardio-renal anemia syndrome (CRAS) possessing a significantly increased risk of death. AIM This review aims to provide an illustrative survey on the impact of ID in CHF patients-based on physiopathological traits, clinical features, and the correlation between functional and absolute ID with CHF-and the benefit of iron supplementation in CHF. METHOD We selected the most recent publications with important scientific content covering the association of CHF and ID with or without anemia. DISCUSSIONS An intricate physiopathological interplay is described in these patients-decrease in erythropoietin levels, activation of the renin-angiotensin-aldosterone system, systemic inflammation, and increases in hepcidin levels. These mechanisms amplify anemia, CHF, and CKD severity and worsen patients' outcomes. CONCLUSIONS Anemia is frequently encountered in CHF and represents a negative prognostic factor. Data from randomized controlled trials have underlined the administration of intravenous iron therapy (ferric carboxymaltose) as the only viable treatment option, with beneficial effects on quality of life and exercise capacity in patients with ID and systolic heart failure.
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22
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Speranza M, Gómez-Mesa JE, Fairman E, Rossel V, Fernández FN, Saldarriaga C, Pow-Chon F, Quesada D, Ramos CE, Rodríguez I, Jerez A, Chávez A, Núñez E, Pereda M, Chazzin G, Sosa-Liprandi MI, Romero A. Consensus document on anemia and iron deficiency in heart failure: Consejo Interamericano de Falla Cardiaca e Hipertensión Pulmonar (CIFACAH) of the Interamerican Society of Cardiology (IASC). ARCHIVOS DE CARDIOLOGIA DE MEXICO 2023; 93:27-38. [PMID: 37918407 PMCID: PMC10665008 DOI: 10.24875/acm.23000060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/28/2023] [Indexed: 11/04/2023] Open
Abstract
Heart failure is a pathology that affects 1% of the population and is accompanied by iron deficiency as a comorbidity in 50% of cases. Anemia, meanwhile, is present between 22-37%. This is a consensus document that seeks to synthesize the information available on anemia and iron deficiency and its behavior in patients with HF, which is divided into pathophysiology, classification, clinical scenarios and algorithms (clinical pathways), treatment, and follow-up. This article integrates international recommendations based on evidence and presents a synthesis of management strategies.
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Affiliation(s)
- Mario Speranza
- Departamento de Cardiología, Hospital Clínica Bíblica, San José, Costa Rica
| | | | - Enrique Fairman
- Departamento de Cardiología, Clínica Bazterrica, Buenos Aires, Argentina
| | - Víctor Rossel
- Departamento de Cardiología, Hospital del Salvador, Santiago, Chile
- Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Felipe N. Fernández
- Departamento de Cardiología, Hospital Central del Instituto de Previsión Social, Asunción, Paraguay
| | | | - Freddy Pow-Chon
- Departamento de Cardiología, Hospital Luis Vernaza, Guayaquil, Ecuador
- Departamento de Cardiología, Universidad Espíritu Santo, Guayaquil, Ecuador
| | - Daniel Quesada
- Departamento de Cardiología, Hospital San Vicente de Paul, Heredia, Costa Rica
| | - Carlos E. Ramos
- Departamento de Cardiología, Instituto Nacional Cardiopulmonar, Tegucigalpa, Honduras
| | - Iris Rodríguez
- Departamento de Cardiología, Grupo Hospitalario La Paz, Ciudad de Guatemala, Guatemala
- Departamento de Cardiología, Liga Guatemalteca del Corazón, Ciudad de Guatemala, Guatemala
| | - Ana Jerez
- Departamento de Cardiología, Instituto de Cardiología y Cirugía Cardiovascular, La Habana, Cuba
| | - Adolfo Chávez
- Departamento de Cardiología, Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, México
| | - Elaine Núñez
- Departamento de Cardiología, Centro de Diagnóstico Medicina Avanzada y Telemedicina (CEDIMAT), Santo Domingo, República Dominicana
| | | | - Gerardo Chazzin
- Departamento de Cardiología, Centro Docente Prevalet, Valencia, Venezuela
| | | | - Alexander Romero
- Departamento de Cardiología, Hospital Santo Tomás, Panamá, Panamá
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23
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Savarese G, von Haehling S, Butler J, Cleland JGF, Ponikowski P, Anker SD. Iron deficiency and cardiovascular disease. Eur Heart J 2023; 44:14-27. [PMID: 36282723 PMCID: PMC9805408 DOI: 10.1093/eurheartj/ehac569] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/11/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023] Open
Abstract
Iron deficiency (ID) is common in patients with cardiovascular disease. Up to 60% of patients with coronary artery disease, and an even higher proportion of those with heart failure (HF) or pulmonary hypertension have ID; the evidence for cerebrovascular disease, aortic stenosis and atrial fibrillation is less robust. The prevalence of ID increases with the severity of cardiac and renal dysfunction and is probably more common amongst women. Insufficient dietary iron, reduced iron absorption due to increases in hepcidin secondary to the low-grade inflammation associated with atherosclerosis and congestion or reduced gastric acidity, and increased blood loss due to anti-thrombotic therapy or gastro-intestinal or renal disease may all cause ID. For older people in the general population and patients with HF with reduced ejection fraction (HFrEF), both anaemia and ID are associated with a poor prognosis; each may confer independent risk. There is growing evidence that ID is an important therapeutic target for patients with HFrEF, even if they do not have anaemia. Whether this is also true for other HF phenotypes or patients with cardiovascular disease in general is currently unknown. Randomized trials showed that intravenous ferric carboxymaltose improved symptoms, health-related quality of life and exercise capacity and reduced hospitalizations for worsening HF in patients with HFrEF and mildly reduced ejection fraction (<50%). Since ID is easy to treat and is effective for patients with HFrEF, such patients should be investigated for possible ID. This recommendation may extend to other populations in the light of evidence from future trials.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas TX, USA
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Wellebing, University of Glasgow, Glasgow, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland
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24
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Tada A, Nagai T, Koya T, Nakao M, Ishizaka S, Mizuguchi Y, Aoyagi H, Imagawa S, Tokuda Y, Takahashi M, Kato Y, Machida M, Matsutani K, Saito T, Anzai T. Applicability of new proposed criteria for iron deficiency in Japanese patients with heart failure. ESC Heart Fail 2022; 10:985-994. [PMID: 36495060 PMCID: PMC10053267 DOI: 10.1002/ehf2.14265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/12/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Iron deficiency (ID) is a common co-morbidity in patients with heart failure (HF). A recent study showed that ID defined by the current guideline criteria was not associated with worse clinical outcomes, and new ID criteria was proposed in patients with HF. However, the external applicability of the new proposed criteria is unclear. We sought to investigate the applicability of the proposed ID criteria in Japanese patients with HF. METHODS AND RESULTS We prospectively examined 763 patients with chronic HF from a Japanese multicentre registry. The proposed ID criteria were transferrin saturation (TSAT) < 20% and serum iron ≤13 mmol/L and the guideline ID criteria were serum ferritin <100 ng/mL or, when ferritin was 100-299 ng/mL, TSAT <20%. Among all patients (456 male, mean age 71 ± 13 years), 213 (28%) and 444 (58%) met the proposed and guideline ID criteria, respectively. During a median follow-up period of 436 days (interquartile range 297-565), the primary outcome of all-cause mortality occurred in 56 (7%) patients. There was no significant difference in the primary outcome between the patients with and without guideline ID criteria (P = 0.32), whereas patients with serum iron ≤10 μmol/L showed higher mortality (P = 0.002). In multivariable Cox regressions, the proposed ID criteria, but not guideline ID criteria, were independently associated with the risk of all-cause mortality (HR 2.01, 95% CI 1.16-3.51 and HR 1.32, 95% CI 0.76-2.28, respectively), even after adjustment for covariates. CONCLUSIONS When defined by the proposed criteria and not the guideline criteria, ID was associated with higher mortality in patients with chronic HF, suggesting that the proposed ID criteria is applicable to the Japanese population.
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Affiliation(s)
- Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Taro Koya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Hiroyuki Aoyagi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Shogo Imagawa
- Department of Clinical Research National Hospital Organization Hakodate National Hospital Hakodate Japan
| | - Yusuke Tokuda
- Division of Cardiology Hakodate Municipal Hospital Hakodate Japan
| | - Masashige Takahashi
- Department of Cardiology Japan Community Health Care Organization Hokkaido Hospital Sapporo Japan
| | - Yoshiya Kato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
- Department of Cardiology Kushiro City General Hospital Kushiro Japan
| | - Masaharu Machida
- Department of Cardiology Tomakomai City Hospital Tomakomai Japan
| | - Kenichi Matsutani
- Department of Cardiology Sunagawa City Medical Center Sunagawa Japan
| | - Takahiko Saito
- Department of Cardiology Japan Red Cross Kitami Hospital Kitami Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
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25
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Management of Iron Deficiency in Heart Failure: A Review of Evidence. J Cardiovasc Pharmacol 2022; 80:755-768. [PMID: 36027595 DOI: 10.1097/fjc.0000000000001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
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.
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26
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Hwang NC, Sivathasan C. Preoperative Evaluation and Care of Heart Transplant Candidates. J Cardiothorac Vasc Anesth 2022; 36:4161-4172. [PMID: 36028377 DOI: 10.1053/j.jvca.2022.07.008] [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] [Received: 06/24/2021] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/11/2022]
Abstract
Heart transplantation is recommended for patients with advanced heart failure refractory to medical and device therapy, and who do not have absolute contraindications. When patients become eligible for heart transplantation, they undergo comprehensive evaluation and preparation to optimize their posttransplantation outcomes. This review provides an overview of the processes that are employed to enable the candidates to be transplant-ready when donor hearts are available.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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27
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Skrzypczak T, Skrzypczak A, Michałowicz J. The Relationship Between Iron Status and Atherosclerotic Cardiovascular Disease Risk in Non-anemic Patients Without a History of Cardiovascular Diseases: A Cross-Sectional Study. Cureus 2022; 14:e29439. [PMCID: PMC9595251 DOI: 10.7759/cureus.29439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 11/05/2022] Open
Abstract
Iron deficiency (ID) and iron status in non-anemic patients with atherosclerotic cardiovascular disease (ASCVD) risk without a history of cardiovascular diseases is still weakly explored. In this study, the authors evaluated the most common ID definitions in this group of patients. A total of 533 participants from the National Health and Nutrition Examination Survey (NHANES) were collected from 2005-2006, 2017-2018, and 2017-2020 records. Participants were divided according to their ASCVD risk score to the following groups: low (n=168, 32%), borderline (n=43, 8%), intermediate (n=200, 37%), and high (n=122, 23%). There was a higher prevalence of ID in low- and borderline-risk groups in contrast to intermediate- and high-risk groups. Higher serum ferritin concentrations were observed in groups with a greater ASCVD risk score. Transferrin saturation (TSAT) was comparable in all ASCVD categories. Lack of ID, defined by three different guidelines that are mainly based on serum ferritin levels, predisposed to a higher ASCVD risk category. Normal iron status, defined by these three guidelines, was positively associated with the male gender. The opposite association was observed for non-Hispanic Whites. The analyzed criteria of ID, based mostly on serum ferritin levels, demonstrated limited usefulness in patients with increased ASCVD risk. Further studies should be done to determine proper ID diagnostic criteria in non-anemic patients without a previous cardiovascular history with elevated ASCVD risk.
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28
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Szklarz M, Gontarz-Nowak K, Matuszewski W, Bandurska-Stankiewicz E. Can Iron Play a Crucial Role in Maintaining Cardiovascular Health in the 21st Century? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11990. [PMID: 36231287 PMCID: PMC9565681 DOI: 10.3390/ijerph191911990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
In the 21st century the heart is facing more and more challenges so it should be brave and iron to meet these challenges. We are living in the era of the COVID-19 pandemic, population aging, prevalent obesity, diabetes and autoimmune diseases, environmental pollution, mass migrations and new potential pandemic threats. In our article we showed sophisticated and complex regulations of iron metabolism. We discussed the impact of iron metabolism on heart diseases, treatment of heart failure, diabetes and obesity. We faced the problems of constant stress, climate change, environmental pollution, migrations and epidemics and showed that iron is really essential for heart metabolism in the 21st century.
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29
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von Haehling S. Erhalt der Selbstständigkeit bei Herzinsuffizienz: Ansatzpunkte und Konsequenzen für den Alltag. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1820-8230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
ZusammenfassungErhalt von Mobilität und sozialer Interaktion hat für Patienten mit Herzinsuffizienz enorme Alltagsbedeutung, die in vielen bisher durchgeführten Therapiestudien nicht in ausreichendem Maße
abgebildet wurde. Ivabradin, die SGLT2-Inhibitoren Empagliflozin und Dapagliflozin sowie der ARNI Sacubitril/Valsartan bieten hier erste Möglichkeiten der Einflussnahme. Auch
Ausdauertraining ist sehr zu empfehlen. Die Therapie von Komorbiditäten bei Herzinsuffizienz zeigt vor allem bei der Therapie des Eisenmangels gute Möglichkeiten der Besserung der
Belastbarkeit, außerdem durch die Pulmonalvenenisolation bei Vorhofflimmern. Andere Aspekte, welche die Mobilität der Patienten verbessern, sind das Ermöglichen von selbstständigem Führen
von Fahrzeugen, von Sport und Hobbys, Berufstätigkeit und Sexualität sowie das Ermöglichen von Reiseaktivitäten, wenn die Patienten entsprechend vorbereitet sind, über ausreichend
Informationen für die Reiseaktivität verfügen und das Reiseziel entsprechend ausgewählt wurde. Wichtig ist, die Bedürfnisse des Patienten zu erfragen, um individualisierte Therapiekonzepte
zu erarbeiten.
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Affiliation(s)
- Stephan von Haehling
- Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Deutsches Zentrum für Herz- und Kreislaufforschung (DZHK), Standort Göttingen, Deutschland
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30
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Cuthbert JJ, Ransome N, Clark AL. Re-defining iron deficiency in patients with heart failure. Expert Rev Cardiovasc Ther 2022; 20:667-681. [DOI: 10.1080/14779072.2022.2100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- JJ Cuthbert
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston-Upon-Hull, East Riding of Yorkshire, UK
- Department of Cardiology, Hull University Teaching Hospital Trust, Castle Hill Hospital, Castle Road, Cottingham, Kingston-Upon-Hull, East Riding of Yorkshire, UK
| | - N Ransome
- Department of Haematology, York and Scarborough Teaching Hospitals NHS Trust, York, UK
| | - AL Clark
- Department of Cardiology, Hull University Teaching Hospital Trust, Castle Hill Hospital, Castle Road, Cottingham, Kingston-Upon-Hull, East Riding of Yorkshire, UK
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31
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Peters CJ, Hanff TC, Genuardi MV, Zhang R, Domenico C, Atluri P, Mazurek JA, Urgo K, Wald J, Tanna MS, Shore S, Acker MA, Goldberg LR, Margulies KB, Birati EY. Safety and Effectiveness of Intravenous Iron Therapy in Patients Supported by Durable Left Ventricular Assist Devices. J Clin Med 2022; 11:jcm11133900. [PMID: 35807184 PMCID: PMC9267846 DOI: 10.3390/jcm11133900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/21/2022] [Accepted: 07/01/2022] [Indexed: 12/04/2022] Open
Abstract
Aims: While it is common practice to use intravenous (IV) iron in patients with left ventricular assist devices (LVADs) and iron deficiency, there is insufficient evidence regarding outcomes in this patient population. We evaluated the safety and effectiveness of IV iron therapy in patients supported by LVADs with iron deficiency. Methods: We performed a retrospective analysis of iron deficient patients on continuous LVAD support at a large academic center between 2008 and 2019. Patients were divided into two cohorts based on IV iron sucrose treatment. The primary endpoint was hemoglobin at 12 weeks. Secondary endpoints were mean corpuscular volume (MCV) and New York Heart Association (NYHA) class at 12 weeks. Safety endpoints included hospitalization, infection, pump thrombosis, arrhythmia, and gastrointestinal bleed. Models were weighted by the inverse probability of receiving IV iron using a propensity score, and endpoints were adjusted for their corresponding baseline values. Results: Among 213 patients, 70 patients received IV iron and 143 patients did not. Hemoglobin at 12 weeks was significantly greater among those treated (intergroup difference: 0.6 g/dL; 95% CI, 0.1 to 1.1; p = 0.01), while MCV was similar in both groups (intergroup difference: 0.7 μm3; 95% CI, −1.3 to 2.7; p = 0.50). NYHA class distribution at 12 weeks was significantly different (odds ratio for improvement: 2.84; 95% CI, 1.42 to 4.68; p = 0.003). The hazards of adverse events in each group were similar. Conclusions: In patients with LVADs and iron deficiency, treatment with IV iron sucrose was safe and associated with improvements in functional status and hemoglobin.
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Affiliation(s)
- Carli J. Peters
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Thomas C. Hanff
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael V. Genuardi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Robert Zhang
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
| | - Christopher Domenico
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Department of Pharmacy, Hospital of The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (P.A.); (K.U.); (M.A.A.)
| | - Jeremy A. Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Kim Urgo
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (P.A.); (K.U.); (M.A.A.)
| | - Joyce Wald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Monique S. Tanna
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Supriya Shore
- Cardiovascular Division, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Michael A. Acker
- Department of Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (P.A.); (K.U.); (M.A.A.)
| | - Lee R. Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kenneth B. Margulies
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (C.J.P.); (T.C.H.); (M.V.G.); (R.Z.); (J.A.M.); (J.W.); (M.S.T.); (L.R.G.); (K.B.M.)
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
- The Lydia and Carol Kittner, Lea and Banjamin Davidai Division of Cardiovascular Medicine and Surgery, Padeh-Poriya Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
- Correspondence: ; Tel.: +972-4-6652648; Fax: +972-4-6652678
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Bomer N, Pavez-Giani MG, Grote Beverborg N, Cleland JGF, van Veldhuisen DJ, van der Meer P. Micronutrient deficiencies in heart failure: Mitochondrial dysfunction as a common pathophysiological mechanism? J Intern Med 2022; 291:713-731. [PMID: 35137472 PMCID: PMC9303299 DOI: 10.1111/joim.13456] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heart failure is a devastating clinical syndrome, but current therapies are unable to abolish the disease burden. New strategies to treat or prevent heart failure are urgently needed. Over the past decades, a clear relationship has been established between poor cardiac performance and metabolic perturbations, including deficits in substrate uptake and utilization, reduction in mitochondrial oxidative phosphorylation and excessive reactive oxygen species production. Together, these perturbations result in progressive depletion of cardiac adenosine triphosphate (ATP) and cardiac energy deprivation. Increasing the delivery of energy substrates (e.g., fatty acids, glucose, ketones) to the mitochondria will be worthless if the mitochondria are unable to turn these energy substrates into fuel. Micronutrients (including coenzyme Q10, zinc, copper, selenium and iron) are required to efficiently convert macronutrients to ATP. However, up to 50% of patients with heart failure are deficient in one or more micronutrients in cross-sectional studies. Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation, moving our view of the failing myocardium away from an "an engine out of fuel" to "a defective engine on a path to self-destruction." This summary of evidence suggests that supplementation with micronutrients-preferably as a package rather than singly-might be a potential therapeutic strategy in the treatment of heart failure patients.
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Affiliation(s)
- Nils Bomer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mario G Pavez-Giani
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Niels Grote Beverborg
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK.,National Heart & Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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MEHEDINTI AM, CAPUSA C, ANDREIANA I, MIRCESCU G. Intravenous Iron-Carbohydrate Nanoparticles and Their Similars. What Do We Choose? MAEDICA 2022; 17:436-448. [PMID: 36032600 PMCID: PMC9375892 DOI: 10.26574/maedica.2022.17.2.436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Anemia is highly prevalent worldwide and iron deficiency is the first cause. Iron deficiency has not only hematologic effects but also non-hematologic effects - immune, metabolic, cognitive dysfunctions and poor cardiovascular and renal outcomes - which generally precede anemia. Iron therapy not only significantly improves the hematological parameters but also has non-hematologic benefits. Given that its efficacy and safety has been revealed over the years, intravenous (IV) iron therapy is frequently used. Intravenous iron products are nanoparticles largely consisting in an iron core surrounded by a carbohydrate shell. They are classified as non-biological complex molecules, being different from small commonly used molecules, with properties and biological behavior impossible to be completely characterized only by physicochemical analysis. To date, there is no appropriate regulatory evaluation system for these medicines and several follow-on versions of the IV iron originators (e.g., iron sucrose) were approved using the same regulatory pathway as for generics. Because of this vulnerability in an adequate pathway for approval, both non-clinical and clinical studies suggested no therapeutic equivalence (thus no interchangeability) between iron sucrose originator (Venofer®), and iron sucrose similars. In this review we aimed to underline the importance of intravenous iron therapy as well as raise awareness regarding the differences between nanomedicines and their intended similar but not identical copies. The potential implications of these differences impact patients (safety, efficacy) but also the medical system (higher costs).
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Affiliation(s)
- Ana Maria MEHEDINTI
- “Carol Davila” University of Medicine and Pharmacy, Nephrology Department, Bucharest, Romania,“Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Cristina CAPUSA
- “Carol Davila” University of Medicine and Pharmacy, Nephrology Department, Bucharest, Romania,“Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Iuliana ANDREIANA
- “Carol Davila” University of Medicine and Pharmacy, Nephrology Department, Bucharest, Romania,“Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel MIRCESCU
- “Carol Davila” University of Medicine and Pharmacy, Nephrology Department, Bucharest, Romania,“Dr. Carol Davila” Teaching Hospital of Nephrology, Bucharest, Romania
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Uskach TM. Management of iron deficiency in chronic heart failure. TERAPEVT ARKH 2022; 94:572-578. [DOI: 10.26442/00403660.2022.04.201451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022]
Abstract
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.
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35
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Practical Guidance for Diagnosing and Treating Iron Deficiency in Patients with Heart Failure: Why, Who and How? J Clin Med 2022; 11:jcm11112976. [PMID: 35683366 PMCID: PMC9181459 DOI: 10.3390/jcm11112976] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 01/27/2023] Open
Abstract
Iron deficiency (ID) is a comorbid condition frequently seen in patients with heart failure (HF). Iron has an important role in the transport of oxygen, and is also essential for skeletal and cardiac muscle, which depend on iron for oxygen storage and cellular energy production. Thus, ID per se, even without anaemia, can be harmful. In patients with HF, ID is associated with a poorer quality of life (QoL) and exercise capacity, and a higher risk of hospitalisations and mortality, even in the absence of anaemia. Despite its negative clinical consequences, ID remains under-recognised. However, it is easily diagnosed and managed, and the recently revised 2021 European Society of Cardiology (ESC) guidelines on HF provide specific recommendations for its diagnosis and treatment. Prospective randomised controlled trials in patients with symptomatic HF with reduced ejection fraction (HFrEF) show that correction of ID using intravenous iron (principally ferric carboxymaltose [FCM]) provides improvements in symptoms of HF, exercise capacity and QoL, and a recent trial demonstrated that FCM therapy following hospitalisation due to acute decompensated HF reduced the risk of subsequent HF hospitalisations. This review provides a summary of the epidemiology and pathophysiology of ID in HFrEF, and practical guidance on screening, diagnosing, and treating ID.
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36
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Kulej-Lyko K, Niewinski P, Tubek S, Ponikowski P. Contribution of Peripheral Chemoreceptors to Exercise Intolerance in Heart Failure. Front Physiol 2022; 13:878363. [PMID: 35492596 PMCID: PMC9046845 DOI: 10.3389/fphys.2022.878363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/29/2022] [Indexed: 01/08/2023] Open
Abstract
Peripheral chemoreceptors (PChRs), because of their strategic localization at the bifurcation of the common carotid artery and along the aortic arch, play an important protective role against hypoxia. Stimulation of PChRs evokes hyperventilation and hypertension to maintain adequate oxygenation of critical organs. A relationship between increased sensitivity of PChRs (hyperreflexia) and exercise intolerance (ExIn) in patients with heart failure (HF) has been previously reported. Moreover, some studies employing an acute blockade of PChRs (e.g., using oxygen or opioids) demonstrated improvement in exercise capacity, suggesting that hypertonicity is also involved in the development of ExIn in HF. Nonetheless, the precise mechanisms linking dysfunctional PChRs to ExIn remain unclear. From the clinical perspective, there are two main factors limiting exercise capacity in HF patients: subjective perception of dyspnoea and muscle fatigue. Both have many determinants that might be influenced by abnormal signalling from PChRs, including: exertional hyperventilation, oscillatory ventilation, ergoreceptor oversensitivity, and augmented sympathetic tone. The latter results in reduced muscle perfusion and altered muscle structure. In this review, we intend to present the milieu of abnormalities tied to malfunctioning PChRs and discuss their role in the complex relationships leading, ultimately, to ExIn.
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Affiliation(s)
- Katarzyna Kulej-Lyko
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
- *Correspondence: Katarzyna Kulej-Lyko,
| | - Piotr Niewinski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | - Stanislaw Tubek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology, University Clinical Hospital, Wroclaw, Poland
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Influence of Health Education Based on IMB on Prognosis and Self-Management Behavior of Patients with Chronic Heart Failure. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:8517802. [PMID: 35432589 PMCID: PMC9012616 DOI: 10.1155/2022/8517802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/22/2022] [Accepted: 03/05/2022] [Indexed: 01/30/2023]
Abstract
As the contemporary society is increasingly entering an aging society, heart failure, as a common disease in the elderly population, has an increasing impact on people. The common one is mainly chronic heart failure. Coupled with the influence of various complications, such as hypostatic pneumonia and venous thrombosis, the mortality and hospital admission rates of patients are very high. Moreover, the current technology is not very effective for the prevention and treatment of chronic heart failure. The per capita consumption level of ordinary people in China is low, and it is not suitable to promote high-cost treatment programs. Based on this, this paper proposes the intervention management of mental failure patients under the intervention of health education based on IMB, in order to explore the impact of the intervention of health education on patients. The research in this paper selected 112 patients with chronic heart failure who were admitted to the cardiovascular ward of a city public hospital in 2017 and divided the patients into two groups. One group received health education intervention, which was the intervention group. The other group was the control group. The control group was given routine education and nursing. The experimental results of this paper show that the satisfaction of the intervention group is higher, accounting for 85.3%, and the satisfaction of the control group is lower than that of the intervention group, about 67.9%. Dissatisfaction with health education and the probability of short-term readmission were higher than those in the intervention group.
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Del Canto I, Santas E, Cardells I, Miñana G, Palau P, Llàcer P, Fácila L, López-Vilella R, Almenar L, Bodí V, López-Lereu MP, Monmeneu JV, Sanchis J, Moratal D, Maceira AM, de la Espriella R, Chorro FJ, Bayés-Genís A, Núñez J. Short-Term Changes in Left and Right Ventricular Cardiac Magnetic Resonance Feature Tracking Strain Following Ferric Carboxymaltose in Patients With Heart Failure: A Substudy of the Myocardial-IRON Trial. J Am Heart Assoc 2022; 11:e022214. [PMID: 35301854 PMCID: PMC9075490 DOI: 10.1161/jaha.121.022214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The mechanisms explaining the clinical benefits of ferric carboximaltose (FCM) in patients with heart failure, reduced or intermediate left ventricular ejection fraction, and iron deficiency remain not fully clarified. The Myocardial‐IRON trial showed short‐term cardiac magnetic resonance (CMR) changes suggesting myocardial iron repletion following administration of FCM but failed to find a significant increase in left ventricular ejection fraction in the whole sample. Conversely, the strain assessment could evaluate more specifically subtle changes in contractility. In this subanalysis, we aimed to evaluate the effect of FCM on the short‐term left and right ventricular CMR feature tracking derived strain. Methods and Results This is a post hoc subanalysis of the double‐blind, placebo‐controlled, randomized clinical trial that enrolled 53 ambulatory patients with heart failure and left ventricular ejection fraction <50%, and iron deficiency [Myocardial‐IRON trial (NCT03398681)]. Three‐dimensional left and 2‐dimensional right ventricular CMR tracking strain (longitudinal, circumferential, and radial) changes were evaluated before, 7 and 30 days after randomization using linear mixed‐effect analysis. The median (interquartile range) age of the sample was 73 years (65–78), and 40 (75.5%) were men. At baseline, there were no significant differences in CMR feature tracking strain parameters across both treatment arms. At 7 days, the only global 3‐dimensional left ventricular circumferential strain was significantly higher in the FCM treatment‐arm (difference: −1.6%, P=0.001). At 30 days, and compared with placebo, global 3‐dimensional left ventricular strain parameters significantly improved in those allocated to FCM treatment‐arm [longitudinal (difference: −2.3%, P<0.001), circumferential (difference: −2.5%, P<0.001), and radial (difference: 4.2%, P=0.002)]. Likewise, significant improvements in global right ventricular strain parameters were found in the active arm at 30 days (longitudinal [difference: −3.3%, P=0.010], circumferential [difference: −4.5%, P<0.001], and radial [difference: 4.5%, P=0.027]). Conclusions In patients with stable heart failure, left ventricular ejection fraction <50%, and iron deficiency, treatment with FCM was associated with short‐term improvements in left and right ventricular function assessed by CMR feature tracking derived strain parameters. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03398681.
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Affiliation(s)
- Irene Del Canto
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain.,Center for Biomaterials and Tissue Engineering Universitat Politècnica de València Valencia Spain
| | - Enrique Santas
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | | | - Gema Miñana
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Patricia Palau
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Pau Llàcer
- Internal Medicine Department Hospital de Manises Manises Spain
| | - Lorenzo Fácila
- Cardiology Department Hospital General Universitario de Valencia Valencia Spain
| | | | - Luis Almenar
- Cardiology Department Hospital Universitario La Fe de Valencia Valencia Spain
| | - Vicent Bodí
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | | | - Jose V Monmeneu
- Cardiovascular Imaging Unit Ascires Biomedical GroupValencia Spain
| | - Juan Sanchis
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - David Moratal
- Center for Biomaterials and Tissue Engineering Universitat Politècnica de València Valencia Spain
| | - Alicia M Maceira
- Cardiovascular Imaging Unit Ascires Biomedical GroupValencia Spain
| | - Rafael de la Espriella
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Francisco J Chorro
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
| | - Antoni Bayés-Genís
- CIBER Cardiovascular Madrid Spain.,Cardiology Department and Heart Failure Unit Hospital Universitari Germans Trias i Pujol Badalona Spain.,Universitat Autonoma de Barcelona Barcelona Spain
| | - Julio Núñez
- Cardiology Department Hospital Clínico Universitario de ValenciaUniversitat de ValenciaINCLIVA Valencia Spain.,CIBER Cardiovascular Madrid Spain
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Masini G, Graham FJ, Pellicori P, Cleland JG, Cuthbert JJ, Kazmi S, Inciardi RM, Clark AL. Criteria for Iron Deficiency in Patients With Heart Failure. J Am Coll Cardiol 2022; 79:341-351. [DOI: 10.1016/j.jacc.2021.11.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 02/07/2023]
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40
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van Dalen DH, Kragten JA, Emans ME, van Ofwegen-Hanekamp CEE, Klaarwater CCR, Spanjers MHA, Hendrick R, van Deursen CTBM, Brunner-La Rocca HP. Acute heart failure and iron deficiency: a prospective, multicentre, observational study. ESC Heart Fail 2021; 9:398-407. [PMID: 34862747 PMCID: PMC8788059 DOI: 10.1002/ehf2.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/11/2021] [Accepted: 11/11/2021] [Indexed: 01/10/2023] Open
Abstract
Aims The prevalence and the natural course of iron deficiency (ID) in acute heart failure (AHF) are still unclear. We investigated the prevalence of ID in unselected patients admitted with AHF on admission, at discharge and up to 3 months thereafter. Methods and results In this prospective, multicentre, observational study, 742 patients admitted with AHF were enrolled. The main study outcome was the percentage of patients with ID (ferritin <100 μg/L = absolute ID or ferritin 100–299 μg/L and transferrin saturation <20% = functional ID) at admission (T0), after clinical stabilization prior to discharge (T1), and 10 ± 6 weeks after discharge (T2). At T0, ID was present in 71.8% of the patients (44.1% absolute and 27.7% functional ID). At T1 and T2, ID was present in 56.4% (32.4% absolute and 24% functional ID) and 50.3% (36.8% absolute and 13.5% functional ID), respectively. Absolute ID persisted from T0 to T2 in 66% of the patients, while functional ID resolved in 56% of the patients. Ferritin (median [interquartile range] 124 μg/L [56–247] to 150 μg/L [73–277]), transferrin saturation (15% [10–20] to 18% [12–27]), and iron levels (9 μmol/L [6–13] to 11 μmol/L [8–16]) increased significantly (all P < 0.001) from T0 to T1. Transferrin saturation (to 21% [15–29]) and iron levels (to 13 μmol/L [9–17]) also increased significantly (both P < 0.01) from T1 to T2 without iron supplementation. Conclusions Iron deficiency is highly prevalent in patients with AHF, but resolves during treatment in some patients, even without iron supplementation. Absolute ID is more likely to persist over time, whereas functional ID often resolves during treatment of AHF, representing probably a reduced iron availability rather than a true deficiency.
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Affiliation(s)
- Dirk H van Dalen
- Department of Cardiology, Jeroen Bosch Hospital, PO Box 90153, room B4.02.022, 's-Hertogenbosch, 5200ME, The Netherlands
| | - Johannes A Kragten
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mireille E Emans
- Department of Cardiology, Ikazia Hospital Rotterdam, Rotterdam, The Netherlands
| | | | | | - Mireille H A Spanjers
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rémond Hendrick
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Cees Th B M van Deursen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Cardiovascular Diseases (CARIM), University of Maastricht, Maastricht, The Netherlands
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Becher PM, Schrage B, Benson L, Fudim M, Corovic Cabrera C, Dahlström U, Rosano GMC, Jankowska EA, Anker SD, Lund LH, Savarese G. Phenotyping heart failure patients for iron deficiency and use of intravenous iron therapy: data from the Swedish Heart Failure Registry. Eur J Heart Fail 2021; 23:1844-1854. [PMID: 34476878 DOI: 10.1002/ejhf.2338] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/11/2021] [Accepted: 08/29/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Iron deficiency (ID) is associated with poor prognosis regardless of anaemia. Intravenous iron improves quality of life and outcomes in patients with ID and heart failure (HF) with reduced ejection fraction (HFrEF). In the Swedish HF registry, we assessed (i) frequency and predictors of ID testing; (ii) prevalence and outcomes of ID with/without anaemia; (iii) use of ferric carboxymaltose (FCM) and its predictors in patients with ID. METHODS AND RESULTS We used multivariable logistic regressions to assess patient characteristics independently associated with ID testing/FCM use, and Cox regressions to assess risk of outcomes associated with ID. Of 21 496 patients with HF and any ejection fraction enrolled in 2017-2018, ID testing was performed in 27%. Of these, 49% had ID and more specifically 36% had ID-/anaemia-, 15% ID-/anaemia+, 29% ID+/anaemia-, and 20% ID+/anaemia+ (48%, 39%, 13%, 30% and 18% in HFrEF, respectively). Risk of recurrent all-cause hospitalizations was higher in patients with ID regardless of anaemia. Of 1959 patients with ID, 19% received FCM (24% in HFrEF). Important independent predictors of ID testing and FCM use were anaemia, higher New York Heart Association class, having HFrEF, and referral to HF specialty care. CONCLUSION In this nationwide HF registry, ID testing occurred in only about a quarter of the patients. Among tested patients, ID was present in one half, but only one in five patients received FCM indicating low adherence to current guidelines on screening and treatment.
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Affiliation(s)
- Peter Moritz Becher
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Benedikt Schrage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Carin Corovic Cabrera
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Giuseppe M C Rosano
- St George's Hospital Medical School, London, UK.,IRCCS San Raffaele Roma, Rome, Italy
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, and Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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42
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Rizzo C, Carbonara R, Ruggieri R, Passantino A, Scrutinio D. Iron Deficiency: A New Target for Patients With Heart Failure. Front Cardiovasc Med 2021; 8:709872. [PMID: 34447793 PMCID: PMC8383833 DOI: 10.3389/fcvm.2021.709872] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 12/28/2022] Open
Abstract
Iron deficiency (ID) is one of the most frequent comorbidities in patients with heart failure (HF). ID is estimated to be present in up to 50% of outpatients and is a strong independent predictor of HF outcomes. ID has been shown to reduce quality of life, exercise capacity and survival, in both the presence and absence of anemia. The most recent 2016 guidelines recommend starting replacement treatment at ferritin cutoff value <100 mcg/l or between 100 and 299 mcg/l when the transferrin saturation is <20%. Beyond its effect on hemoglobin, iron plays an important role in oxygen transport and in the metabolism of cardiac and skeletal muscles. Mitochondria are the most important sites of iron utilization and energy production. These factors clearly have roles in the diminished exercise capacity in HF. Oral iron administration is usually the first route used for iron repletion in patients. However, the data from the IRONOUT HF study do not support the use of oral iron supplementation in patients with HF and a reduced ejection fraction, because this treatment does not affect peak VO2 (the primary endpoint of the study) or increase serum ferritin levels. The FAIR-HF and CONFIRM-HF studies have shown improvements in symptoms, quality of life and functional capacity in patients with stable, symptomatic, iron-deficient HF after the administration of intravenous iron (i.e., FCM). Moreover, they have shown a decreased risk of first hospitalization for worsening of HF, as later confirmed in a subsequent meta-analysis. In addition, the EFFECT-HF study has shown an improvement in peak oxygen consumption at CPET (a parameter generally considered the gold standard of exercise capacity and a predictor of outcome in HF) in patients randomized to receive ferric carboxymaltose. Finally, the AFFIRM AHF trial evaluating the effects of FCM administration on the outcomes of patients hospitalized for acute HF has found significantly fewer hospital readmissions due to HF among patients treated with FCM rather than placebo.
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Affiliation(s)
- Caterina Rizzo
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Bari, Italy
| | - Rosa Carbonara
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Bari, Italy
| | - Roberta Ruggieri
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Bari, Italy
| | - Andrea Passantino
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Bari, Italy
| | - Domenico Scrutinio
- Department of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Bari, Italy
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43
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Safety and Efficacy of Intravenous Ferric Derisomaltose Compared to Iron Sucrose for Iron Deficiency Anemia in Patients with Chronic Kidney Disease With and Without Heart Failure. Am J Cardiol 2021; 152:138-145. [PMID: 34162484 DOI: 10.1016/j.amjcard.2021.04.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 11/23/2022]
Abstract
Ferric derisomaltose (FDI) is an intravenous (IV) high-dose iron formulation approved in the US for the treatment of iron deficiency anemia in adults who are intolerant of/have had an unsatisfactory response to oral iron, or who have non-dialysis-dependent chronic kidney disease (NDD-CKD). FERWON-NEPHRO was a randomized, open-label, multicenter clinical trial evaluating the safety and efficacy of a single infusion of FDI 1,000 mg versus up to 5 doses of iron sucrose (IS) 200 mg (recommended cumulative dose, 1,000 mg) over 8 weeks in patients with NDD-CKD and iron deficiency anemia. Of 1,525 patients included in the safety analysis, 244 (16%) had a history of heart failure (HF). Overall, the rate of serious or severe hypersensitivity reactions was low and did not differ between treatment groups. Cardiovascular adverse events (AEs) were reported for 9.4% of patients who had HF and 4.2% who did not. Time to first cardiovascular AE was longer following administration of FDI compared with IS (hazard ratio: 0.59 [95% CI: 0.37, 0.92]; p=0.0185), a difference that was similar in patients with or without HF (p=0.908 for interaction). Patients achieved a faster hematological response (assessed by changes in hemoglobin and ferritin concentrations, and increase in transferrin saturation) with FDI versus IS. In conclusion, in patients with NDD-CKD, a single infusion of FDI was safe, well tolerated, and was associated with fewer cardiovascular AEs and a faster hematological response, compared to multiple doses of IS. These effects were similar for patients with and without HF.
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44
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Tajes M, Díez-López C, Enjuanes C, Moliner P, Ferreiro JL, Garay A, Jiménez-Marrero S, Yun S, Sosa SG, Alcoberro L, González-Costello J, García-Romero E, Yañez-Bisbe L, Benito B, Comín-Colet J. Neurohormonal activation induces intracellular iron deficiency and mitochondrial dysfunction in cardiac cells. Cell Biosci 2021; 11:89. [PMID: 34001233 PMCID: PMC8130332 DOI: 10.1186/s13578-021-00605-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Background Iron deficiency (ID) is common in patients with heart failure (HF) and is associated with poor outcomes, yet its role in the pathophysiology of HF is not well-defined. We sought to determine the consequences of HF neurohormonal activation in iron homeostasis and mitochondrial function in cardiac cells. Methods HF was induced in C57BL/6 mice by using isoproterenol osmotic pumps and embryonic rat heart-derived H9c2 cells were subsequently challenged with Angiotensin II and/or Norepinephrine. The expression of several genes and proteins related to intracellular iron metabolism were assessed by Real time-PCR and immunoblotting, respectively. The intracellular iron levels were also determined. Mitochondrial function was analyzed by studying the mitochondrial membrane potential, the accumulation of radical oxygen species (ROS) and the adenosine triphosphate (ATP) production. Results Hearts from isoproterenol-stimulated mice showed a decreased in both mRNA and protein levels of iron regulatory proteins, transferrin receptor 1, ferroportin 1 and hepcidin compared to control mice. Furthermore, mitoferrin 2 and mitochondrial ferritin were also downregulated in the hearts from HF mice. Similar data regarding these key iron regulatory molecules were found in the H9c2 cells challenged with neurohormonal stimuli. Accordingly, a depletion of intracellular iron levels was found in the stimulated cells compared to non-stimulated cells, as well as in the hearts from the isoproterenol-induced HF mice. Finally, neurohormonal activation impaired mitochondrial function as indicated by the accumulation of ROS, the impaired mitochondrial membrane potential and the decrease in the ATP levels in the cardiac cells. Conclusions HF characteristic neurohormonal activation induced changes in the regulation of key molecules involved in iron homeostasis, reduced intracellular iron levels and impaired mitochondrial function. The current results suggest that iron could be involved in the pathophysiology of HF.
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Affiliation(s)
- M Tajes
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - C Díez-López
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Advanced Heart Failure and Heart Transplant Unit, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - C Enjuanes
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - P Moliner
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J L Ferreiro
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Garay
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - S Jiménez-Marrero
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - S Yun
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - S G Sosa
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - L Alcoberro
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J González-Costello
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Advanced Heart Failure and Heart Transplant Unit, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
| | - E García-Romero
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.,Advanced Heart Failure and Heart Transplant Unit, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - L Yañez-Bisbe
- Vascular Biology and Metabolism Program, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - B Benito
- Vascular Biology and Metabolism Program, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Cardiology Department, Hospital Vall d'Hebron Hospital, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Comín-Colet
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain. .,Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain. .,Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain. .,Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain.
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45
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Xia H, Shen H, Cha W, Lu Q. The Prognostic Significance of Anemia in Patients With Heart Failure: A Meta-Analysis of Studies From the Last Decade. Front Cardiovasc Med 2021; 8:632318. [PMID: 34055927 PMCID: PMC8155282 DOI: 10.3389/fcvm.2021.632318] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/29/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Haijiang Xia
- Department of Cardiology, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Hongfeng Shen
- Department of Cardiology, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Wei Cha
- Department of Cardiology, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Qiaoli Lu
- Department of General Medicine, Zhuji People's Hospital of Zhejiang Province, Shaoxing, China
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Loncar G, Obradovic D, Thiele H, von Haehling S, Lainscak M. Iron deficiency in heart failure. ESC Heart Fail 2021; 8:2368-2379. [PMID: 33932115 PMCID: PMC8318436 DOI: 10.1002/ehf2.13265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Goran Loncar
- Institute for Cardiovascular Diseases 'Dedinje', University of Belgrade, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danilo Obradovic
- Department of Cardiology-Internal Medicine at Heart Center Leipzig, University of Leipzig, Strümpellstraße 39, Leipzig, 04289, Germany
| | - Holger Thiele
- Department of Cardiology-Internal Medicine at Heart Center Leipzig, University of Leipzig, Strümpellstraße 39, Leipzig, 04289, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
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47
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Iron Deficiency without Anemia Decreases Physical Endurance and Mitochondrial Complex I Activity of Oxidative Skeletal Muscle in the Mouse. Nutrients 2021; 13:nu13041056. [PMID: 33805065 PMCID: PMC8064065 DOI: 10.3390/nu13041056] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 12/16/2022] Open
Abstract
Iron deficiency (ID), with or without anemia, is responsible for physical fatigue. This effect may be linked to an alteration of mitochondrial metabolism. Our aim was to assess the impact of ID on skeletal striated muscle mitochondrial metabolism. Iron-deficient non-anemic mice, obtained using a bloodletting followed by a low-iron diet for three weeks, were compared to control mice. Endurance was assessed using a one-hour submaximal exercise on a Rotarod device and activities of mitochondrial complexes I and IV were measured by spectrophotometry on two types of skeletal striated muscles, the soleus and the quadriceps. As expected, ID mice displayed hematologic markers of ID and reduced iron stores, although none of them were anemic. In ID mice, endurance was significantly reduced and activity of the respiratory chain complex I, normalized to citrate synthase activity, was significantly reduced in the soleus muscle but not in the quadriceps. Complex IV activities were not significantly different, neither in the soleus nor in the quadriceps. We conclude that ID without anemia is responsible for impaired mitochondrial complex I activity in skeletal muscles with predominant oxidative metabolism. These results bring pathophysiological support to explain the improved physical activity observed when correcting ID in human. Further studies are needed to explore the mechanisms underlying this decrease in complex I activity and to assess the role of iron therapy on muscle mitochondrial metabolism.
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48
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Abstract
Anemia is a very common comorbidity in patients with heart failure (HF), affecting ∼30% of stable ambulatory patients and 50% patients with acute decompensated HF. Absolute or functional iron deficiency (ID) is seen in ∼50% patients with HF. Both of these comorbidities often coexist and are independently associated with increased mortality and hospitalizations. These findings led several investigators to test the hypotheses that treatment of anemia and ID in HF would improve symptoms and long-term outcomes. Small studies showed that erythropoiesis-stimulating agents (ESAs) improve subjective measures of HF. However, a large pivotal outcome trial found that the ESA darbepoetin alfa did not improve long-term outcomes in patients with HF with reduced ejection fraction and instead was associated with adverse effects. Studies using IV iron have had somewhat greater success, showing improvements in subjective and some objective measures of HF. However, more research is needed to establish the best treatment options for these high-risk patients. We present 5 common scenarios of patients with HF and anemia and describe our personal approach on how we might treat them based on objective evidence where available. An algorithm that offers guidance in regard to personalized therapy for such patients is also presented.
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49
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Abstract
Anemia is common in heart failure with preserved and reduced ejection fraction. It is independently associated with poor functional status, hospitalization, and reduced survival. Its etiology is complex and multifactorial. Hemodynamic and nonhemodynamic compensatory mechanisms have been discussed as a response to chronic anemia. Whether anemia is a risk marker of advanced disease or a risk factor for progressive heart failure is debated. Current guidelines recommend a diagnostic workup as a part of standard management. Studies investigating intravenous iron administration reported beneficial effects on clinical outcomes. This article reviews current information on anemia.
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Affiliation(s)
- Carmen C Beladan
- University of Medicine and Pharmacy "Carol Davila", Euroecolab; Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania.
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50
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Chopra VK, Anker SD. Anaemia, iron deficiency and heart failure in 2020: facts and numbers. ESC Heart Fail 2020; 7:2007-2011. [PMID: 32602663 PMCID: PMC7524223 DOI: 10.1002/ehf2.12797] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/15/2020] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Vijay K. Chopra
- Heart Failure Programme and ResearchMax Super Specialty Hospital, SaketNew DelhiIndia
| | - Stefan D. Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT)German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Charité‐Universitätsmedizin Berlin (Campus CVK)BerlinGermany
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