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Gan T, Hu J, Liu W, Li C, Xu Q, Wang Y, Lu S, Aledan AKO, Wang Y, Wang Z. Causal Association Between Anemia and Cardiovascular Disease: A 2-Sample Bidirectional Mendelian Randomization Study. J Am Heart Assoc 2023:e029689. [PMID: 37301769 DOI: 10.1161/jaha.123.029689] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023]
Abstract
Background Although previous observational studies have shown an association between anemia and cardiovascular disease (CVD), the underlying causal relationship between anemia and CVD remains uncertain. Methods and Results We conducted a 2-sample bidirectional Mendelian randomization (MR) study to assess the causal association between anemia and CVD. We extracted summary statistics data for anemia, heart failure (HF), coronary artery disease (CAD), atrial fibrillation, any stroke, and any ischemic stroke (AIS) from relevant published genome-wide association studies. After rigorous quality control steps, independent single-nucleotide polymorphisms for each disease were selected as instrumental variables. Inverse-variance weighting was used as the primary method to estimate the causal association between anemia and CVD in the 2-sample MR analysis. Simultaneously, we performed a series of multiple methods analyses (median weighting, maximum likelihood [MR robust adjusted profile score]), sensitivity analyses (Cochran's Q test and MR-Egger intercept, leave-one-out test [MR pleiotropy residual sum and outlier]), instrumental variable strength evaluations (F statistic), and statistic power estimates to verify the robustness and reliability of our results. Furthermore, the associations between anemia and CVD from different studies, including the UK Biobank and FinnGen studies, were combined by meta-analysis. The MR analysis showed that genetically predicted anemia was significantly associated with HF risk at the Bonferroni-corrected significance level (odds ratio [OR], 1.11 [95% CI, 1.04-1.18]; P=0.002) and was suggestively associated with CAD risk (OR, 1.11 [95% CI, 1.02-1.22]; P=0.020). However, the associations between anemia and atrial fibrillation, any stroke, or AIS were not statistically significant. In the reverse MR analysis, we found that genetic susceptibility to HF, CAD, and AIS was significantly associated with anemia risk. The ORs of HF, CAD, and AIS were 1.64 (95% CI, 1.39-1.94; P=7.60E-09), 1.16 (95% CI, 1.08-1.24; P=2.32E-05), and 1.30 (95% CI, 1.11-1.52; P=0.001), respectively. Genetically predicted atrial fibrillation was suggestively associated with anemia (OR, 1.06 [95% CI, 1.01-1.12]; P=0.015). Sensitivity analyses found weak evidence of horizontal pleiotropy and heterogeneity, which ensured the robustness and reliability of the results. Meta-analysis also showed the statistically significant association between anemia and HF risk. Conclusions Our study supports bidirectional causality between anemia and HF and significant associations between genetic predisposition to CAD and AIS with anemia, which contributes to the clinical management of both diseases.
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Affiliation(s)
- Ting Gan
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Jing Hu
- Department of Infectious Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Wenhu Liu
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Cui Li
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Qian Xu
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Ya Wang
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Shuai Lu
- Department of Cardiac Surgery, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Anwer Khalid Okab Aledan
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Yan Wang
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
| | - Zhaohui Wang
- Department of Cardiology, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
- Hubei Provincial Engineering Research Center of Immunological Diagnosis and Therapy for Cardiovascular Diseases, Union Hospital Tongji Medical College, Huazhong University of Science and Technology Wuhan China
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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: 59] [Impact Index Per Article: 59.0] [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
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Centre for Regenerative Therapies, German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
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Hanna-Rivero N, Tu SJ, Elliott AD, Pitman BM, Gallagher C, Lau DH, Sanders P, Wong CX. Anemia and iron deficiency in patients with atrial fibrillation. BMC Cardiovasc Disord 2022; 22:204. [PMID: 35508964 PMCID: PMC9066804 DOI: 10.1186/s12872-022-02633-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac tachyarrhythmia and has a rising global prevalence. Given the increasing burden of AF-related symptoms and complications, new approaches to management are required. Anemia and iron deficiency are common conditions in patients with AF. Furthermore, emerging evidence suggests that the presence of anemia may be associated with worse outcome in these patients. The role of anemia and iron deficiency has been extensively explored in other cardiovascular states, such as heart failure and ischemic heart disease. In particular, the role of iron repletion amongst patients with heart failure is now an established treatment modality. However, despite the strong bidirectional inter-relationship between AF and heart failure, the implications of anemia and iron-deficiency in AF have been scarcely studied. This area is of mechanistic and clinical relevance given the potential that treatment of these conditions may improve symptoms and prognosis in the increasing number of individuals with AF. In this review, we summarise the current published literature on anemia and iron deficiency in patients with AF. We discuss AF complications such as stroke, bleeding, and heart failure, in addition to AF-related symptoms such as exercise intolerance, and the potential impact of anemia and iron deficiency on these. Finally, we summarize current research gaps on anemia, iron deficiency, and AF, and underscore potential research directions.
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Affiliation(s)
- Nicole Hanna-Rivero
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Samuel J Tu
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Bradley M Pitman
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia.
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia.
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