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Lacour P, Dang PL, Morris DA, Parwani AS, Doehner W, Schuessler F, Hohendanner F, Heinzel FR, Stroux A, Tschoepe C, Haverkamp W, Boldt LH, Pieske B, Blaschke F. The effect of iron deficiency on cardiac resynchronization therapy: results from the RIDE-CRT Study. ESC Heart Fail 2020; 7:1072-1084. [PMID: 32189474 PMCID: PMC7261541 DOI: 10.1002/ehf2.12675] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/09/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
Aims Cardiac resynchronization therapy (CRT) improves functional status, induces reverse left ventricular remodelling, and reduces hospitalization and mortality in patients with symptomatic heart failure, left ventricular systolic dysfunction, and QRS prolongation. However, the impact of iron deficiency on CRT response remains largely unclear. The purpose of the study was to assess the effect of functional and absolute iron deficiency on reverse cardiac remodelling, clinical response, and outcome after CRT implantation. Methods and results The relation of iron deficiency and cardiac resynchronization therapy response (RIDE‐CRT) study is a prospective observational study. We enrolled 77 consecutive CRT recipients (mean age 71.3 ± 10.2 years) with short‐term follow‐up of 3.3 ± 1.9 months and long‐term follow‐up of 13.0 ± 3.2 months. Primary endpoints were reverse cardiac remodelling on echocardiography and clinical CRT response, assessed by change in New York Heart Association classification. Echocardiographic CRT response was defined as relative improvement of left ventricular ejection fraction ≥ 20% or left ventricular global longitudinal strain ≥ 20%. Secondary endpoints were hospitalization for heart failure and all‐cause mortality (mean follow‐up of 29.0 ± 8.4 months). At multivariate analysis, iron deficiency was identified as independent predictor of echocardiographic (hazard ratio 4.97; 95% confidence interval 1.15–21.51; P = 0.03) and clinical non‐response to CRT (hazard ratio 4.79; 95% confidence interval 1.30–17.72, P = 0.02). We found a significant linear‐by‐linear association between CRT response and type of iron deficiency (P = 0.004 for left ventricular ejection fraction improvement, P = 0.02 for left ventricular global longitudinal strain improvement, and P = 0.003 for New York Heart Association response). Iron deficiency was also significantly associated with an increase in all‐cause mortality (P = 0.045) but not with heart failure hospitalization. Conclusions Iron deficiency is a negative predictor of effective CRT therapy as assessed by reverse cardiac remodelling and clinical response. Assessment of iron substitution might be a relevant treatment target to increase CRT response and outcome in chronic heart failure patients.
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Affiliation(s)
- Philipp Lacour
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Phi Long Dang
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Daniel Armando Morris
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Abdul Shokor Parwani
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Wolfram Doehner
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,BCRT-Center for Regenerative Therapies.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Franziska Schuessler
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Felix Hohendanner
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Frank R Heinzel
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Andrea Stroux
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12203, Germany.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Carsten Tschoepe
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Wilhelm Haverkamp
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Leif-Hendrik Boldt
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Burkert Pieske
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Florian Blaschke
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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3
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Moliner P, Enjuanes C, Tajes M, Cainzos-Achirica M, Lupón J, Garay A, Jimenez-Marrero S, Yun S, Farré N, Cladellas M, Díez C, Gonzalez-Costello J, Comin-Colet J. Association Between Norepinephrine Levels and Abnormal Iron Status in Patients With Chronic Heart Failure: Is Iron Deficiency More Than a Comorbidity? J Am Heart Assoc 2020; 8:e010887. [PMID: 30760082 PMCID: PMC6405646 DOI: 10.1161/jaha.118.010887] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Mechanisms underlying iron homeostasis dysregulation in patients with chronic heart failure remain unsettled. In cardiomyocyte models, norepinephrine may lead to intracellular iron depletion, but the potential association between catecholamines (sympathetic activation markers) and iron metabolism biomarkers in chronic heart failure is unknown. Methods and Results In this cross‐sectional analysis, we studied the association between plasma norepinephrine levels and serum iron status biomarkers indicating iron storage (ferritin), iron transport (transferrin saturation), and iron demand (soluble transferrin receptor) in a prospective cohort of 742 chronic heart failure patients (mean age, 72±11 years; 56% male). Impaired iron status was defined as ferritin <100 μg/L or transferrin saturation <20%. Impaired iron status was observed in 69% of patients. In multivariate models, greater norepinephrine levels were associated with impaired iron transport (transferrin saturation <20%, odds ratio=2.28; 95% CI [1.19–4.35]; P=0.013), but not with impaired iron storage (ferritin <100 μg/L, odds ratio=1.25; 95% CI [0.73–2.16]; P=0.415). Norepinephrine was a significant predictor of increased iron demand (soluble transferrin receptor, standardized β‐coefficient=0.12; P=0.006) and low transferrin saturation (standardized β‐coefficient=−0.12; P=0.003). However, norepinephrine levels were not associated with iron or ferritin levels (P>0.05). Adjusted norepinephrine marginal means were significantly higher in patients with impaired iron status compared with those with normal iron status (528 pg/mL [505–551] versus 482 pg/mL [448–518], respectively; P=0.038). Conclusions In chronic heart failure patients, increased sympathetic activation estimated with norepinephrine levels is associated with impaired iron status and, particularly, dysregulation of biomarkers suggesting impaired iron transport and increased iron demand. Whether the relationship between norepinephrine and iron metabolism is bidirectional and entails causality need to be elucidated in future research.
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Affiliation(s)
- Pedro Moliner
- 1 Heart Failure Unit Department of Cardiology Hospital Universitari Germans Trias i Pujol Badalona Spain.,2 Department of Medicine Universitat Autònoma de Barcelona Spain
| | - Cristina Enjuanes
- 3 Community Heart Failure Program Cardiology Department Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain.,4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain.,5 Heart Diseases Biomedical Research Group Program of Research in Inflammatory and Cardiovascular Disorders Hospital del Mar Biomedical Research Institute (IMIM) Barcelona Spain
| | - Marta Tajes
- 5 Heart Diseases Biomedical Research Group Program of Research in Inflammatory and Cardiovascular Disorders Hospital del Mar Biomedical Research Institute (IMIM) Barcelona Spain
| | - Miguel Cainzos-Achirica
- 3 Community Heart Failure Program Cardiology Department Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain.,4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain.,6 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Department of Cardiology Johns Hopkins Medical Institutions Baltimore MD.,7 School of Medicine and Medical Sciences Universitat Internacional de Catalunya Sant Cugat del Valles Barcelona Spain
| | - Josep Lupón
- 1 Heart Failure Unit Department of Cardiology Hospital Universitari Germans Trias i Pujol Badalona Spain.,2 Department of Medicine Universitat Autònoma de Barcelona Spain
| | - Alberto Garay
- 3 Community Heart Failure Program Cardiology Department Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain.,4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain
| | - Santiago Jimenez-Marrero
- 3 Community Heart Failure Program Cardiology Department Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain.,4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain
| | - Sergi Yun
- 3 Community Heart Failure Program Cardiology Department Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain.,4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain
| | - Núria Farré
- 2 Department of Medicine Universitat Autònoma de Barcelona Spain.,5 Heart Diseases Biomedical Research Group Program of Research in Inflammatory and Cardiovascular Disorders Hospital del Mar Biomedical Research Institute (IMIM) Barcelona Spain.,8 Heart Failure Program Department of Cardiology Hospital del Mar Parc de Salut Mar Barcelona Spain
| | - Mercé Cladellas
- 2 Department of Medicine Universitat Autònoma de Barcelona Spain.,9 Department of Cardiology Hospital del Mar Parc de Salut Mar Barcelona Spain
| | - Carles Díez
- 4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain.,10 Advanced Heart Failure and Heart Transplant Unit Department of Cardiology Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain
| | - Jose Gonzalez-Costello
- 4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain.,10 Advanced Heart Failure and Heart Transplant Unit Department of Cardiology Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain
| | - Josep Comin-Colet
- 3 Community Heart Failure Program Cardiology Department Bellvitge University Hospital Hospitalet de Llobregat Barcelona Spain.,4 Cardiovascular Diseases Research Group Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat Barcelona Spain.,5 Heart Diseases Biomedical Research Group Program of Research in Inflammatory and Cardiovascular Disorders Hospital del Mar Biomedical Research Institute (IMIM) Barcelona Spain.,11 Department of Clinical Sciences School of Medicine Universitat de Barcelona Spain
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5
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Cunha GJL, Rocha BML, Menezes Falcão L. Iron deficiency in chronic and acute heart failure: A contemporary review on intertwined conditions. Eur J Intern Med 2018; 52:1-7. [PMID: 29680173 DOI: 10.1016/j.ejim.2018.04.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/11/2018] [Accepted: 04/12/2018] [Indexed: 12/13/2022]
Abstract
Iron Deficiency (ID) is increasingly recognized as a prevalent comorbid condition in Heart Failure (HF). Despite this, the pathophysiological mechanisms for progressive ID in either chronic or acute HF are still poorly understood. Beyond the traditional factors for iron deficit in the general population, we ought to review the specificities of such paucity in the HF patient, particularly focusing on the interplay between heightened inflammation, overactivity of the sympathetic nervous system and the so-called cardio-renal-anaemia-ID syndrome. Currently, ID constitutes not only an independent prognostic marker but also a novel safe therapeutic target. Particularly, in selected stable HF patients with reduced left ventricular ejection fraction, intravenous (IV) iron improves symptomatic burden and reduces hospitalizations due to worsening HF. On this topic, the main trials of IV iron with either iron sucrose (Toblli et al., FERRIC-HF and IRON-HF) or ferric carboxymaltose (FAIR-HF, CONFIRM-HF and EFFECT-HF) will be summarized and discussed. Finally, we debate the gaps in knowledge of ID in special populations, namely the unreliability of routine plasmatic surrogate markers to assess iron status in acute and advanced HF, the challenging patient with both HF and Chronic Kidney Disease, as well as efficacy and safety concerns in these settings and the potential role of iron correction in cardiac resynchronization therapy candidates.
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Affiliation(s)
| | | | - Luiz Menezes Falcão
- Department of Internal Medicine, Hospital Santa Maria, Lisbon, Portugal; Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
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