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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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3
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Cheema B, Chokshi A, Orimoloye O, Ardehali H. Intravenous Iron Repletion for Patients With Heart Failure and Iron Deficiency: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:2674-2689. [PMID: 38897678 DOI: 10.1016/j.jacc.2024.03.431] [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: 01/23/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 06/21/2024]
Abstract
Iron deficiency and heart failure frequently co-occur, sparking clinical research into the role of iron repletion in this condition over the last 20 years. Although early nonrandomized studies and subsequent moderate-sized randomized controlled trials showed an improvement in symptoms and functional metrics with the use of intravenous iron, 3 recent larger trials powered to detect a difference in hard cardiovascular outcomes failed to meet their primary endpoints. Additionally, there are potential concerns related to side effects from intravenous iron, both in the short and long term. This review discusses the basics of iron biology and regulation, the diagnostic criteria for iron deficiency and the clinical evidence for intravenous iron in heart failure, safety concerns, and alternative therapies. We also make practical suggestions for the management of patients with iron deficiency and heart failure and outline key areas in need of future research.
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Affiliation(s)
- Baljash Cheema
- Bluhm Cardiovascular Institute, Center for Artificial Intelligence, Northwestern Medicine, Chicago, Illinois, USA; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Anuj Chokshi
- McGaw Medical Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Olusola Orimoloye
- McGaw Medical Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hossein Ardehali
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P, Talha KM. Critical re-evaluation of the identification of iron deficiency states and effective iron repletion strategies in patients with chronic heart failure. Eur J Heart Fail 2024; 26:1298-1312. [PMID: 38727791 DOI: 10.1002/ejhf.3237] [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: 12/22/2023] [Revised: 03/17/2024] [Accepted: 03/30/2024] [Indexed: 06/28/2024] Open
Abstract
According to current guidelines, iron deficiency is defined by a serum ferritin level <100 ng/ml or a transferrin saturation (TSAT) <20% if the serum ferritin level is 100-299 μg/L. These criteria were developed to encourage the use of intravenous iron as an adjunct to erythropoiesis-stimulating agents in the treatment of renal anaemia. However, in patients with heart failure, these criteria are not supported by any pathophysiological or clinical evidence that they identify an absolute or functional iron deficiency state. A low baseline TSAT-but not serum ferritin level-appears to be a reliable indicator of the effect of intravenous iron to reduce major heart failure events. In randomized controlled trials, intravenous iron decreased the risk of cardiovascular death or total heart failure hospitalization in patients with a TSAT <20% (risk ratio 0.67 [0.49-0.92]) but not in patients with a TSAT ≥20% (risk ratio 0.99 [0.74-1.30]), with the magnitude of the risk reduction being proportional to the severity of hypoferraemia. Patients who were enrolled in clinical trials solely because they had a serum ferritin level <100 μg/L showed no significant benefit on heart failure outcomes, and it is noteworthy that serum ferritin levels of 20-300 μg/L lie entirely within the range of normal values for healthy adults. Current guidelines reflect the eligibility criteria of clinical trials, which inadvertently adopted unvalidated criteria to define iron deficiency. Reliance on these guidelines would lead to the treatment of many patients who are not iron deficient (serum ferritin level <100 μg/L but normal TSAT) and ignores the possibility of iron deficiency in patients with a low TSAT but with serum ferritin level of >300 μg/L. Importantly, analyses of benefit based on trial eligibility-driven guidelines substantially underestimate the magnitude of heart-failure-event risk reduction with intravenous iron in patients who are truly iron deficient. Based on all available data, we recommend a new mechanism-based and trial-tested approach that reflects the totality of evidence more faithfully than the historical process adopted by clinical investigators and by the guidelines. Until additional evidence is forthcoming, an iron deficiency state in patients with heart failure should be defined by a TSAT <20% (as long as the serum ferritin level is <400 μg/L), and furthermore, the use of a serum ferritin level <100 μg/L alone as a diagnostic criterion should be discarded.
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Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, and Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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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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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P. Identification of three mechanistic pathways for iron-deficient heart failure. Eur Heart J 2024:ehae284. [PMID: 38733250 DOI: 10.1093/eurheartj/ehae284] [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: 11/13/2023] [Revised: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Current understanding of iron-deficient heart failure is based on blood tests that are thought to reflect systemic iron stores, but the available evidence suggests greater complexity. The entry and egress of circulating iron is controlled by erythroblasts, which (in severe iron deficiency) will sacrifice erythropoiesis to supply iron to other organs, e.g. the heart. Marked hypoferraemia (typically with anaemia) can drive the depletion of cardiomyocyte iron, impairing contractile performance and explaining why a transferrin saturation < ≈15%-16% predicts the ability of intravenous iron to reduce the risk of major heart failure events in long-term trials (Type 1 iron-deficient heart failure). However, heart failure may be accompanied by intracellular iron depletion within skeletal muscle and cardiomyocytes, which is disproportionate to the findings of systemic iron biomarkers. Inflammation- and deconditioning-mediated skeletal muscle dysfunction-a primary cause of dyspnoea and exercise intolerance in patients with heart failure-is accompanied by intracellular skeletal myocyte iron depletion, which can be exacerbated by even mild hypoferraemia, explaining why symptoms and functional capacity improve following intravenous iron, regardless of baseline haemoglobin or changes in haemoglobin (Type 2 iron-deficient heart failure). Additionally, patients with advanced heart failure show myocardial iron depletion due to both diminished entry into and enhanced egress of iron from the myocardium; the changes in iron proteins in the cardiomyocytes of these patients are opposite to those expected from systemic iron deficiency. Nevertheless, iron supplementation can prevent ventricular remodelling and cardiomyopathy produced by experimental injury in the absence of systemic iron deficiency (Type 3 iron-deficient heart failure). These observations, taken collectively, support the possibility of three different mechanistic pathways for the development of iron-deficient heart failure: one that is driven through systemic iron depletion and impaired erythropoiesis and two that are characterized by disproportionate depletion of intracellular iron in skeletal and cardiac muscle. These mechanisms are not mutually exclusive, and all pathways may be operative at the same time or may occur sequentially in the same patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, TX 75226, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Awad AK, Abdelgalil MS, Gonnah AR, Mouffokes A, Ahmad U, Awad AK, Elbadawy MA, Roberts DH. Intravenous iron for acute and chronic heart failure with reduced ejection fraction (HFrEF) patients with iron deficiency: An updated systematic review and meta-analysis. Clin Med (Lond) 2024; 24:100211. [PMID: 38643833 PMCID: PMC11092397 DOI: 10.1016/j.clinme.2024.100211] [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: 02/04/2024] [Accepted: 02/23/2024] [Indexed: 04/23/2024]
Abstract
Patients with heart failure (HF) and iron deficiency are at increased risk of adverse clinical outcomes. We searched databases for randomised controlled trials that compared IV iron to placebo, in patients with HF with reduced ejection fraction (HFrEF). A total of 7,813 participants, all having HFrEF with 3,998 receiving IV iron therapy, and 3,815 control recipients were included. There was a significant improvement in Kansas City Cardiomyopathy Questionnaire favouring IV iron with MD 7.39, 95% CI [3.55, 11.22], p = 0.0002. Subgroup analysis, based on acute and chronic HF, has displayed a sustained statistical significance. Additionally, a significant increase in the left ventricular ejection fraction % was observed, with MD 3.76, 95% CI [2.32, 5.21], p < 0.00001. A significant improvement in 6-min walk test was noted, with MD 34.87, 95% CI [20.02, 49.72], p < 0.00001. Furthermore, IV iron showed significant improvement in NYHA class, peak VO2, serum ferritin, and haemoglobin levels. Finally, despite the lack of difference in terms of all-cause hospitalisation and HF-related death, IV iron was associated with a significant reduction in HF-related, any cardiovascular reason hospitalisations, and all-cause death; which supports the need for implementation of IV iron as a standard of care in patients with HF and iron deficiency.
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Affiliation(s)
- Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | | | - Ahmed R Gonnah
- Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Adel Mouffokes
- Faculty of Medicine, University of Oran 1 Ahmed Ben Bella, Oran, Algeria
| | | | - Ayman K Awad
- Faculty of Medicine, El-Galala University, Suez, Egypt
| | | | - David Hesketh Roberts
- Lancashire Cardiac Centre, Blackpool, United Kingdom; University of Liverpool, Liverpool, United Kingdom
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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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Ranucci L, Brischigiaro L, Mazzotta V, Anguissola M, Menicanti L, Bedogni F, Ranucci M. Neurocognitive function in procedures correcting severe aortic valve stenosis: patterns and determinants. Front Cardiovasc Med 2024; 11:1372792. [PMID: 38682100 PMCID: PMC11055462 DOI: 10.3389/fcvm.2024.1372792] [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: 01/18/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Background Neurocognitive changes occurring after a surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) procedure for the correction of severe aortic stenosis (AS) have not been widely addressed and, if addressed, have produced conflicting results. The purpose of this study is to identify the pre-procedural neurocognitive pattern and its determinants in a setting of elderly (>65 years) patients with severe AS undergoing SAVR or TAVI and the changes occurring at a 2-3 month follow-up. Methods This was a prospective cohort study included in the Italian Registry on Outcomes in Aortic Stenosis Treatment in Elderly Patients. Patients were assessed both before and after (2-3 months) the procedure using the Montreal Cognitive Assessment (MoCA) test. Data on periprocedural demographics, clinical factors, and outcome measures were collected. Results Before the procedure, 70% of the patients demonstrated a MoCA score <23 points, which was indicative of cognitive dysfunction. The factors associated with neurocognitive dysfunction were age, functional capacity, chronic heart failure, and hemoglobin levels. After the procedure, there was an overall improvement in the MoCA score of the patients, but 28% of the patients showed a reliable worsening of their condition. The factors associated with MoCA worsening were platelet transfusions and the amount of red blood cell units transfused. Conclusion The correction of severe AS leads to an improvement in neurocognitive function after 2-3 months. This improvement does not differentiate between SAVR and TAVI after matching for pre-procedural factors. The only modifiable factor associated with pre-procedural neurocognitive function is anemia, and anemia correction with red blood cell transfusions is associated with a worsening of neurocognitive function. This leads to the hypothesis that anemia correction before the procedure (with iron and/or erythropoietin) may limit the risk of a post-procedural worsening of neurocognitive function.
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Affiliation(s)
- L. Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - L. Brischigiaro
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - V. Mazzotta
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - M. Anguissola
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - L. Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - F. Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - M. Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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Payán-Pernía S, Pérez-Simón JA, García-Erce JA. Comment on: Intravenous iron for critically ill children. Comparison of three dose regimens. Pediatr Blood Cancer 2024; 71:e30857. [PMID: 38251819 DOI: 10.1002/pbc.30857] [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: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Salvador Payán-Pernía
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS)-CSIC, Universidad de Sevilla, Sevilla, Spain
| | - José Antonio Pérez-Simón
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS)-CSIC, Universidad de Sevilla, Sevilla, Spain
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Mhanna M, Sauer MC, Al-Abdouh A, Jabri A, Beran A, Barbarawi M, Mansour S, Hanna EB. Intravenous iron therapy for patients with iron deficiency and heart failure: a systematic review and meta-analysis of randomized controlled trials. Proc AMIA Symp 2024; 37:466-476. [PMID: 38628339 PMCID: PMC11018061 DOI: 10.1080/08998280.2024.2326387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/19/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Heart failure (HF) presents a significant health challenge, with intravenous (IV) iron therapy considered a potential treatment avenue. Method We assessed IV iron therapy's efficacy in HF patients with concurrent iron deficiency versus standard of care. Primary outcomes included the composite of HF hospitalizations or cardiovascular-related mortality, HF hospitalizations, and all-cause, HF, and cardiovascular mortality rates. Secondary measures encompassed improvements in New York Heart Association functional classification, quality of life, 6-minute walk test, left ventricular ejection fraction, and adverse events. We used a random-effects model to compute relative risk (RR) or mean difference (MD) with 95% confidence intervals (CIs). Results Based on an analysis of 14 randomized controlled trials involving 6614 patients, IV iron therapy significantly reduced composite outcome (RR: 0.84, 95% CI: 0.73, 0.96; P = 0.01) and HF hospitalizations (RR: 0.74, 95% CI: 0.61, 0.89; P = 0.002) compared to standard of care. Mortality rates showed no significant difference. IV iron therapy improved New York Heart Association functional classification, quality of life, and 6-minute walk test, with no major impact on left ventricular ejection fraction. Adverse events remained stable. Conclusions IV iron therapy holds promise for diminishing HF hospitalizations and enhancing quality of life and 6-minute walk test in HF patients. Yet, its effect on all-cause or cardiovascular mortalities appears limited.
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Affiliation(s)
- Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Ahmad Al-Abdouh
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Ahmad Jabri
- Department of Cardiology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH, USA
| | - Azizullah Beran
- Department of Gastroenterology, Indiana University, Indianapolis, IN, USA
| | - Mahmoud Barbarawi
- Department of Cardiology, University of Connecticut, Farmington, CT, USA
| | - Shareef Mansour
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - Elias B. Hanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA, USA
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Luxford JC, Casey CE, Roberts PA, Irving CA. Iron deficiency and anemia in pediatric dilated cardiomyopathy are associated with clinical, biochemical, and hematological markers of severe disease and adverse outcomes. J Heart Lung Transplant 2024; 43:379-386. [PMID: 38012978 DOI: 10.1016/j.healun.2023.11.014] [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: 06/21/2023] [Revised: 10/21/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND There is limited evidence regarding the prevalence and impact of iron deficiency (ID) in children with dilated cardiomyopathy (DCM). METHODS Retrospective single-center review of all children between 2010 and 2020 with a diagnosis of DCM and complete iron studies. ID was defined as ≥2 of ferritin <20 μg/liter, iron <9 μmol/liter, transferrin >3 g/liter, or transferrin saturation (TSat) <15%. Clinical and laboratory indices and freedom from a composite adverse event (CAE) of mechanical circulatory support (MCS), heart transplant, or death were compared between children with and without ID. RESULTS Of 138 patients with DCM, 47 had available iron studies. Twenty-nine (62%) were iron deficient. Children with ID were more likely to be receiving inotropes (17, 59%, p = 0.005) or invasive/noninvasive ventilation (13, 45%, p = 0.016) than those who were iron replete. They had a higher incidence of anemia (22, 76%, p = 0.004) and higher NT-proBNP (1,590 pmol/liter, IQR 456-3,447, p = 0.001). Children with ID had significantly less freedom from the CAE at 1-year (54% ± 10%), 2-years (45 ± 10), and 5-years (37% ± 11%) than those without (p = 0.011). ID and anemia were the only significant predictors of the CAE on univariate Cox regression. CONCLUSIONS ID is highly prevalent in children with DCM. Iron studies are undermeasured in clinical practice, but ID is associated with severe heart failure (HF) and an increased risk of the CAE. The need for iron replacement therapy should be considered in children who present in HF with DCM.
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Affiliation(s)
- Jack C Luxford
- Heart Centre for Children, Children's Hospital at Westmead, Sydney, Australia; Childrens Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia.
| | - Charlene E Casey
- Heart Centre for Children, Children's Hospital at Westmead, Sydney, Australia
| | - Philip A Roberts
- Heart Centre for Children, Children's Hospital at Westmead, Sydney, Australia
| | - Claire A Irving
- Heart Centre for Children, Children's Hospital at Westmead, Sydney, Australia; Childrens Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
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Martens P, Augusto SN, Mullens W, Tang WHW. Meta-Analysis and Metaregression of the Treatment Effect of Intravenous Iron in Iron-Deficient Heart Failure. JACC. HEART FAILURE 2024; 12:525-536. [PMID: 38069996 DOI: 10.1016/j.jchf.2023.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Guidelines recommend that intravenous iron should be considered to improve symptoms of heart failure (HF) and reduce the risk for HF admissions in patients after acute HF. OBJECTIVES This study sought to analyze the effect of intravenous iron on cardiovascular (CV) death and HF admissions in a broad population of HF patients with iron deficiency and the relation with baseline transferrin saturation (TSAT). METHODS A systematic review of all published randomized controlled trials assessing the effect of intravenous iron in patients with iron deficiency and HF between January 1, 2000, and August 26, 2023, was performed. The overall treatment effect was estimated using a fixed effect model for: 1) CV death; 2) CV death and HF admission; 3) first HF admission; and 4) total HF admissions. Metaregression through a mixed effect model was used to explore the impact of baseline TSAT in case of heterogeneity among trial results. RESULTS A total of 14 randomized controlled trials were identified in the systematic review and retained in the meta-analysis. Aggregate-level data were included on 6,624 HF patients, 3,407 of whom were randomized to intravenous iron and 3,217 to placebo. Treatment with intravenous iron resulted in a lower risk for CV death (OR: 0.867 [95% CI: 0.755-0.955]; P = 0.0427), combined CV death and HF admission (OR: 0.838 [95% CI: 0.751-0.936]; P = 0.0015), first HF admission (OR: 0.855 [95% CI: 0.744-0.983]; P = 0.0281), and total HF admissions (rate ratio: 0.739 [95% CI: 0.661-0.827]; P < 0.0001). Significant heterogeneity among trial results was observed for first and total HF admissions. Metaregression suggested that some of the heterogeneity was related to the baseline TSAT of the enrolled population, with trials enrolling patients with lower TSAT exhibiting a large effect size on HF-related events. CONCLUSIONS The totality of data suggests that treatment with intravenous iron reduces both CV death and HF-related events in a broad population with HF. A lower baseline TSAT might be important for the effect on HF-related events.
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Affiliation(s)
- Pieter Martens
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium; Hasselt University, Diepenbeek/Hasselt, Belgium.
| | - Silvio Nunes Augusto
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium; Hasselt University, Diepenbeek/Hasselt, Belgium
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Sephien A, Dayto DC, Reljic T, Prida X, Joly JM, Tavares M, Katz JN, Kumar A. Efficacy of Intravenous Iron in Patients with Heart Failure with Reduced Ejection Fraction and Iron Deficiency: A Systematic Review and Meta-Analysis of Randomized Control Trials. Am J Cardiovasc Drugs 2024; 24:285-302. [PMID: 38519808 DOI: 10.1007/s40256-024-00635-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The European Society of Cardiology (ESC) provided a focused update to the 2021 Guideline for the Management of Heart Failure, now providing a 1A recommendation for intravenous iron in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency (ID). However, the findings from randomized controlled trials (RCT) are mixed. This systematic review of RCTs aims to provide an update and synthesize the evidence addressing the association of intravenous iron with patient-based outcomes in patients with HFrEF and ID. METHODS Any RCT evaluating the effect of intravenous iron in patients with HFrEF and ID was eligible for inclusion. A complete search of the EMBASE and PubMed databases was conducted from inception until 15 September 2023. The primary outcome was the composite of the quality of life (QoL) questionnaires, while the secondary outcomes included first heart failure (HF) hospitalizations and all-cause mortality. Data extraction was performed independently by two reviewers. Data were pooled using a random-effects model. RESULTS Of the 1035 references, 15 RCTs enrolling 6649 patients were included in this study. Intravenous iron was associated with significant improvement in the composite of QoL (standardized mean difference - 1.36, 95% confidence interval [CI] - 2.24 to - 0.48; p = 0.002), a significant reduction in first HF hospitalizations (hazard ratio [HR] 0.73, 95% CI 0.56-0.95; p = 0.02), and with no change in all-cause mortality (HR 0.90, 95% CI 0.79-1.03; p = 0.12). The certainty of the evidence ranged from moderate to very low. CONCLUSION Intravenous iron is possibly associated with improved QoL and reduced HF hospitalizations, without impacting all-cause mortality. These findings not only support the use of intravenous iron in patients with HFrEF but also emphasize the need for well-designed and executed RCTs with granular outcome reporting and powered sufficiently to address the impact of intravenous iron on mortality in patients with HFrEF and ID. REGISTRATION PROSPERO identifier number CRD42023389.
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Affiliation(s)
- Andrew Sephien
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Denisse Camille Dayto
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA
| | - Tea Reljic
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida, Tampa, FL, USA
| | - Joanna M Joly
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew Tavares
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
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15
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Bhatia K, Sabharwal B, Gupta K, Lopez PD, Kaur A, Bhatia HK, Gandhi KD, Niroula S, Correa A, Birati EY, Argulian E, Fox A, Mahmood K. Clinical outcomes of intravenous iron therapy in patients with heart failure and iron deficiency: Meta-analysis and trial sequential analysis of randomized clinical trials. J Cardiol 2024; 83:105-112. [PMID: 37380069 DOI: 10.1016/j.jjcc.2023.06.012] [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: 04/03/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Iron deficiency in patients with heart failure (HF) is underdiagnosed and undertreated. The role of intravenous (IV) iron is well-established to improve quality of life measures. Emerging evidence also supports its role in preventing cardiovascular events in patients with HF. METHODOLOGY We conducted a literature search of multiple electronic databases. Randomized controlled trials that compared IV iron to usual care among patients with HF and reported cardiovascular (CV) outcomes were included. Primary outcome was the composite of first heart failure hospitalization (HFH) or CV death. Secondary outcomes included HFH (first or recurrent), CV death, all-cause mortality, hospitalization for any cause, gastrointestinal (GI) side effects, or any infection. We performed trial sequential and cumulative meta-analyses to evaluate the effect of IV iron on the primary endpoint, and on HFH. RESULTS Nine trials enrolling 3337 patients were included. Adding IV iron to usual care significantly reduced the risk of first HFH or CV death [risk ratio (RR) 0.84; 95 % confidence interval (CI) 0.75-0.93; I2 = 0 %; number needed to treat (NNT) 18], which was primarily driven by a reduction in the risk of HFH of 25 %. IV iron also reduced the risk of the composite of hospitalization for any cause or death (RR 0.92; 95 % CI 0.85-0.99; I2 = 0 %; NNT 19). There was no significant difference in the risk of CV death, all-cause mortality, adverse GI events, or any infection among patients receiving IV iron compared to usual care. The observed benefits of IV iron were directionally consistent across trials and crossed both the statistical and trial sequential boundaries of benefit. CONCLUSION In patients with HF and iron deficiency, the addition of IV iron to usual care reduces the risk of HFH without affecting the risk of CV or all-cause mortality.
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Affiliation(s)
- Kirtipal Bhatia
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Basera Sabharwal
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Kartik Gupta
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Persio D Lopez
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Arpanjeet Kaur
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, NY, USA
| | - Harsimran K Bhatia
- Department of Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | | | - Shailesh Niroula
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Ashish Correa
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine, Poriya Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Tel Aviv, Israel
| | - Edgar Argulian
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Arieh Fox
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiran Mahmood
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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16
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Doumani G, Spanos G, Theofilis P, Vordoni A, Kalaitzidis RG. Cardiorenal syndrome and iron supplementation-more benefits than risks: a narrative review. Int Urol Nephrol 2024; 56:597-606. [PMID: 37606747 DOI: 10.1007/s11255-023-03741-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Intravenous iron administration has emerged as a crucial intervention for managing patients with cardiorenal syndrome (CRS) and iron deficiency, with or without the presence of anemia. Multiple studies have demonstrated the benefits of intravenous iron supplementation in improving anemia, symptoms, and functional capacity in patients with HF and iron deficiency. Furthermore, iron supplementation has been associated with a reduction in hospitalizations for HF exacerbation and the improvement of patients' quality of life and clinical outcomes. In addition to its effects on HF management, emerging evidence suggests a potential positive impact on kidney function in patients with CRS. Studies have shown an increase in estimated glomerular filtration rate and improvements in renal function markers in patients receiving intravenous iron therapy, highlighting the potential of this intervention in patients with CRS. This paper reviews the existing literature on the impact of intravenous iron therapy in these patient populations and explores its effects on various clinical outcomes. Future research endeavors are eagerly awaited to further improve our understanding of its clinical implications and optimize patient outcomes.
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Affiliation(s)
- Georgia Doumani
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece
| | - Georgios Spanos
- Department of Nephrology, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | - Panagiotis Theofilis
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece
| | - Aikaterini Vordoni
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece
| | - Rigas G Kalaitzidis
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece.
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17
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Ponikowski P, Mentz RJ, Hernandez AF, Butler J, Khan MS, van Veldhuisen DJ, Roubert B, Blackman N, Friede T, Jankowska EA, Anker SD. Efficacy of ferric carboxymaltose in heart failure with iron deficiency: an individual patient data meta-analysis. Eur Heart J 2023; 44:5077-5091. [PMID: 37632415 PMCID: PMC10733736 DOI: 10.1093/eurheartj/ehad586] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND AND AIMS Whereas a beneficial effect of intravenous ferric carboxymaltose (FCM) on symptoms and exercise capacity among patients with iron deficiency and heart failure (HF) has been consistently demonstrated, the effects of treatment on clinical events remain the subject of research. This meta-analysis aimed to characterize the effects of FCM therapy on hospitalizations and mortality. METHODS Patient-level data from randomized, placebo-controlled FCM trials including adults with HF and iron deficiency with ≥52 weeks follow-up were analysed. The co-primary efficacy endpoints were (i) composite of total/recurrent cardiovascular hospitalizations and cardiovascular death and (ii) composite of total HF hospitalizations and cardiovascular death, through 52 weeks. Key secondary endpoints included individual composite endpoint components. Event rates were analysed using a negative binomial model. Treatment-emergent adverse events were also examined. RESULTS Three FCM trials with a total of 4501 patients were included. Ferric carboxymaltose was associated with a significantly reduced risk of co-primary endpoint 1 (rate ratio 0.86; 95% confidence interval 0.75-0.98; P = .029; Cochran Q: 0.008), with a trend towards a reduction of co-primary endpoint 2 (rate ratio 0.87; 95% confidence interval 0.75-1.01; P = .076; Cochran Q: 0.024). Treatment effects appeared to result from reduced hospitalization rates, not improved survival. Treatment appeared to have a good safety profile and was well tolerated. CONCLUSIONS In iron-deficient patients with HF with reduced left ventricular ejection fraction, intravenous FCM was associated with significantly reduced risk of hospital admissions for HF and cardiovascular causes, with no apparent effect on mortality.
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Affiliation(s)
- Piotr Ponikowski
- Institute for Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | | | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bernard Roubert
- Research, Development, and Sciences, CSL Vifor, Glattbrugg, Switzerland
| | - Nicole Blackman
- Quantitative Sciences, American Regent, Inc., Shirley, NY, USA
| | - Tim Friede
- Department of Medical Statistics and DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - Ewa A Jankowska
- Institute for Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
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18
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Abu-Own H, Webb I, Okonko DO. Intravenous iron repletion in heart failure: bridging the gap between symptom relief and hard clinical outcomes. Eur Heart J 2023; 44:5092-5094. [PMID: 38124672 DOI: 10.1093/eurheartj/ehad746] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Huda Abu-Own
- School of Cardiovascular & Metabolic Medicine and Science, James Black Centre, King's College London British Heart Foundation Centre of Excellence, 125 Coldharbour Lane, London SE5 9NU, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, UK
| | - Darlington O Okonko
- School of Cardiovascular & Metabolic Medicine and Science, James Black Centre, King's College London British Heart Foundation Centre of Excellence, 125 Coldharbour Lane, London SE5 9NU, UK
- King's College Hospital NHS Foundation Trust, London, UK
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19
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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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20
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Phillips L, Richmond M, Neunert C, Jin Z, Brittenham GM. Iron Deficiency in Chronic Pediatric Heart Failure: Overall Assessment and Outcomes in Dilated Cardiomyopathy. J Pediatr 2023; 263:113721. [PMID: 37673205 DOI: 10.1016/j.jpeds.2023.113721] [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] [Received: 01/20/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To evaluate the frequency of iron status assessment in pediatric heart failure and the prevalence and adverse effects of absolute iron deficiency in dilated cardiomyopathy-induced heart failure. STUDY DESIGN We retrospectively reviewed records of children with chronic heart failure at our center between 2010 and 2020. In children with dilated cardiomyopathy, we analyzed baseline cardiac function, hemoglobin level, and subsequent risk of composite adverse events (CAE), including death, heart transplant, ventricular assist device (VAD) placement, and transplant registry listing. Absolute iron deficiency and iron sufficiency were defined as transferrin saturations <20% and ≥30%, respectively; and indeterminant iron status as 20%-29%. RESULTS Of 799 patients with chronic heart failure, 471 (59%) had no iron-related laboratory measurements. Of 68 children with dilated cardiomyopathy, baseline transferrin saturation, and quantitative left ventricular ejection fraction (LVEF), 33 (49%) and 14 (21%) were iron deficient and sufficient, respectively, and 21 (31%) indeterminant. LVEF was reduced to 23.6 ± 12.1% from 32.9 ± 16.8% in iron deficiency and sufficiency, respectively (P = .04), without a significant difference in hemoglobin. After stratification by New York Heart Association classification, in advanced class IV, hemoglobin was reduced to 10.9 ± 1.3 g/dL vs 12.7 ± 2.0 g/dL in iron deficiency and sufficiency, respectively (P = .01), without a significant difference in LVEF. CONCLUSIONS In this single-center study, iron deficiency was not monitored in most children with chronic heart failure. In pediatric dilated cardiomyopathy-induced heart failure, absolute iron deficiency was prevalent and associated with clinically consequential and possibly correctable decreases in cardiac function and hemoglobin concentration.
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Affiliation(s)
- Lia Phillips
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY.
| | - Marc Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Cindy Neunert
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Gary M Brittenham
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
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21
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Techasatian W, Nishimura Y, Tanariyakul M, Morihara C, Arayangkool C, Settle A, Aiumtrakul N, Kewcharoen J. Intravenous Iron for Heart Failure: Updated Systematic Review and Meta-Analysis. Angiology 2023:33197231213181. [PMID: 37916421 DOI: 10.1177/00033197231213181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
While the administration of intravenous (IV) iron to those with heart failure has been implicated to be associated with a possible reduction in hospitalizations and improvement in symptoms, a recent large multicenter trial only showed modest benefits in reducing hospitalization, necessitating the updated systematic review. We conducted a systematic review and meta-analysis, searching the MEDLINE and EMBASE database until January 9, 2023. Outcomes included total heart failure hospitalizations, first heart failure hospitalization, six-minute walk test (6MWT) distance, and incidence of infection. There were 13 studies with 3410 participants (1,790 with IV iron). Pooled analysis that reported the incidence of cardiovascular death showed that patients with IV iron did not have significantly lower odds of cardiovascular death or first heart failure hospitalization. In contrast, those who received IV iron had significantly lower total heart failure hospitalization (pooled odds ratio (OR) 0.63, 95% confidence interval (CI) 0.44-0.90, I2 59.0%, P = .017) and a composite of cardiovascular death and first heart failure hospitalization (pooled OR 0.55, 95% CI 0.47-0.64, I2 0%, P = .656). While the efficacy is modest, IV iron therapy could be associated with reduced hospitalization for heart failure without significant adverse events.
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Affiliation(s)
- Witina Techasatian
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Manasawee Tanariyakul
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Clarke Morihara
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Chinnawat Arayangkool
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Alexander Settle
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Noppawit Aiumtrakul
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
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22
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Biegus J, Ponikowski P. Striving for the 'perfect' definition of iron deficiency in heart failure. Eur J Heart Fail 2023; 25:2075-2077. [PMID: 37792720 DOI: 10.1002/ejhf.3051] [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: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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23
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Jankowska EA, Ponikowski P. Iron Deficiency in Heart Failure: A Korea-Oriented Review. INTERNATIONAL JOURNAL OF HEART FAILURE 2023; 5:173-183. [PMID: 37937204 PMCID: PMC10625879 DOI: 10.36628/ijhf.2023.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 11/09/2023]
Abstract
Iron deficiency (ID) occurs at high frequency across the spectrum of heart failure (HF), with HF severity and race being potentially important predictors for its development. ID, irrespective of anaemia status, leads to poor outcomes in patients with HF, including exacerbated reduction in exercise capacity, poor quality of life (QoL) and increased risk of HF hospitalisation. As ID has a large public health and economic burden in Asia, and patients hospitalised with acute HF in the Asia Pacific vs. other regions commonly present with more severe clinical symptoms, there is a clear need to identify and treat ID promptly in Asian patients with HF. The biomarkers serum ferritin and transferrin saturation are used for ID diagnosis, and periodic screening is recommended in all patients with HF. The intravenous iron treatments, ferric carboxymaltose (FCM) and ferric derisomaltose, have demonstrated efficacy and tolerability in patients with acute or chronic HF and ID, with FCM shown to be cost-effective (and in some cases cost-saving). Meta-analyses support the likely benefits of intravenous FCM for improving QoL and reducing HF hospitalisation, without reducing mortality risk in patients with HF and ID. Accordingly, European Society of Cardiology guidelines recommend considering intravenous FCM for patients with symptomatic HF with left ventricular ejection fraction ≤50% who were recently hospitalised for HF and have ID. Although analyses of Asian patients with HF and ID are limited, the effects of intravenous iron would be expected to be similar to that in White populations; further clarifying studies may be of interest.
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Affiliation(s)
- Ewa A. Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, 10 University Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, 10 University Hospital, Wroclaw, Poland
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24
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Gosavi R, Jadhav NB, Nashte A. Intravenous Iron Technique Evaluation in Chronic Heart Failure With Iron Deficiency Anemia. Cureus 2023; 15:e47778. [PMID: 38022240 PMCID: PMC10676512 DOI: 10.7759/cureus.47778] [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: 08/24/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE This study aimed to investigate and assess whether IV iron improves symptoms of chronic heart failure (CHF) in patients with iron deficiency anemia (IDA). METHOD A total of 66 subjects with heart failure (HF) seeking therapy in the Department of Medicine's Inpatient Department (IPD) and Outpatient Department (OPD) were included. The data were collected during an outpatient or inpatient visit, documented in a predesigned and pretested proforma and then evaluated. All subjects received history-taking, examinations and regular laboratory tests after being informed and signing an agreement. On admission, the following data was collected: name, age, gender and comorbidities. The examination of subjects included a general examination and a systematic examination. Hematological parameters including hemoglobin (Haemometer, Top Tech Bio Medicals Mumbai), serum iron (Roche Cobas c501, USA), total iron binding capacity (TIBC, Beckman Coulter AU480, India), transferrin saturation percentage (TSAT% = (serum iron/TIBC) × 100), left ventricular ejection fraction (LVEF, 2D echocardiography, Nivan Healthcare Solutions, India) and ferritin (Abbott Architect Ferritin Assay, Delhi) are also important. Other blood tests like liver and renal function tests include an electrocardiogram (12-lead ECG) and two-dimensional echocardiography on admission and follow-up. RESULTS In our study, 66 patients in total received IV iron as a treatment option to improve the symptoms of CHF with IDA; the New York Heart Association (NYHA) classification showed significant improvement (p-value <0.001). Before the intervention, 57.58% of patients had NYHA class II and 42.4% of patients had NYHA class III. After treatment, 33.33% of patients showed NYHA class II and 19.70% of patients showed NYHA class III. After iron therapy treatment, out of 29 cases of NYHA class III, nine (31.03%) cases converted to NYHA class I, seven (24.14%) cases converted to NYHA class II, and 13 (44.83%) cases belonged to the same NYHA class. Out of 37 cases of NYHA class II, 22 (59.45%) cases converted to NYHA class I, and 15 (40.54%) cases belong to the same NYHA class. CONCLUSION Thus, we come to the conclusion that the NYHA classification has exhibited notable enhancement subsequent to the administration of parenteral iron therapy. Sufficient evidence exists to substantiate the advantageous effects of intravenous iron therapy in the treatment of iron deficiency anemia. The administration of iron therapy has been observed to yield favorable outcomes in the mitigation of symptoms among individuals afflicted with cardiac insufficiency.
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Affiliation(s)
- Rohit Gosavi
- Department of Medicine, Krishna Vishwa Vidyapeeth, Karad, IND
| | - Nitin B Jadhav
- Department of Medicine, Krishna Vishwa Vidyapeeth, Karad, IND
| | - Abhijeet Nashte
- Department of Medicine, Krishna Vishwa Vidyapeeth, Karad, IND
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Kido K, Fang W, Broscious R, Colvin BM, Kamal KM, Bianco C, Caccamo M, Felpel K, Sokos G. Evaluation of a pharmacist-provider collaborative clinic for treatment of iron deficiency in patients with heart failure. Am J Health Syst Pharm 2023; 80:1326-1335. [PMID: 37368751 PMCID: PMC10516710 DOI: 10.1093/ajhp/zxad149] [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: 06/25/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE Intravenous iron therapy is recommended to improve symptoms and exercise tolerance in patients with heart failure (HF) with -reduced ejection fraction and iron deficiency (ID), but there are limited published data on the implementation of intravenous iron therapy in practice. A pharmacist-provider collaborative ID treatment clinic was established within an advanced HF and pulmonary hypertension service to optimize IV iron therapy. The objective was to evaluate the clinical impacts of the pharmacist-provider collaborative ID treatment clinic. METHODS A retrospective cohort study was performed to compare clinical outcomes among patients of the collaborative ID treatment clinic (the postimplementation group) and a cohort of patients who received usual care (the preimplementation group). The study included patients 18 years of age or older with diagnosed HF or pulmonary hypertension who met prespecified criteria for ID. The primary outcome was adherence to institutional intravenous iron therapy guidance. A key secondary outcome was ID treatment goal achievement. RESULTS A total of 42 patients in the preimplementation group and 81 in the postimplementation group were included in the study. The rate of adherence to the institutional guidance was significantly improved in the postimplementation group (93%) compared to the preimplementation group (40%). There was no significant difference in the ID therapeutic target achievement rate between the pre- and postimplementation groups (38% vs 48%). CONCLUSION Implementing a pharmacist-provider collaborative ID treatment clinic significantly increased the number of patients who adhered to intravenous iron therapy guidance compared to usual care.
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Affiliation(s)
- Kazuhiko Kido
- West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Wei Fang
- West Virginia Center for Translational Science Institute, Morgantown, WV, USA
| | - Rachael Broscious
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - Bailey M Colvin
- Department of Pharmacy, West Virginia University Medicine, Morgantown, WV, USA
| | - Khalid M Kamal
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Christopher Bianco
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
| | - Marco Caccamo
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
| | - Kevin Felpel
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
| | - George Sokos
- Department of Medicine, West Virginia University Medicine, Morgantown, WV, USA
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Hamza M, Sattar Y, Manasrah N, Patel NN, Rashdi A, Khanal R, Naveed H, Zafar M, Khan AM, Alharbi A, Aamir M, Gonuguntla K, Raina S, Balla S. Meta-Analysis of Efficacy and Safety of Intravenous Iron in Patients With Iron Deficiency and Heart Failure With Reduced Ejection Fraction. Am J Cardiol 2023; 202:119-130. [PMID: 37429060 DOI: 10.1016/j.amjcard.2023.06.066] [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] [Received: 03/12/2023] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
Iron deficiency is an independent risk factor for heart failure (HF) exacerbation. We aim to study the safety and efficacy of intravenous (IV) iron therapy in patients with HF with reduced ejection fraction (HFrEF). A literature search was conducted on MEDLINE (Embase and PubMed) using a systematic search strategy by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) until October 2022. CRAN-R software (The R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias and Newcastle-Ottawa Scale. We included 12 studies with a total of 4,376 patients (IV iron n = 1,985 [45.3%]; standard of care [SOC] n = 2,391 [54.6%]). The mean age was 70.37 ± 8.14 years and 71.75 ± 7.01 years in the IV iron and SOC groups, respectively. There was no significant difference in all-cause mortality and cardiovascular mortality (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74 to 1.04, p <0.15). However, HF readmissions were significantly lower in the IV iron group (RR 0.73, 95% CI 0.56 to 0.96, p = 0.026). Non-HF cardiac readmissions were not significantly different between the IV iron and SOC groups (RR 0.92, 95% CI 0.82 to 1.02, p = 0.12). In terms of safety, there was a similar rate of infection-related adverse events in both arms (RR 0.86, 95% CI 0.74 to 1, p = 0.05). IV iron therapy in patients with HFrEF is safe and shows a significant reduction in HF hospitalizations compared with SOC. There was no difference in the rate of infection-related adverse events. The changing landscape of HFrEF pharmacotherapy in the last decade may warrant a re-demonstration of the benefit of IV iron with current SOC. The cost-effectiveness of IV iron use also needs further study.
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Affiliation(s)
- Mohammad Hamza
- Department of Internal Medicine, Albany Medical Center, Albany, New York
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Nouraldeen Manasrah
- Department of Internal Medicine, Detroit Medical Center, Sinai Grace Hospital, Wayne State University, Detroit, Michigan
| | - Neel Navinkumar Patel
- Neel Navinkumar Patel Department of Internal Medicine, New York Medical College/Landmark Medical Center, Woonsocket, Rhode Island
| | - Amna Rashdi
- Department of Cardiology, Windsor Heart Institute, Windsor, Ontario, Canada
| | - Resha Khanal
- Department of Internal Medicine, Promedica Physician Group, Toledo, Ohio
| | - Hamza Naveed
- Department of Internal Medicine HCA Houston Healthcare/ University of Houston, Kingwood Medical Center, Houston, Texas
| | - Maha Zafar
- Department of Internal Medicine, Arkansas College of Osteopathic Medicine Mercy Program, Mercy Hospital Fort Smith, Arkansas
| | - Ahsan Mahmood Khan
- Department of Internal Medicine, Pakistan Ordnance Factories Hospital, Wah Cantonment, Pakistan
| | - Anas Alharbi
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Muhammad Aamir
- Department of Cardiology, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Karthik Gonuguntla
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Sameer Raina
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Sudarshan Balla
- Department of Cardiology, West Virginia University, Morgantown, West Virginia.
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Kotak K, Aggarwal K, Garg S, Gupta V, Anamika F, Jain R. Understanding the Interplay between Iron Deficiency and Congestive Heart Failure: A comprehensive review. Cardiol Rev 2023:00045415-990000000-00147. [PMID: 37643208 DOI: 10.1097/crd.0000000000000603] [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] [Indexed: 08/31/2023]
Abstract
Iron is an essential micronutrient for abounding physiological processes in the body, and its deficiency can be caused by various factors, such as low iron intake due to economic difficulties or loss of appetite, decreased iron absorption due to gastrointestinal issues, or increased iron loss due to hemorrhages or proteinuria. Iron deficiency is a prevalent issue among heart failure (HF) patients and is a significant contributor to anemia, affecting 30-50% of patients regardless of their gender, ethnicity, or left ventricular ejection fraction. Individuals with HF have high levels of pro-inflammatory cytokines, which can inhibit erythropoiesis by degrading the membrane iron exporter ferroportin, mediated by an increased release of hepcidin. In addition, elevated sympathetic and renin-angiotensin-aldosterone system activity retains salt and water, resulting in high cardiac output HF in people with normal left ventricular function. This review provides an overview of iron deficiency and HF.
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Affiliation(s)
- Kopal Kotak
- From the Department of Internal Medicine, Pandit Dindayal Upadhyay Medical College, Gujarat, India
| | - Kanishk Aggarwal
- Department of Internal Medicine, Dayanand Medical College and Hospital, Punjab, India
| | - Shreya Garg
- Department of Internal Medicine, Dayanand Medical College and Hospital, Punjab, India
| | - Vasu Gupta
- Department of Internal Medicine, Dayanand Medical College and Hospital, Punjab, India
| | - Fnu Anamika
- Department of Internal Medicine, University College of Medical Sciences, New Delhi, India
| | - Rohit Jain
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, PA
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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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Vinke JSJ, Gorter AR, Eisenga MF, Dam WA, van der Meer P, van den Born J, Bakker SJ, Hoes MF, de Borst MH. Iron deficiency is related to lower muscle mass in community-dwelling individuals and impairs myoblast proliferation. J Cachexia Sarcopenia Muscle 2023; 14:1865-1879. [PMID: 37386912 PMCID: PMC10401536 DOI: 10.1002/jcsm.13277] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Loss of muscle mass is linked with impaired quality of life and an increased risk of morbidity and premature mortality. Iron is essential for cellular processes such as energy metabolism, nucleotide synthesis and numerous enzymatic reactions. As the effects of iron deficiency (ID) on muscle mass and function are largely unknown, we aimed to assess the relation between ID and muscle mass in a large population-based cohort, and subsequently studied effects of ID on cultured skeletal myoblasts and differentiated myocytes. METHODS In a population-based cohort of 8592 adults, iron status was assessed by plasma ferritin and transferrin saturation, and muscle mass was estimated using 24-h urinary creatinine excretion rate (CER). The relationships of ferritin and transferrin saturation with CER were assessed by multivariable logistic regression. Furthermore, mouse C2C12 skeletal myoblasts and differentiated myocytes were subjected to deferoxamine with or without ferric citrate. Myoblast proliferation was measured with a colorimetric 5-bromo-2'-deoxy-uridine ELISA assay. Myocyte differentiation was assessed using Myh7-stainings. Myocyte energy metabolism, oxygen consumption rate and extracellular acidification rate were assessed using Seahorse mitochondrial flux analysis, and apoptosis rate with fluorescence-activated cell sorting. RNA sequencing (RNAseq) was used to identify ID-related gene and pathway enrichment in myoblasts and myocytes. RESULTS Participants in the lowest age- and sex-specific quintile of plasma ferritin (OR vs middle quintile 1.62, 95% CI 1.25-2.10, P < 0.001) or transferrin saturation (OR 1.34, 95% CI 1.03-1.75, P = 0.03) had a significantly higher risk of being in the lowest age- and sex-specific quintile of CER, independent of body mass index, estimated GFR, haemoglobin, hs-CRP, urinary urea excretion, alcohol consumption and smoking status. In C2C12 myoblasts, deferoxamine-induced ID reduced myoblast proliferation rate (P-trend <0.001) but did not affect differentiation. In myocytes, deferoxamine reduced myoglobin protein expression (-52%, P < 0.001) and tended to reduce mitochondrial oxygen consumption capacity (-28%, P = 0.10). Deferoxamine induced gene expression of cellular atrophy markers Trim63 (+20%, P = 0.002) and Fbxo32 (+27%, P = 0.048), which was reversed by ferric citrate (-31%, P = 0.04 and -26%, P = 0.004, respectively). RNAseq indicated that both in myoblasts and myocytes, ID predominantly affected genes involved in glycolytic energy metabolism, cell cycle regulation and apoptosis; co-treatment with ferric citrate reversed these effects. CONCLUSIONS In population-dwelling individuals, ID is related to lower muscle mass, independent of haemoglobin levels and potential confounders. ID impaired myoblast proliferation and aerobic glycolytic capacity, and induced markers of myocyte atrophy and apoptosis. These findings suggest that ID contributes to loss of muscle mass.
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Affiliation(s)
- Joanna Sophia J. Vinke
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Alan R. Gorter
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Michele F. Eisenga
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Wendy A. Dam
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Peter van der Meer
- Department of CardiologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Jacob van den Born
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Stephan J.L. Bakker
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Martijn F. Hoes
- Department of Clinical GeneticsMaastricht University Medical Center+MaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastrichtThe Netherlands
| | - Martin H. de Borst
- Departments of NephrologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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Greenwood SA, Oliveira BA, Asgari E, Ayis S, Baker LA, Beckley-Hoelscher N, Goubar A, Banerjee D, Bhandari S, Chilcot J, Burton JO, Kalra PA, Lightfoot CJ, Macdougall IC, McCafferty K, Mercer TH, Okonko DO, Reid C, Reid F, Smith AC, Swift PA, Mangelis A, Watson E, Wheeler DC, Wilkinson TJ, Bramham K. A Randomized Trial of Intravenous Iron Supplementation and Exercise on Exercise Capacity in Iron-Deficient Nonanemic Patients With CKD. Kidney Int Rep 2023; 8:1496-1505. [PMID: 37547514 PMCID: PMC10403653 DOI: 10.1016/j.ekir.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/11/2023] [Accepted: 05/01/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Patients with chronic kidney disease (CKD) are often iron deficient, even when not anemic. This trial evaluated whether iron supplementation enhances exercise capacity of nonanemic patients with CKD who have iron-deficiency. Methods Prospective, multicenter double-blind randomized controlled trial of nondialysis patients with CKD and iron-deficiency but without anemia (Hemoglobin [Hb] >110 g/l). Patients were assigned 1:1 to intravenous (IV) iron therapy, or placebo. An 8-week exercise program commenced at week 4. The primary outcome was the mean between-group difference in 6-minute walk test (6MWT) at 4 weeks. Secondary outcomes included 6MWT at 12 weeks, transferrin saturation (TSAT), serum ferritin (SF), Hb, renal function, muscle strength, functional capacity, quality of life, and adverse events at baseline, 4 weeks, and at 12 weeks. Mean between-group differences were analyzed using analysis of covariance models. Results Among 75 randomized patients, mean (SD) age for iron therapy (n = 37) versus placebo (n = 38) was 54 (16) versus 61 (12) years; estimated glomerular filtration rate (eGFR) (34 [12] vs. 35 [11] ml/min per 1.73 m2], TSAT (23 [12] vs. 21 [6])%; SF (57 [64] vs. 62 [33]) μg/l; Hb (122.4 [9.2] vs. 127 [13.2] g/l); 6MWT (384 [95] vs. 469 [142] meters) at baseline, respectively. No significant mean between-group difference was observed in 6MWT distance at 4 weeks. There were significant increases in SF and TSAT at 4 and 12 weeks (P < 0.02), and Hb at 12 weeks (P = 0.009). There were no between-group differences in other secondary outcomes and no adverse events attributable to iron therapy. Conclusion This trial did not demonstrate beneficial effects of IV iron therapy on exercise capacity at 4 weeks. A larger study is needed to confirm if IV iron is beneficial in nondialysis patients with CKD who are iron-deficient.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Philip A. Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Courtney J. Lightfoot
- University of Leicester, Leicester, UK
- National Institute of Health Research Leicester Biomedical Research Center, Leicester, UK
| | - Iain C. Macdougall
- King’s College Hospital NHS Trust, London, UK
- King’s College London, London, UK
| | | | | | | | - Chante Reid
- King’s College Hospital NHS Trust, London, UK
| | | | - Alice C. Smith
- University of Leicester, Leicester, UK
- National Institute of Health Research Leicester Biomedical Research Center, Leicester, UK
| | | | | | | | | | - Thomas J. Wilkinson
- University of Leicester, Leicester, UK
- National Institute of Health Research, Applied Research Collaboration East Midlands, Leicester, UK
| | - Kate Bramham
- King’s College Hospital NHS Trust, London, UK
- King’s College London, London, UK
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Tkaczyszyn M, Fudim M, Ponikowski P, Biegus J. Pathophysiology and Treatment Opportunities of Iron Deficiency in Heart Failure: Is There a Need for Further Trials? Curr Heart Fail Rep 2023; 20:300-307. [PMID: 37428429 PMCID: PMC10421819 DOI: 10.1007/s11897-023-00611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE OF REVIEW Iron deficiency (ID) complicates heart failure (HF) at different stages of the natural history of the disease; however, this frequent comorbidity is still not comprehensively understood and investigated in terms of pathophysiology. Intravenous iron therapy with ferric carboxymaltose (FCM) should be considered to improve the quality of life, exercise capacity, and symptoms in stable HF with ID, as well as to reduce HF hospitalizations in iron-deficient patients stabilized after an episode of acute HF. The therapy with intravenous iron, however, continues to generate important clinical questions for cardiologists. RECENT FINDINGS In the current paper, we discuss the class effect concept for intravenous iron formulations beyond FCM, based on the experiences of nephrologists who administer different intravenous iron formulations in advanced chronic kidney disease complicated with ID and anemia. Furthermore, we discuss the neutral effects of oral iron therapy in patients with HF, because there are still some reasons to further explore this route of supplementation. The different definitions of ID applied in HF studies and new doubts regarding possible interactions of intravenous iron with sodium-glucose co-transporter type 2 inhibitors are also emphasized. The experiences of other medical specializations may provide new information on how to optimally replenish iron in patients with HF and ID.
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Affiliation(s)
- Michał Tkaczyszyn
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland.
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland.
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Lang Y, Xu S, Zhang C. Hydrothermal Synthesis of Molybdenum Disulfide Quantum Dots for Highly Sensitive Detection of Iron Ions in Protein Succinate Oral Solution. MICROMACHINES 2023; 14:1368. [PMID: 37512679 PMCID: PMC10385574 DOI: 10.3390/mi14071368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/14/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023]
Abstract
In this paper, a molybdenum disulfide fluorescent probe with an Fe3+ fluorescent system was first synthesized by the hydrothermal method for the detection of iron ion concentration in oral solution of protein succinate. It was characterized by infrared, fluorescence, X-ray photoelectron spectroscopy, scanning electron microscopy, and transmission electron microscopy. The probes were found to have good stability, photobleaching, and storage stability. The effects of dilution, pH, reaction time, and iron ion concentration on the fluorescent system were also investigated. The relative fluorescence intensity [(I0 - I)/I0] showed a good linear relationship with the iron ion concentration in the range of 0-50 μM, with the linear equation [(I0 - I)/I0] = 0.0148[Fe3+] + 0.0833 (r2 = 0.9943, n = 11) and the detection limit of 2.43 μM. The reaction mechanism was also explored, as well as its ion selectivity, reversibility, accuracy, precision, and concentration of Fe ions in the actual sample. It was found that the probe can selectively detect Fe ions with a certain degree of reversibility, accuracy, precision, and ideal recovery, and it can be used for the determination of Fe3+ in proteosuccinic acid oral solution.
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Affiliation(s)
- Yan Lang
- Department of Rehabilitation Therapy, Wuyi University, Nanping 354301, China
| | - Shuru Xu
- Department of Medical Technology, Zhangzhou Health Vocational College/Collaborative Innovation Center for Translation Medical Testing and Application Technology, Zhangzhou 363000, China
| | - Chunbin Zhang
- Department of Medical Technology, Zhangzhou Health Vocational College/Collaborative Innovation Center for Translation Medical Testing and Application Technology, Zhangzhou 363000, China
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33
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Plumb JOM, Otto JM, Kumar SB, Bali S, Wakatsuki M, Schmidt WFJ, Montgomery HE, Grocott MPW, Levett DZ. Cardiopulmonary exercise testing before and after intravenous iron in preoperative patients: a prospective clinical study. Perioper Med (Lond) 2023; 12:31. [PMID: 37400931 DOI: 10.1186/s13741-023-00319-x] [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: 05/23/2022] [Accepted: 06/16/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Anemia is associated with impaired physical performance and adverse perioperative outcomes. Iron-deficiency anemia is increasingly treated with intravenous iron before elective surgery. We explored the relationship between exercise capacity, anemia, and total hemoglobin mass (tHb-mass) and the response to intravenous iron in anemic patients prior to surgery. METHODS A prospective clinical study was undertaken in patients having routine cardiopulmonary exercise testing (CPET) with a hemoglobin concentration ([Hb]) < 130 g.l-1 and iron deficiency/depletion. Patients underwent CPET and tHb-mass measurements before and a minimum of 14 days after receiving intravenous (i.v.) Ferric derisomaltose (Monofer®) at the baseline visit. Comparative analysis of hematological and CPET variables was performed pre and post-iron treatment. RESULTS Twenty-six subjects were recruited, of whom 6 withdrew prior to study completion. The remaining 20 (9 [45%] male; mean ± SD age 68 ± 10 years) were assessed 25 ± 7 days between baseline and the final visit. Following i.v. iron, increases were seen in [Hb] (mean ± SD) from 109 ± 14 to 116 ± 12 g l-1 (mean rise 6.4% or 7.3 g l-1, p = < 0.0001, 95% CI 4.5-10.1); tHb-mass from 497 ± 134 to 546 ± 139 g (mean rise 9.3% or 49 g, p = < 0.0001, 95% CI 29.4-69.2). Oxygen consumption at anerobic threshold ([Formula: see text] O2 AT) did not change (9.1 ± 1.7 to 9.8 ± 2.5 ml kg-1 min-1, p = 0.09, 95% CI - 0.13 - 1.3). Peak oxygen consumption ([Formula: see text] O2 peak) increased from 15.2 ± 4.1 to 16 ± 4.4 ml.kg.-1 min-1, p = 0.02, 95% CI 0.2-1.8) and peak work rate increased from 93 [67-112] watts to 96 [68-122] watts (p = 0.02, 95% CI 1.3-10.8). CONCLUSION Preoperative administration of intravenous iron to iron-deficient/deplete anemic patients is associated with increases in [Hb], tHb-mass, peak oxygen consumption, and peak work rate. Further appropriately powered prospective studies are required to ascertain whether improvements in tHb-mass and performance in turn lead to reductions in perioperative morbidity. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT 033 46213.
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Affiliation(s)
- James O M Plumb
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK.
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK.
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK.
| | - James M Otto
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Shriya B Kumar
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Sitara Bali
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Mai Wakatsuki
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
| | - Walter F J Schmidt
- Department of, Sports Medicine/Sports Physiology, University of Bayreuth, Bayreuth, Germany
| | - Hugh E Montgomery
- Centre for Human Health and Performance/Institute of Sport, Exercise and Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Denny Z Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
- Centre for Human Integrative Physiology, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHSFT, Southampton, UK
- Shackleton Department of Anaesthesia, University Hospital Southampton NHSFT, Southampton, UK
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Park SM, Lee SY, Jung MH, Youn JC, Kim D, Cho JY, Cho DH, Hyun J, Cho HJ, Park SM, Choi JO, Chung WJ, Kang SM, Yoo BS. Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure. INTERNATIONAL JOURNAL OF HEART FAILURE 2023; 5:127-145. [PMID: 37554691 PMCID: PMC10406556 DOI: 10.36628/ijhf.2023.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/01/2023] [Accepted: 07/11/2023] [Indexed: 08/10/2023]
Abstract
Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.
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Affiliation(s)
- Sang Min Park
- Division of Cardiology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Soo Youn Lee
- Department of Cardiology, Cardiovascular Center, Incheon Sejong Hospital, Incheon, Korea
| | - Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University Medicine, Seoul, Korea
| | - Junho Hyun
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook-Jin Chung
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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35
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Park SM, Lee SY, Jung MH, Youn JC, Kim D, Cho JY, Cho DH, Hyun J, Cho HJ, Park SM, Choi JO, Chung WJ, Kang SM, Yoo BS. Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure. Korean Circ J 2023; 53:425-451. [PMID: 37525389 PMCID: PMC10406530 DOI: 10.4070/kcj.2023.0114] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/01/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.
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Affiliation(s)
- Sang Min Park
- Division of Cardiology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Soo Youn Lee
- Department of Cardiology, Cardiovascular Center, Incheon Sejong Hospital, Incheon, Korea
| | - Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University Medicine, Seoul, Korea
| | - Junho Hyun
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook-Jin Chung
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
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Beavers CJ, Ambrosy AP, Butler J, Davidson BT, Gale SE, Piña IL, Mastoris I, Reza N, Mentz RJ, Lewis GD. Iron Deficiency in Heart Failure: A Scientific Statement from the Heart Failure Society of America. J Card Fail 2023; 29:1059-1077. [PMID: 37137386 DOI: 10.1016/j.cardfail.2023.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/10/2023] [Accepted: 03/23/2023] [Indexed: 05/05/2023]
Abstract
Iron deficiency is present in approximately 50% of patients with symptomatic heart failure and is independently associated with worse functional capacity, lower quality of, life and increased mortality. The purpose of this document is to summarize current knowledge of how iron deficiency is defined in heart failure and its epidemiology and pathophysiology, as well as pharmacological considerations for repletion strategies. This document also summarizes the rapidly expanding array of clinical trial evidence informing when, how, and in whom to consider iron repletion.
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Affiliation(s)
- Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky.
| | - Andrew P Ambrosy
- Kaiser Permanente Northern California - Division of Research (DOR), Oakland, CA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, Mississippi
| | - Beth T Davidson
- Centennial Heart Cardiovascular Consultants, Nashville, Tennessee
| | - Stormi E Gale
- Novant Health Matthews Medical Center, Matthews, North Carolina
| | - Ileana L Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Nosheen Reza
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina
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37
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Ogugua FM, Aguilar FA, Gamam A, Maqsood MH, Yoo TK, Kasmi F, AlKowatli O, Lo K. Treating Iron Deficiency (ID) Anemia in Heart Failure (HF) Patients with IV Iron: A Meta-Analysis. Cureus 2023; 15:e41895. [PMID: 37581143 PMCID: PMC10423640 DOI: 10.7759/cureus.41895] [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] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Findings on the effects of iron on heart failure (HF) hospitalizations and mortality among patients with iron deficiency (ID) and HF remain conflicting across different studies. We performed a meta-analysis of clinical trials assessing the clinical, hematic and cardiovascular benefits of treating ID in HF patients. We completed a systematic search for studies comparing IV iron to placebo in HF patients with ID. The primary outcomes were rates of HF hospitalization and all-cause mortality. Secondary outcomes included change in hematic values, New York Heart Association (NYHA) class and ejection fraction. We applied a random-effects model with planned sensitivity analyses of studies with skewed effect sizes. Nine studies were included with a total of 2,261 patients. Analysis revealed that treatment of HF patients with IV iron replacement significantly reduced the odds of HF hospitalization (odds ratio (OR): 0.44; 95% confidence interval (CI): 0.24 to 0.78; p=0.005, I2=67%),) but did not significantly impact all-cause mortality compared to placebo (OR: 0.89; 95%, CI: 0.67 to 1.19; p=0.44, I2: 0%). Analysis showed that IV iron treatment group had significantly higher serum ferritin, transferrin saturation and hemoglobin (Hb) levels. They also had lower NYHA class -1.90 (95% CI (-2.91 to -0.89); p<0.001, I2:89%) with higher ejection fraction 0.50 (95% CI (0.09 to 0.90) p=0.016, I2:86%). Treatment with IV iron in HF patients with ID is associated with a significant reduction of HF hospitalization but no effects on all-cause mortality. There were also significant increases in hematic values and ejection fraction with a reduction in NYHA class.
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Affiliation(s)
| | | | | | | | | | - Fedi Kasmi
- Internal Medicine, Sheikh Khalifa Hospital, Ajman, ARE
| | - Oubada AlKowatli
- Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, USA
| | - Kevin Lo
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
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Buliga-Finis ON, Ouatu A, Tanase DM, Gosav EM, Seritean Isac PN, Richter P, Rezus C. Managing Anemia: Point of Convergence for Heart Failure and Chronic Kidney Disease? Life (Basel) 2023; 13:1311. [PMID: 37374094 DOI: 10.3390/life13061311] [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: 04/30/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The pathologic triangle formed by chronic heart failure (HF), chronic kidney disease (CKD), and anemia carries high morbidity and mortality rates and decreases quality of life. Anemia represents a common condition in patients with advanced HF and CKD, with a total prevalence in cardiorenal syndrome (CRS) ranging from 5% to 55%. Searching for a pragmatic approach for these patients with guided and disease-specific recommendations beyond just targeted hemoglobin therapeutic behavior represents the core of research for ongoing clinical trials. It is well known that the prevalence of anemia increases with the advancement of CKD and HF. The physiopathological mechanisms of anemia, such as the reduction of endogenous erythropoietin and the decrease in oxygen transport, are leading to tissue hypoxia, peripheral vasodilation, stimulating neurohormonal activity, and maintenance of the progressive renal and cardiac dysfunction. Given the challenges with the treatment options for patients with cardiorenal anemia syndrome (CRSA), new therapeutic agents such as hypoxia-inducible factor-prolyl hydroxylase domain inhibitors (HIF-PH) or hepcidin antagonists are emerging in the light of recent research. This review summarizes the potential therapeutic tools for anemia therapy in the cardiorenal population.
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Affiliation(s)
- Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Anca Ouatu
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Daniela Maria Tanase
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Evelina Maria Gosav
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Petronela Nicoleta Seritean Isac
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology and Physiotherapy, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Rheumatology Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Internal Medicine Clinic, "Sf. Spiridon" County Clinical Emergency Hospital, 700111 Iasi, Romania
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Amaechi UM, Chukwudum E, Aiwuyo HO, Ilerhunmwuwa N, Osarenkhoe JO, Kweki AG, Onuwaje OE, Obilahi JO, Irabor GI, Attuquayefio S. Clinical and Echocardiographic Correlates of Iron Status in Chronic Heart Failure Patients: A Cross-Sectional Descriptive Study. Cureus 2023; 15:e39998. [PMID: 37415988 PMCID: PMC10321567 DOI: 10.7759/cureus.39998] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Chronic heart failure (HF) is one of the conditions commonly seen in the medical outpatient departments, and iron deficiency (ID) has been reported as the commonest nutritional deficiency in these patients. The presence of ID may interfere with the clinical parameters of chronic HF. The relationship between iron status and chronic HF needs more attention and should be given more consideration in the evaluation of patients with chronic HF. AIM The aim of the study was to determine the relationship, if any, between iron status and clinical/echocardiographic variables in chronic HF. METHODS AND MATERIALS A cross-sectional descriptive study was carried out at the Lagos University Teaching Hospital (LUTH), Nigeria, where 88 patients with chronic HF were recruited to participate in this study. The participants underwent clinical and laboratory assessments. Iron status was assessed with full blood count parameters; serum ferritin and transferrin saturation (Tsat) and its relationship with clinical parameters among these participants were also studied. RESULTS No correlations existed between the duration of chronic HF and iron status when compared using Tsat. However, a significant weak negative correlation was observed between the duration of HF and the serum ferritin levels. The clinical characteristics of the HF participants with and without ID were compared. There was no significant difference in the frequency of prior hospitalization in both groups. However, a higher proportion of participants with severe HF (New York Heart Association (NYHA) classes III/IV) (n = 14; 46.7%) were iron-deficient compared to those with moderate chronic HF (NYHA II) (n = 11; 36.7%). This relationship was statistically significant. Left ventricular ejection fraction (LVEF) was similar in the iron-deficient and iron-replete groups (using serum ferritin or Tsat) both when compared as means and when compared after categorizing LVEF as HF with preserved ejection fraction (HFpEF) vs HF with reduced ejection fraction (HFrEF). There was no statistically significant correlation between the severity of ID and LVEF. Conclusion: A spectrum of clinical changes occurs in patients with chronic HF. ID can make these changes more profound and the condition less amenable to standard HF treatments. These patients may therefore benefit from further evaluation for this nutritional deficiency. Laboratory measurements including Tsat and serum ferritin may help in further assessment of select patients with worse and/or non-responsive clinical parameters.
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Affiliation(s)
| | | | - Henry O Aiwuyo
- Internal Medicine, Brookdale University Hospital and Medical Center, New York, USA
| | | | - John O Osarenkhoe
- Medicine and Surgery, Igbinedion University Teaching Hospital, Benin City, NGA
| | - Anthony G Kweki
- Internal Medicine and Cardiology, Colchester Hospital, East Suffolk and North Essex NHS Foundation Trust, Colchester, GBR
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40
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Hamed M, Elseidy SA, Ahmed A, Thakker R, Mansoor H, Khalili H, Mohsen A, Mamas MA, Banerjee S, Kumbhani DJ, Elgendy IY, Elbadawi A. Intravenous iron therapy among patients with heart failure and iron deficiency: An updated meta-analysis of randomized controlled trials. Heliyon 2023; 9:e17245. [PMID: 37383191 PMCID: PMC10293724 DOI: 10.1016/j.heliyon.2023.e17245] [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: 05/12/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023] Open
Abstract
Background Randomized clinical trials (RCTs) evaluating the role of intravenous (IV) iron administration in patients with heart failure (HF) and iron deficiency (ID) have yielded inconsistent results. Methods Electronic search of MEDLINE, EMBASE and OVID databases was performed until November 2022 for RCTs that evaluated the role of IV iron administration in patients with HF and ID. The main study outcomes were the composite of HF hospitalization or cardiovascular mortality, and individual outcome of HF hospitalization. Summary estimates were evaluated using random effects model. Results The final analysis included 12 RCTs with 3,492 patients (1,831 patients in the IV iron group and 1,661 patients in the control group). The mean follow-up was 8.3 months. IV iron was associated with a lower incidence in the composite of HF hospitalization or cardiovascular mortality (31.9% vs. 45.3%; relative risk [RR] 0.72; 95% confidence interval [CI] 0.59-0.88) and individual outcome of HF hospitalization (28.4% vs. 42.2; RR 0.69; 95% CI 0.57-0.85). There was no significant difference between both groups in cardiovascular mortality (RR 0.88; 95% CI 0.75-1.04) and all-cause mortality (RR 0.95; 95% CI 0.83-1.09). IV iron was associated with lower New York Heart Association class and higher left ventricular ejection fraction (LVEF). Meta-regression analyses showed no effect modification for the main outcomes based on age, hemoglobin level, ferritin level or LVEF. Conclusion Among patients with HF and ID, IV iron administration was associated with reduction in the composite of HF hospitalization or cardiovascular mortality and driven by a reduction in HF hospitalization.
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Affiliation(s)
- Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Sheref A. Elseidy
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Asmaa Ahmed
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Ravi Thakker
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Hend Mansoor
- Department of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Houman Khalili
- Division of Cardiology, Memorial Healthcare System, Hollywood, FL, USA
| | - Amr Mohsen
- Division of Cardiology, Loma Linda University, Loma Linda, CA, USA
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
| | - Subhash Banerjee
- Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Dharam J. Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Islam Y. Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Caminiti G, Sposato B, Volterrani M. The role of iron deficiency in heart failure. Eur Heart J Suppl 2023; 25:C306-C308. [PMID: 37125305 PMCID: PMC10132631 DOI: 10.1093/eurheartjsupp/suad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Iron is an essential micronutrient for several physiological processes in the body beyond erythropoiesis. Iron deficiency (ID) is a common comorbidity observed in about 50% of patients with stable heart failure (HF) irrespective of the left ventricular function. The presence of ID is often as a multi-factorial condition, and it is associated with exercise intolerance, reduced quality of life, increased hospitalization rate, and mortality risk regardless of anaemia. The intravenous administration of iron to correct ID has emerged as a promising treatment in HF with reduced ejection fraction as it has been shown to alleviate symptoms, improve quality of life and exercise capacity, and reduce hospitalizations.
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Affiliation(s)
| | - Barbara Sposato
- Cardio-Pulmonary Department, IRCCS San Raffaele, via della Pisana, 235, 00163 Rome, Italy
| | - Maurizio Volterrani
- Cardio-Pulmonary Department, IRCCS San Raffaele, via della Pisana, 235, 00163 Rome, Italy
- Department of Human Science and Promotion of Quality of Life, San Raffaele Open University, via di Val Cannuta, 247, 00166 Rome, Italy
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Bakogiannis C, Mouselimis D, Tsarouchas A, Papadopoulos CE, Theofillogiannakos EK, Lechat E, Antoniadis AP, Pagourelias ED, Kelemanis I, Tzikas S, Fragakis N, Efthimiadis GK, Karamitsos TD, Doumas M, Vassilikos VP. Iron therapy and severe arrhythmias in HFrEF: rationale, study design, and baseline results of the RESAFE-HF trial. ESC Heart Fail 2023; 10:1184-1192. [PMID: 36647691 PMCID: PMC10053179 DOI: 10.1002/ehf2.14276] [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: 03/25/2022] [Revised: 08/11/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS The Iron Intravenous Therapy in Reducing the burden of Severe Arrhythmias in HFrEF (RESAFE-HF) registry study aims to provide real-word evidence on the impact of intravenous ferric carboxymaltose (FCM) on the arrhythmic burden of patients with heart failure with reduced ejection fraction (HFrEF), iron deficiency (ID), and implanted cardiac implantable electronic devices (CIEDs). METHODS AND RESULTS The RESAFE-HF (NCT04974021) study was designed as a prospective, single-centre, and open-label registry study with baseline, 3, 6, and 12 month visits. Adult patients with HFrEF and CIEDs scheduled to receive IV FCM as treatment for ID as part of clinical practice were eligible to participate. The primary endpoint is the composite iron-related endpoint of haemoglobin ≥ 12 g/dL, ferritin ≥ 50 ng/L, and transferrin saturation > 20%. Secondary endpoints include unplanned HF-related hospitalizations, ventricular tachyarrhythmias detected by CIEDs and Holter monitors, echocardiographic markers, functional status (VO2 max and 6 min walk test), blood biomarkers, and quality of life. In total, 106 patients with a median age of 72 years (14.4) were included. The majority were male (84.9%), whereas 92.5% of patients were categorized to New York Heart Association II/III. Patients' arrhythmic burden prior to FCM administration was significant-19 patients (17.9%) received appropriate CIED therapy for termination of ventricular tachyarrhythmia in the preceding 12 months, and 75.5% of patients have frequent, repetitive multiform premature ventricular contractions. CONCLUSIONS The RESAFE-HF trial is expected to provide evidence on the effect of treating ID with FCM in HFrEF based on real-world data. Special focus will be given on the arrhythmic burden post-FCM administration.
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Affiliation(s)
- Constantinos Bakogiannis
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Dimitrios Mouselimis
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Anastasios Tsarouchas
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Christodoulos E. Papadopoulos
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Efstratios K. Theofillogiannakos
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | | | - Antonios P. Antoniadis
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Efstathios D. Pagourelias
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Ioannis Kelemanis
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Stergios Tzikas
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Nikolaos Fragakis
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Georgios K. Efthimiadis
- First Cardiology Department, School of MedicineAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Theodoros D. Karamitsos
- First Cardiology Department, School of MedicineAHEPA University Hospital, Aristotle University of ThessalonikiThessalonikiGreece
| | - Michael Doumas
- Second Propaedeutics Department of Internal MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
- Georgetown University and VAMC and George Washington UniversityWashingtonDCUSA
| | - Vassilios P. Vassilikos
- Third Cardiology Department, School of MedicineHippokration General Hospital, Aristotle University of ThessalonikiThessalonikiGreece
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43
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Graham FJ, Pellicori P, Kalra PR, Ford I, Bruzzese D, Cleland JG. Intravenous iron in patients with heart failure and iron deficiency: an updated meta-analysis. Eur J Heart Fail 2023; 25:528-537. [PMID: 36823953 PMCID: PMC10946839 DOI: 10.1002/ejhf.2810] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/04/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
AIMS For patients with heart failure (HF) and iron deficiency (ID), randomized trials suggest that intravenous (IV) iron reduces hospitalizations for heart failure (HHF), but uncertainty exists about the effects in subgroups and the impact on mortality. We conducted a meta-analysis of randomized trials investigating the effect of IV iron on clinical outcomes in patients with HF. METHODS AND RESULTS We identified randomized trials published between 1 January 2000 and 5 November 2022 investigating the effect of IV iron versus standard care/placebo in patients with HF and ID in any clinical setting, regardless of HF phenotype. Trials of oral iron or not in English were not included. The main outcomes of interest were a composite of HHF and cardiovascular death (CVD), on HHF alone and on cardiovascular and all-cause mortality. Ten trials were identified with 3373 participants, of whom 1759 were assigned to IV iron. IV iron reduced the composite of recurrent HHF and CVD (rate ratio 0.75, 95% confidence interval [CI] 0.61-0.93; p < 0.01) and first HHF or CVD (odds ratio [OR] 0.72, 95% CI 0.53-0.99; p = 0.04). Effects on cardiovascular (OR 0.86, 95% CI 0.70-1.05; p = 0.14) and all-cause mortality (OR 0.93, 95% CI 0.78-1.12; p = 0.47) were inconclusive. Results were similar in analyses confined to the first year of follow-up, which was less disrupted by the COVID-19 pandemic. Subgroup analyses found little evidence of heterogeneity for the effect on the primary endpoint, although patients with transferrin saturation <20% (OR 0.67, 95% CI 0.49-0.92) may have benefited more than those with values ≥20% (OR 0.99, 95% CI 0.74-1.30) (heterogeneity p = 0.07). CONCLUSION In patients with HF and ID, this meta-analysis suggests that IV iron reduces the risk of HHF but whether this is associated with a reduction in cardiovascular or all-cause mortality remains inconclusive.
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Affiliation(s)
- Fraser J. Graham
- Robertson Centre for BiostatisticsUniversity of GlasgowGlasgowUK
| | | | - Paul R. Kalra
- Department of CardiologyPortsmouth Hospitals University NHS TrustPortsmouthUK
- College of Medical, Veterinary & Life SciencesUniversity of GlasgowGlasgowUK
- Faculty of Science and HealthUniversity of PortsmouthPortsmouthUK
| | - Ian Ford
- Robertson Centre for BiostatisticsUniversity of GlasgowGlasgowUK
| | - Dario Bruzzese
- Department of Public HealthUniversity of Naples Federico IINaplesItaly
| | - John G.F. Cleland
- School of Cardiovascular and Metabolic HealthUniversity of GlasgowGlasgowUK
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44
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Vinke JS, Eisenga MF, Sanders JSF, Berger SP, Spikman JM, Abdulahad WH, Bakker SJ, Gaillard CAJM, van Zuilen AD, van der Meer P, de Borst MH. Effect of Intravenous Ferric Carboxymaltose on Exercise Capacity After Kidney Transplantation (EFFECT-KTx): rationale and study protocol for a double-blind, randomised, placebo-controlled trial. BMJ Open 2023; 13:e065423. [PMID: 36948568 PMCID: PMC10040026 DOI: 10.1136/bmjopen-2022-065423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Iron deficiency (ID) is common and has been associated with an excess mortality risk in kidney transplant recipients (KTRs). In patients with chronic heart failure and ID, intravenous iron improves exercise capacity and quality of life. Whether these beneficial effects also occur in KTRs is unknown. The main objective of this trial is to address whether intravenous iron improves exercise tolerance in iron-deficient KTRs. METHODS AND ANALYSIS The Effect of Ferric Carboxymaltose on Exercise Capacity after Kidney Transplantation study is a multicentre, double-blind, randomised, placebo-controlled clinical trial that will include 158 iron-deficient KTRs. ID is defined as plasma ferritin <100 µg/L or plasma ferritin 100-299 µg/L with transferrin saturation <20%. Patients are randomised to receive 10 mL of ferric carboxymaltose (50 mg Fe3+/mL, intravenously) or placebo (0.9% sodium chloride solution) every 6 weeks, four dosages in total. The primary endpoint is change in exercise capacity, as quantified by the 6 min walk test, between the first study visit and the end of follow-up, 24 weeks later. Secondary endpoints include changes in haemoglobin levels and iron status, quality of life, systolic and diastolic heart function, skeletal muscle strength, bone and mineral parameters, neurocognitive function and safety endpoints. Tertiary (explorative) outcomes are changes in gut microbiota and lymphocyte proliferation and function. ETHICS AND DISSEMINATION The protocol of this study has been approved by the medical ethical committee of the University Medical Centre Groningen (METc 2018/482;) and is being conducted in accordance with the principles of the Declaration of Helsinki, the Standard Protocol Items: Recommendations for Interventional Trials checklist and the Good Clinical Practice guidelines provided by the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use. Study results will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03769441.
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Affiliation(s)
- Joanna Sj Vinke
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Michele F Eisenga
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan P Berger
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jacoba M Spikman
- Department of Neuropsychology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Wayel H Abdulahad
- Department of Immunology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan Jl Bakker
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Carlo A J M Gaillard
- Department of Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin H de Borst
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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Reinhold J, Burra V, Corballis N, Tsampasian V, Matthews G, Papadopoulou C, Vassiliou VS. Effects of Intravenous Iron Replacement Therapy on Cardiovascular Outcomes in Patients with Heart Failure: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:116. [PMID: 36975880 PMCID: PMC10057806 DOI: 10.3390/jcdd10030116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
(1) Background: Iron deficiency (ID) is an important adverse prognostic marker in patients with heart failure (HF); however, it is unclear whether intravenous iron replacement reduces cardiovascular mortality in this patient group. Here, we estimate the effect of intravenous iron replacement therapy on hard clinical outcomes following the publication of IRONMAN, the largest trial in this field. (2) Methods: In this systematic review and meta-analysis, prospectively registered with PROSPERO and reported according to PRISMA guidelines, we searched PubMed and Embase for randomized controlled trials investigating intravenous iron replacement in patients with HF and co-existing ID. The primary outcome was cardiovascular mortality and secondary outcomes were all-cause mortality, hospitalizations for HF and a combination of the primary outcome and hospitalizations for HF. (3) Results: A total of 1671 items were identified and after removal of duplicates we screened titles and abstracts of 1202 records. Some 31 studies were identified for full-text review and 12 studies were included in the final review. The odds ratio (OR) for cardiovascular death using a random effects model was 0.85 (95% CI 0.69 to 1.04) and for all-cause mortality it was 0.83 (95% CI 0.59 to 1.15). There was a significant reduction in hospitalizations for HF (OR 0.49, 95% CI 0.35 to 0.69) and the combination of hospitalizations for HF and cardiovascular death (OR 0.65, 95% CI 0.5 to 0.85). (4) Conclusions: This review supports the use of IV iron replacement reducing hospitalization rates for HF, however more research is required to determine the effect on cardiovascular mortality and to identify the patient population most likely to benefit.
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Affiliation(s)
- Johannes Reinhold
- Norwich Medical School, University of East Anglia (UEA), Norwich Research Park, Norwich NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Vyas Burra
- Medical School, King’s College London, Strand, London WC2R 2LS, UK
| | - Natasha Corballis
- Norwich Medical School, University of East Anglia (UEA), Norwich Research Park, Norwich NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Vasiliki Tsampasian
- Norwich Medical School, University of East Anglia (UEA), Norwich Research Park, Norwich NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Gareth Matthews
- Norwich Medical School, University of East Anglia (UEA), Norwich Research Park, Norwich NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Charikleia Papadopoulou
- Department of Biochemistry, University of Cambridge, 80 Tennis Court Road, Cambridge CB2 1GA, UK
- Royal Papworth Hospital, Papworth Rd, Trumpington, Cambridge CB2 0AY, UK
| | - Vassilios S. Vassiliou
- Norwich Medical School, University of East Anglia (UEA), Norwich Research Park, Norwich NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
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Abstract
The cardiovascular system requires iron to maintain its high energy demands and metabolic activity. Iron plays a critical role in oxygen transport and storage, mitochondrial function, and enzyme activity. However, excess iron is also cardiotoxic due to its ability to catalyze the formation of reactive oxygen species and promote oxidative damage. While mammalian cells have several redundant iron import mechanisms, they are equipped with a single iron-exporting protein, which makes the cardiovascular system particularly sensitive to iron overload. As a result, iron levels are tightly regulated at many levels to maintain homeostasis. Iron dysregulation ranges from iron deficiency to iron overload and is seen in many types of cardiovascular disease, including heart failure, myocardial infarction, anthracycline-induced cardiotoxicity, and Friedreich's ataxia. Recently, the use of intravenous iron therapy has been advocated in patients with heart failure and certain criteria for iron deficiency. Here, we provide an overview of systemic and cellular iron homeostasis in the context of cardiovascular physiology, iron deficiency, and iron overload in cardiovascular disease, current therapeutic strategies, and future perspectives.
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Affiliation(s)
- Konrad Teodor Sawicki
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Adam De Jesus
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
| | - Hossein Ardehali
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL 60611
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
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47
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Salah HM, Savarese G, Rosano GMC, Ambrosy AP, Mentz RJ, Fudim M. Intravenous iron infusion in patients with heart failure: a systematic review and study-level meta-analysis. ESC Heart Fail 2023; 10:1473-1480. [PMID: 36734033 PMCID: PMC10053151 DOI: 10.1002/ehf2.14310] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/04/2023] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
AIMS There is considerable variability in the effect of intravenous iron on hard cardiovascular (CV)-related outcomes in patients with heart failure (HF) in randomized controlled trials (RCTs). We use a meta-analytic approach to analyse data from existing RCTs to derive a more robust estimate of the effect size of intravenous iron infusion on CV-related outcomes in patients with HF. METHOD AND RESULTS PubMed/Medline was searched using the following terms: ('intravenous' and 'iron' and 'heart failure') from inception till 6 November 2022 for RCTs comparing intravenous iron infusion with placebo or standard of care in patients with HF and iron deficiency. Outcomes were the composite of CV mortality and first hospitalization for HF; all-cause mortality; CV mortality; first hospitalization for HF; and total hospitalizations for HF. Random effects risk ratio (RR) with 95% confidence intervals (CIs) were calculated. Ten RCTs with a total of 3438 patients were included. Intravenous iron resulted in a significant reduction in the composite of CV mortality and first hospitalization for HF [RR 0.0.85; 95% CI (0.77, 0.95)], first hospitalization for HF [RR 0.82; 95% CI (0.67, 0.99)], and total hospitalizations for HF [RR 0.74; 95% CI (0.60, 0.91)] but no statistically significant difference in all-cause mortality [RR 0.95; 95% CI. (0.83, 1.09)] or CV mortality [OR 0.89; 95% CI (0.75, 1.05)]. CONCLUSIONS Intravenous iron infusion in patients with HF reduces the composite risk of first hospitalization for HF and CV mortality as well as the risks of first and recurrent hospitalizations for HF, with no effect on all-cause mortality or CV mortality alone.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Choy M, Zhen Z, Dong B, Chen C, Dong Y, Liu C, Liang W, Xue R. Mean corpuscular haemoglobin concentration and outcomes in heart failure with preserved ejection fraction. ESC Heart Fail 2023; 10:1214-1221. [PMID: 36695165 PMCID: PMC10053270 DOI: 10.1002/ehf2.14225] [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: 06/27/2022] [Revised: 10/11/2022] [Accepted: 10/28/2022] [Indexed: 01/26/2023] Open
Abstract
AIMS This study aims to evaluate the prognostic value of mean corpuscular haemoglobin concentration (MCHC) on clinical outcomes in patients with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS We analysed HFpEF participants from the Americas in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial with available baseline data (n = 1747). Patients were grouped into hypochromia or non-hypochromia group according to a MCHC cut-off level of 330 g/L. Cox proportional hazard model was used to explore the prognostic value of hypochromia on the long-term clinical outcomes (the primary endpoint [composite of cardiovascular mortality, HF hospitalization and aborted cardiac arrest], any-cause and HF hospitalization, all-cause and cardiovascular mortality). Patients were further stratified according to baseline estimated glomerular filtration rate (eGFR) to explore the impact of renal dysfunction on the prognostic value of hypochromia. Baseline hypochromia was prevalent (n = 662, 37.9%) and strongly associated with worse clinical outcomes. In patients with worse renal function (eGFR < 60 mL/min per 1.73 m2 ), hypochromia was independently associated with primary endpoint (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.23-1.98; P < 0.001), any-cause hospitalization (HR, 1.43; 95% CI, 1.20-1.71, P < 0.001) and HF hospitalization (HR, 1.40; 95% CI, 1.07-1.84; P = 0.015), whereas no significant association between hypochromia and these outcomes was found in patients with better renal function. CONCLUSIONS Among HFpEF patients, hypochromia (i.e. MCHC ≤ 330 g/L) is independently associated with adverse clinical outcomes, especially when in the presence of co-morbidity renal dysfunction.
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Affiliation(s)
- Manting Choy
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Zhe Zhen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Bin Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Cong Chen
- Division of Cardiology, Department of Medicine, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Weihao Liang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Ruicong Xue
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
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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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50
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Vinke JSJ, Altulea DHA, Eisenga MF, Jagersma RL, Niekolaas TM, van Baarle D, Heiden MVD, Steenhuis M, Rispens T, Abdulahad WH, Sanders JSF, De Borst MH. Ferric carboxymaltose and SARS-CoV-2 vaccination-induced immunogenicity in kidney transplant recipients with iron deficiency: The COVAC-EFFECT randomized controlled trial. Front Immunol 2023; 13:1017178. [PMID: 36618359 PMCID: PMC9822258 DOI: 10.3389/fimmu.2022.1017178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/05/2022] [Indexed: 12/25/2022] Open
Abstract
Background Kidney transplant recipients (KTRs) have an impaired immune response after vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Iron deficiency (ID) may adversely affect immunity and vaccine efficacy. We aimed to investigate whether ferric carboxymaltose (FCM) treatment improves humoral and cellular responses after SARS-CoV-2 vaccination in iron-deficient KTRs. Methods We randomly assigned 48 iron-deficient KTRs to intravenous FCM (1-4 doses of 500mg with six-week intervals) or placebo. Co-primary endpoints were SARS-CoV-2-specific anti-Receptor Binding Domain (RBD) Immunoglobulin G (IgG) titers and T-lymphocyte reactivity against SARS-CoV-2 at four weeks after the second vaccination with mRNA-1273 or mRNA-BNT162b2. Results At four weeks after the second vaccination, patients receiving FCM had higher plasma ferritin and transferrin saturation (P<0.001 vs. placebo) and iron (P=0.02). However, SARS-CoV-2-specific anti-RBD IgG titers (FCM: 66.51 [12.02-517.59] BAU/mL; placebo: 115.97 [68.86-974.67] BAU/mL, P=0.07) and SARS-CoV-2-specific T-lymphocyte activation (FCM: 93.3 [0.85-342.5] IFN-ɣ spots per 106 peripheral blood mononuclear cells (PBMCs), placebo: 138.3 [0.0-391.7] IFN-ɣ spots per 106 PBMCs, P=0.83) were not significantly different among both arms. After the third vaccination, SARS-CoV-2-specific anti-RBD IgG titers remained similar between treatment groups (P=0.99). Conclusions Intravenous iron supplementation efficiently restored iron status but did not improve the humoral or cellular immune response against SARS-CoV-2 after three vaccinations.
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Affiliation(s)
| | - Dania H. A. Altulea
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | - Michele F. Eisenga
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | - Renate L. Jagersma
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | - Tessa M. Niekolaas
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands
| | - Debbie van Baarle
- Department of Immunology, University Medical Center Groningen, Groningen, Netherlands
| | | | - Maurice Steenhuis
- Department of Immunopathology, Sanquin Research, Amsterdam, Netherlands
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research, Amsterdam, Netherlands
| | - Wayel H. Abdulahad
- Department of Immunology, University Medical Center Groningen, Groningen, Netherlands
| | | | - Martin H. De Borst
- Department of Nephrology, University Medical Center Groningen, Groningen, Netherlands,*Correspondence: Martin H. De Borst,
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