Anemia and chronic heart failure implications and treatment options

Effect of anaemia and iron deficiency in heart failure with mildly reduced ejection fraction

OBJECTIVE

The present study aims to clarify the prevalence and prognostic impact of anaemia and iron deficiency in patients with heart failure with mildly reduced ejection fraction (HFmrEF).

BACKGROUND

The prognostic impact of anaemia and iron deficiency in HFmrEF has not yet been clarified.

METHODS

Consecutive patients with HFmrEF were retrospectively included at one institution from 2016 to 2022. Patients with anaemia (i.e. haemoglobin <13 g/dL in males and < 12 g/dL in females) were compared to patients without, respectively patients with or without iron deficiency. The primary endpoint was all-cause mortality at 30 months (median follow-up), secondary endpoints comprised HF-related rehospitalisation.

RESULTS

Two thousand one hundred and fifty four patients with HFmrEF with a median haemoglobin level of 12.2 g/dL were included. Anaemia was present in 52% of patients with HFmrEF and associated with a higher risk of all-cause mortality (44% vs. 18%; HR = 3.021; 95% CI 2.552-3.576; p =.001) and HF-related rehospitalisation (18% vs. 8%; HR = 2.351; 95% CI 1.819-3.040; p =.001) at 30 months, which was confirmed after multivariable adjustment. Although iron status was infrequently assessed in anaemics with HFmrEF (27%), the presence of iron deficiency was associated with higher risk of rehospitalisation for worsening HF (25% vs. 15%; HR = 1.746; 95% CI 1.024-2.976; p =.038), but not all-cause mortality (p =.279) at 30 months.

CONCLUSION

Anaemia and iron deficiency are very common in atleast half of patients with HFmrEF and independently associated with adverse long-term prognosis.

The treatment of chronic anemia in heart failure: a global approach

Chronic anemia is an independent risk factor for mortality in patients with heart failure (HF). Restoring physiological hemoglobin (Hb) levels is essential to increase oxygen transport capacity to tissues and improve cell metabolism as well as physical and cardiac performance. Nutritional deficits and iron deficiency are the major causes of chronic anemia, but other etiologies include chronic kidney disease, inflammatory processes, and unexplained anemia. Hormonal therapy, including erythropoietin (EPO) and anabolic treatment in chronic anemia HF patients, may contribute to improving Hb levels and clinical outcomes. Although preliminary studies showed a beneficial effect of EPO therapy on cardiac efficiency and in HF, more recent studies have not confirmed this positive impact of EPO, alluding to its side effect profile. Physical exercise significantly increases Hb levels and the response of anemia to treatment. In malnourished patients and chronic inflammatory processes, low levels of anabolic hormones, such as testosterone and insulin-like growth factor-1, contribute to the development of chronic anemia. This paper aims to review the effect of nutrition, EPO, anabolic hormones, standard HF treatments, and exercise as regulatory mechanisms of chronic anemia and their cardiovascular consequences in patients with HF.

Impact of Anemia on Mortality and Morbidity in Transthyretin Amyloid Cardiomyopathy

Anemia is prevalent in transthyretin amyloid cardiomyopathy (ATTR-CM), but its prognostic significance remains uncertain because of conflicting data mainly in patients not receiving disease-modifying therapy. Additionally, the effect of anemia on morbidity in this population has not been studied. This retrospective study included 270 patients diagnosed with ATTR-CM, receiving disease-modifying treatment (tafamidis), of which 30% (n = 80) were anemic (defined as a hemoglobin level <13 g/100 ml for males and <12 g/100 ml for females according to the World Health Organization). At baseline, patients with anemia were on average older (mean age 79 vs 77 years), more likely to be female (21% vs 12%), and exhibited higher symptom severity based on the New York Heart Association class (42% in class III vs 27%) compared with those without anemia. Additionally, they had a worse Columbia score (mean score 3 vs 5) and Columbia stage (12% in late-stage vs 7.1%) than those without anemia. Kaplan-Meier analysis indicates that anemia was associated with a higher likelihood of mortality, all-cause, and cardiovascular (CV) hospitalizations (p <0.05). However, in the Cox regression analysis, after adjusting for baseline age, ATTR genotype, and Columbia score, anemia was only associated with a higher risk of all-cause hospitalizations (hazard ratio 1.9 (1.3 to 2.7), p <0.001) and CV-related hospitalizations (hazard ratio 1.9 (1.2 to 2.9), p = 0.006). In conclusion, this study indicates that anemic patients with ATTR-CM have higher risks of CV and all-cause hospitalizations compared with nonanemic ATTR-CM patients. Further research is needed to understand how treating anemia may improve outcomes in this high-risk patient population.

Anemia in Heart Failure: A Perspective from 20-Year Bibliometric Analysis

Background & Objective

Anemia in patients with heart failure (HF) is a growing concern. However, there has no bibliometric analysis in this area up to now. The aim of this study is to explore the status and trends in the field of anemia in HF through the bibliometric analysis, and to provide an outlook on future research.

Methods

We retrieved publications from the Web of Science Core Collection database, and the following data analysis and visualization tools were utilized to perform data processing, statistical computing and graphics generation: VOSviewer (v.1.6.18), CiteSpace (v.6.2 R5), Scimago Graphica (v.1.0.36), Biblimatrix and Microsoft Excel.

Results

We identified a total of 3490 publications from 2004 to 2023. The publications in the field of anemia in HF are growing steadily. The United States, the United Kingdom, and Italy were the leading countries in this area. Stefan D Anker, as the most influential author, held the most total citations and publications. Harvard University was the most productive institution in this area. The European Journal of Heart Failure had published the most papers. Through the analysis of co-citations, 14 major clusters based on cluster labels were identified. Keyword analysis showed that mortality, outcome, prevalence, and risk were the most frequent keywords, and the potential research hotspots in the future will be intravenous iron and iron deficiency.

Conclusion

This study provides a comprehensive analysis of countries, authors, institutions, journals, co-cited references, and keywords in the field of anemia in HF through bibliometric analysis and data visualization. The status, hotspots and future trends in this field offer a reference for in-depth research. Further studies are necessary in the future to broaden the spectrum of research in this field, to evaluate comprehensive approaches to treating anemia in patients with HF, and to find rational targets for the management of anemia.

Association between low selenoprotein P concentrations and anaemia in hospitalized heart failure patients

AIMS

Heart failure (HF) patients with anaemia tend to have a worse outcome, with increased hospitalization rates, decreased exercise tolerance, and higher mortality compared to those without anaemia. Limited research exists on the association between selenium deficiency and anaemia specifically in HF patients, despite previous findings of a correlation in different populations. The BIOSTAT-CHF study demonstrated that higher selenium levels in HF patients were associated to a lower risk of anaemia and iron deficiency. This study investigates the relationship between selenoprotein P (SELENOP) concentrations, a major contributor and functional biomarker of selenium transport, and anaemia, Hb levels, and iron status in hospitalized HF patients.

METHODS AND RESULTS

SELENOP was analysed in 320 hospitalized HF subjects, with complete data available for 310 subjects. The relationships between continuous SELENOP concentrations and 1) Hb concentrations, 2) anaemia (Hb < 115 g/L (women), <130 g/L (men)), and 3) iron status (as measured by transferrin receptor 1 (TfR1) which increases in iron deficiency) were evaluated using multivariable logistic and linear regression models. Additionally, SELENOP concentrations in the lowest quartile were related to anaemia, haemoglobin, and iron state in multivariable logistic and linear models. The mean age of the study population was 75.0 ± 11.6 years, and 30% were women. Anaemia was present in 133 subjects (42.9%). SELENOP concentrations were positively correlated with haemoglobin concentrations (0.238; P < 0.001) and negatively with TfR1 concentrations (-0.238, P < 0.001). In multivariable regression models, higher SELENOP concentrations were associated with higher Hb concentrations (B = 3.23; P = 0.002) and lower TfR1 concentrations (B = -0.20; P < 0.001). Furthermore, SELENOP deficiency was associated with lower Hb concentrations (B = -7.64: P = 0.001), higher TfR1 concentrations (B = 0.31; P = 0.003), and higher odds of anaemia in HF patients (odds ratio 2.17; 95% confidence interval 1.23-3.82; P = 0.008).

CONCLUSIONS

In hospitalized heart failure patients, lower concentrations of SELENOP were associated with higher prevalence of anaemia.

The modified Rajan's heart failure risk score predicts all-cause mortality in patients hospitalized for heart failure with reduced ejection fraction: a retrospective cohort study

Background

The dimensionless Rajan's heart failure (R-hf) risk score was proposed to predict all-cause mortality in patients hospitalized with chronic heart failure (HF) and reduced ejection fraction (EF) (HFrEF).

Purpose

To examine the association between the modified R-hf risk score and all-cause mortality in patients with HFrEF.

Methods

Retrospective cohort study included adults hospitalized with HFrEF, as defined by clinical symptoms of HF with biplane EF less than 40% on transthoracic echocardiography, at a tertiary centre in Dalian, China, between 1 November 2015, and 31 October 2019. All patients were followed up until 31 October 2020. A modified R-hf risk score was calculated by substituting brain natriuretic peptide (BNP) for N-terminal prohormone of BNP (NT-proBNP) using EF× estimated glomerular filtration rate (eGFR)× haemoglobin (Hb))/BNP. The patients were stratified into tertiles according to the R-hf risk score. The measured outcome was all-cause mortality. The score performance was assessed using C-statistics.

Results

A total of 840 patients were analyzed (70.2% males; mean age, 64±14 years; median (interquartile range) follow-up 37.0 (27.8) months). A lower modified R-hf risk score predicted a higher risk of all-cause mortality, independent of sex and age [1st tertile vs. 3rd tertile: adjusted hazard ratio (aHR), 3.46; 95% CI: 2.11-5.67; P<0.001]. Multivariate Cox regression analysis indicated that a lower modified R-hf risk score was associated with increased cumulative all-cause mortality [univariate: (1st tertile vs. 3rd tertile: aHR, 3.45; 95% CI: 2.11-5.65; P<0.001) and multivariate: (1st tertile vs. 3rd tertile: aHR 2.21, 95% CI: 1.29-3.79; P=0.004)]. The performance of the model, as reported by C-statistic was 0.67 (95% CI: 0.62-0.72).

Conclusion

The modified R-hf risk score predicted all-cause mortality in patients hospitalized with HFrEF. Further validation of the modified R-hf risk score in other cohorts of patients with HFrEF is needed before clinical application.

Impact of anaemia and iron deficiency on outcomes in cardiogenic shock complicating acute myocardial infarction

AIMS

Anaemia and iron deficiency (ID) are common comorbidities in cardiovascular patients and are associated with a poor clinical status, as well as a worse outcome in patients with heart failure and acute myocardial infarction (AMI). Nevertheless, data concerning the impact of anaemia and ID on clinical outcomes in patients with cardiogenic shock (CS) are scarce. This study aimed to assess the impact of anaemia and ID on clinical outcomes in patients with CS complicating AMI.

METHODS AND RESULTS

The presence of anaemia (haemoglobin <13 g/dl in men and <12 g/dl in women) or ID (ferritin <100 ng/ml or transferrin saturation <20%) was determined in patients with CS due to AMI from the CULPRIT-SHOCK trial. Blood samples were collected in the catheterization laboratory during initial percutaneous coronary intervention. Clinical outcomes were compared in four groups of patients having neither anaemia nor ID, against patients with anaemia with or without ID and patients with ID only. A total of 427 CS patients were included in this analysis. Anaemia without ID was diagnosed in 93 (21.7%), anaemia with ID in 54 study participants (12.6%), ID without anaemia in 72 patients (16.8%), whereas in 208 patients neither anaemia nor ID was present (48.9%). CS patients with anaemia without ID were older (73 ± 10 years, p = 0.001), had more frequently a history of arterial hypertension (72.8%, p = 0.01), diabetes mellitus (47.8%, p = 0.001), as well as chronic kidney disease (14.1%, p = 0.004) compared to CS patients in other groups. Anaemic CS patients without ID presence were at higher risk to develop a composite from all-cause death or renal replacement therapy at 30-day follow-up (odds ratio [OR] 3.83, 95% confidence interval [CI] 2.23-6.62, p < 0.001) than CS patients without anaemia/ID. The presence of ID in CS patients, with and without concomitant anaemia, did not increase the risk for the primary outcome (OR 1.17, 95% CI 0.64-2.13, p = 0.64; and OR 1.01, 95% CI 0.59-1.73, p = 0.54; respectively) within 30 days of follow-up. In time-to-event Kaplan-Meier analysis, anaemic CS patients without ID had a significantly higher hazard ratio (HR) for the primary outcome (HR 2.11, 95% CI 1.52-2.89, p < 0.001), as well as for death from any cause (HR 1.90, 95% CI 1.36-2.65, p < 0.001) and renal replacement therapy during 30-day follow-up (HR 2.99, 95% CI 1.69-5.31, p < 0.001).

CONCLUSION

Concomitant anaemia without ID presence in patients with CS at hospital presentation is associated with higher risk for death from any cause or renal replacement therapy and the individual components of this composite endpoint within 30 days after hospitalization. ID has no relevant impact on clinical outcomes in patients with CS.

Impact of anemia on clinical outcomes in patients with acute heart failure: A systematic review and meta-analysis

Anemia and acute heart failure (AHF) frequently coexist. Several published studies have investigated the association of anemia with all-cause mortality and all-cause heart failure events in AHF patients, but their findings remain controversial. This study is intended to evaluate the relationship between anemia and AHF. We systematically searched PubMed, Medline, the Cochrane Library, Embase, and Elsevier's ScienceDirect databases until July 30, 2023, and selected prospective or retrospective cohort studies to evaluate anemia for AHF. A total of nine trials involving 29 587 AHF patients were eventually included. Pooled analyses demonstrated anemia is associated with a higher risk of all-cause heart failure event rate (OR: 1.82, 95% CI: 1.58-2.10, p < .01) and all-cause mortality, both for short-term (30 days) all-cause mortality (OR: 1.91, 95% CI: 1.31-2.79, p < .01) and long-term (1 year) all-cause mortality (OR: 1.72, 95% CI: 1.27-2.32, p < .01). The evidence from this meta-analysis suggested that anemia may be an independent risk factor for all-cause mortality and all-cause heart failure events in patients with AHF and might emphasize the importance of anemia correction before discharge.

Association of anaemia on heart failure and left ventricular function: A bidirectional Mendelian randomization study

AIMS

Observational studies have suggested that anaemia is associated with an increased risk of heart failure (HF). But the potential causal association is not clear. We aimed to investigate the association between anaemia and HF risk.

METHODS AND RESULTS

A Mendelian randomization (MR) analysis was performed to confirm the causal association of anaemia with the risk of HF and left ventricular structure and function. Furthermore, a reverse-direction MR analyses was conducted to assess the causal effect of HF on anaemia. The MR analysis indicated that genetically predicted anaemia is associated with the increased risk of HF (meta: odd ratio (OR) = 1.12; 95% confidence interval (CI) [1.04, 1.20]; P = 0.002), and left ventricular mass index (β = 1.051; 95% CI [0.384, 1.718]; P = 0.002), left ventricular mass (β = 2.063; 95% CI [0.578, 3.547]; P = 0.006), left atrial minimum volume (β = 0.076; 95% CI [0.008, 0.143]; P = 0.028), and left atrial maximum volume (β = 0.090; 95% CI [0.023, 0.157]; P = 0.009). In the reverse-direction MR analyses, we found that genetic susceptibility to HF was significantly associated with the increased risk of anaemia (meta: OR = 1.40; 95% CI [1.24, 1.59]; P = 1.79 × 10-7 ).

CONCLUSIONS

This MR study supports the genetic evidence that there is bidirectional causality between anaemia and the risk of HF as well as anaemia may cause left ventricular hypertrophy and enlargement of the left atrium. Considering the adverse causal effects between the two diseases, more attention should be paid to the prevention and treatment of anaemia in patients with HF.

Association of iron therapy with incidence of chronic kidney disease

OBJECTIVE

We investigated the association of oral iron replacement with the incidence of chronic kidney disease (CKD) in a population with normal kidney function to study the effects of iron replacement on the development of new onset CKD.

METHODS

In a national cohort of US Veterans with no pre-existing CKD, we identified 33 894 incident new users of oral iron replacement and a comparable group of 112 780 patients who did not receive any iron replacement during 2004-2018. We examined the association of oral iron replacement versus no iron replacement with the incidence of eGFR <60 mL/min/1.73 m2 and the incidence of urine albumin creatinine ratio (UACR) ≥30 mg/g in competing risk regressions and in Cox models. We used propensity score weighing to account for differences in key baseline characteristics associated with the use of oral iron replacement.

RESULTS

In the cohort of 146 674 patients, a total of 18 547 (13%) patients experienced incident eGFR <60 mL/min/1.73 m2 , and 16 117 patients (11%) experienced new onset UACR ≥30 mg/g. Oral iron replacement was associated with significantly higher risk of incident eGFR <60 mL/min/1.73 m2 (subhazard ratio, 95% confidence interval [CI]: 1.3 [1.22-1.38], p < .001) and incident albuminuria (subhazard ratio, 95% CI: 1.14 [1.07-1.22], p < .001).

CONCLUSION

Oral iron replacement is associated with higher risk of new onset CKD. The long-term kidney safety of oral iron replacement should be tested in clinical trials.

Metabolomics Assessment of Volume Overload-Induced Heart Failure and Oxidative Stress in the Kidney

The incidence of heart failure (HF) is increasing and is associated with a poor prognosis. Moreover, HF often coexists with renal dysfunction and is associated with a worsened outcome. In many experimental studies on cardiac dysfunction, the function of other organs was either not addressed or did not show any decline. Until now, the exact mechanisms for initiating and sustaining this interaction are still unknown. The objective of this study is to use volume overload to induce cardiac hypertrophy and HF in aortocaval fistula (ACF) rat models, and to elucidate how volume overload affects metabolic changes in the kidney, even with normal renal function, in HF. The results showed the metabolic changes between control and ACF rats, including taurine metabolism; purine metabolism; glycine, serine, and threonine metabolism; glycerophospholipid metabolism; and histidine metabolism. Increasing the downstream purine metabolism from inosine to uric acid in the kidneys of ACF rats induced oxidative stress through xanthine oxidase. This result was consistent with HK-2 cells treated with xanthine and xanthine oxidase. Under oxidative stress, taurine accumulation was observed in ACF rats, indicating increased activity of the hypotaurine-taurine pathway as a defense mechanism against oxidative stress in the kidney. Another antioxidant, ascorbic acid 2-sulfate, showed lower levels in ACF rats, indicating that the kidneys experience elevated oxidative stress due to volume overload and HF. In summary, metabolic profiles are more sensitive than clinical parameters in reacting to damage to the kidney in HF.

Intravenous Iron Technique Evaluation in Chronic Heart Failure With Iron Deficiency Anemia

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.

Red blood cell count and risk of adverse outcomes in patients with mildly reduced left ventricular ejection fraction

BACKGROUND

Anemia is associated with increased rates of heart failure (HF)-related mortality and hospitalization. No studies have focused on the association between the red blood cell (RBC) count and the prognosis of patients with HF with mildly reduced left ventricular ejection fraction (HFmrEF). We retrospectively analyzed the effect of the RBC count on outcome events in patients with HFmrEF.

METHODS

We investigated the association of the RBC count with outcome events in 1691 patients with HFmrEF (mean age: 68 years; 35% female) in Xiangtan Central Hospital. Using Cox proportional hazards models, the RBC count was assessed as both a continuous and categorical variable.

RESULTS

During follow-up (median: 33 months), cardiovascular death occurred in 168 patients (114 men and 54 women). After adjusting for established risk factors, each 1.0 × 1012 cell/L increase in the RBC count was associated with a 28% lower risk of cardiovascular death in men and a 43% lower risk in women. Patients with low RBC counts had a 0.5-fold higher risk of cardiovascular death than those with normal RBC counts. The hazard ratio for men was 1.42 (95% confidence interval [CI]: 1.07-1.89), and the hazard ratio for women was 1.79 (95% CI: 1.20-2.67). The RBC count was not significantly associated with the composite endpoint of cardiovascular death and HF readmission (cardiovascular events) (p > .05).

CONCLUSIONS

A decreased RBC count is associated with increased cardiovascular mortality in patients with HFmrEF. Correcting a low RBC count might potentially reduce the risk of cardiovascular death in patients with HFmrEF.

Anemia is associated with long-term exposure to PM2.5 and its components: a large population-based study in Southwest China

Background

Anemia is linked to PM2.5 (particulate matter with aerodynamic diameters of ⩽2.5 μm) exposure, which can increase the risk of various negative health outcomes. It remains unclear which PM2.5 components are associated with anemia and the respective contribution of each component to this association.

Objective

This study aimed at investigating the association between PM2.5 and anemia in the general population and to identify the most critical PM2.5 toxic components in this association.

Design

Cross-sectional study.

Methods

Our study involved a large cohort of 73,511 individuals aged 30-79 from China's multi-ethnic population. We employed satellite observations and the chemical transport model (GEOS-Chem)to estimate the long-term exposure to PM2.5 and its components. Anemia was defined, according to WHO guidelines, as Hb levels below 130 g/L for men and below 120 g/L for women. Through logistic regression, we investigated the association between PM2.5 components and anemia. By utilizing weighted quantile sum (WQS) analysis, we identified key components and gained insights into their combined impact on anemia. Overall, our study sheds light on the relationship between PM2.5 exposure, its constituents, and the risk of anemia in a large cohort.

Results

PM2.5 and three components, nitrate (NIT), organic matter (OM), and soil particles (SOIL), were associated with anemia. Per-standard deviation increase in the 3-year average concentrations of PM2.5 [odds ratio (OR): 1.14, 95% confidence interval (CI): 1.01, 1.28], NIT (1.20, 1.06, 1.35), OM (1.17, 1.04, 1.32), and SOIL (1.22, 1.11, 1.33) were associated with higher odds of anemia. In WQS regression analysis, the WQS index was associated with anemia (OR: 1.29, 95% CI: 1.13, 1.47). SOIL has the highest weight among all PM2.5 components.

Conclusions

Long-term exposure to PM2.5 and its constituents is associated with anemia. Moreover, SOIL might be the most critical component of the relationship between PM2.5 and anemia. Our research increases the evidence of the association between PM2.5 and anemia in the general population, and targeted emission control measures should be taken into consideration to mitigate the adverse effects of PM2.5-related anemia.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

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.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

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.

Prevalence and prognostic impact of chronic kidney disease and anaemia across ACC/AHA precursor and symptomatic heart failure stages

BACKGROUND

The importance of chronic kidney disease (CKD) and anaemia has not been comprehensively studied in asymptomatic patients at risk for heart failure (HF) versus those with symptomatic HF. We analysed the prevalence, characteristics and prognostic impact of both conditions across American College of Cardiology/American Heart Association (ACC/AHA) precursor and HF stages A-D.

METHODS AND RESULTS

2496 participants from three non-pharmacological German Competence Network HF studies were categorized by ACC/AHA stage; stage C patients were subdivided into C1 and C2 (corresponding to NYHA classes I/II and III, respectively). Overall, patient distribution was 8.1%/35.3%/32.9% and 23.7% in ACC/AHA stages A/B/C1 and C2/D, respectively. These subgroups were stratified by the absence ( - ) or presence ( +) of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2) and anaemia (haemoglobin in women/men < 12/ < 13 g/dL). The primary outcome was all-cause mortality at 5-year follow-up. Prevalence increased across stages A/B/C1 and C2/D (CKD: 22.3%/23.6%/31.6%/54.7%; anaemia: 3.0%/7.9%/21.7%/33.2%, respectively), with concordant decreases in median eGFR and haemoglobin (all p < 0.001). Across all stages, hazard ratios [95% confidence intervals] for all-cause mortality were 2.1 [1.8-2.6] for CKD + , 1.7 [1.4-2.0] for anaemia, and 3.6 [2.9-4.6] for CKD + /anaemia + (all p < 0.001). Population attributable fractions (PAFs) for 5-year mortality related to CKD and/or anaemia were similar across stages A/B, C1 and C2/D (up to 33.4%, 30.8% and 34.7%, respectively).

CONCLUSIONS

Prevalence and severity of CKD and anaemia increased across ACC/AHA stages. Both conditions were individually and additively associated with increased 5-year mortality risk, with similar PAFs in asymptomatic patients and those with symptomatic HF.

Treating Iron Deficiency (ID) Anemia in Heart Failure (HF) Patients with IV Iron: A Meta-Analysis

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.

Causal Association Between Anemia and Cardiovascular Disease: A 2-Sample Bidirectional Mendelian Randomization Study

Background Although previous observational studies have shown an association between anemia and cardiovascular disease (CVD), the underlying causal relationship between anemia and CVD remains uncertain. Methods and Results We conducted a 2-sample bidirectional Mendelian randomization (MR) study to assess the causal association between anemia and CVD. We extracted summary statistics data for anemia, heart failure (HF), coronary artery disease (CAD), atrial fibrillation, any stroke, and any ischemic stroke (AIS) from relevant published genome-wide association studies. After rigorous quality control steps, independent single-nucleotide polymorphisms for each disease were selected as instrumental variables. Inverse-variance weighting was used as the primary method to estimate the causal association between anemia and CVD in the 2-sample MR analysis. Simultaneously, we performed a series of multiple methods analyses (median weighting, maximum likelihood [MR robust adjusted profile score]), sensitivity analyses (Cochran's Q test and MR-Egger intercept, leave-one-out test [MR pleiotropy residual sum and outlier]), instrumental variable strength evaluations (F statistic), and statistic power estimates to verify the robustness and reliability of our results. Furthermore, the associations between anemia and CVD from different studies, including the UK Biobank and FinnGen studies, were combined by meta-analysis. The MR analysis showed that genetically predicted anemia was significantly associated with HF risk at the Bonferroni-corrected significance level (odds ratio [OR], 1.11 [95% CI, 1.04-1.18]; P=0.002) and was suggestively associated with CAD risk (OR, 1.11 [95% CI, 1.02-1.22]; P=0.020). However, the associations between anemia and atrial fibrillation, any stroke, or AIS were not statistically significant. In the reverse MR analysis, we found that genetic susceptibility to HF, CAD, and AIS was significantly associated with anemia risk. The ORs of HF, CAD, and AIS were 1.64 (95% CI, 1.39-1.94; P=7.60E-09), 1.16 (95% CI, 1.08-1.24; P=2.32E-05), and 1.30 (95% CI, 1.11-1.52; P=0.001), respectively. Genetically predicted atrial fibrillation was suggestively associated with anemia (OR, 1.06 [95% CI, 1.01-1.12]; P=0.015). Sensitivity analyses found weak evidence of horizontal pleiotropy and heterogeneity, which ensured the robustness and reliability of the results. Meta-analysis also showed the statistically significant association between anemia and HF risk. Conclusions Our study supports bidirectional causality between anemia and HF and significant associations between genetic predisposition to CAD and AIS with anemia, which contributes to the clinical management of both diseases.

Trends in prevalence and determinants of severe and moderate anaemia among women of reproductive age during the last 15 years in India

BACKGROUND

Anaemia is a serious global public health problem that disproportionally affects children, adolescent girls, and women of reproductive age, especially pregnant women. Women of reproductive age are more vulnerable to anaemia, particularly severe and moderate anaemia leads to adverse outcomes among pregnant women. Despite continuous Government efforts, anaemia burden still poses a serious challenge in India. The objective of this study is to assess the trends in prevalence and determinants of severe and moderate anaemia among women of reproductive age between 15 and 49 years.

METHOD

We used three rounds of the large-scale National Family Health Survey (NFHS) India, conducted on a representative sample of households using a cross-sectional design across the country in 2005-06, 2015-16 and 2019-2021. We included all the women aged 15 to 49 years in our analysis. We used the same haemoglobin (Hb) cut-off values for all the three rounds of surveys to ensure comparability. Generalized linear regression analyses with log link were done. Survey weights were incorporated in the analysis.

RESULTS

The prevalence of severe or moderate Anaemia (SMA) in non-pregnant women was 14.20%, 12.43% and 13.98%; it was 31.11%, 25.98% and 26.66% for pregnant women in 2006, 2016 and 2021 respectively. The decline in SMA prevalence was 1.54% in non-pregnant women, whereas it was 14.30% in pregnant women in 15 years. Women who were poor, and without any formal education had a higher risk for severe and moderate Anaemia.

CONCLUSION

Despite the intensive anaemia control program in India, SMA has not declined appreciably in non-pregnant women during the last two decades. Despite the decline, the prevalence of SMA was about 26% in pregnant women which calls for a comprehensive review of the existing anaemia control programmes and there must be targeted programmes for the most vulnerable and high-risk women such as rural, poor and illiterate women of reproductive age to reduce the burden of anaemia among them.

Initial experience of hypoxia-inducible factor prolyl hydroxylase inhibitors in patients with heart failure and renal anemia

Hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitors might improve renal anemia maintaining fewer cardiovascular complications. However, its safety and efficacy, as well as its impact on inflammatory biomarkers, in heart failure patients remain unknown. We initiated HIF-PH inhibitors in 13 patients with chronic heart failure and renal anemia (median age 77 years, median estimated glomerular filtration rate 24.9 mL/min/1.73m²) between September 2021 and February 2022. There were no drug-related complications, except for a patient who had a headache and hot flash, resulting in discontinuation of HIF-PH inhibitor at 3 months. Among 10 patients who continued HIF-PH inhibitors for over 3 months, hemoglobin levels increased significantly (median from 9.6 g/dL to 10.7 g/dL, p = 0.004) and hepcidin-25 levels tended to decrease (median from 11.5 ng/mL to 3.0 ng/mL, p = 0.294) at 3-month follow-up. In conclusion, HIF-PH inhibitors might be safe and effective for the treatment of renal anemia in patients with chronic heart failure.

Can Iron Play a Crucial Role in Maintaining Cardiovascular Health in the 21st Century?

In the 21st century the heart is facing more and more challenges so it should be brave and iron to meet these challenges. We are living in the era of the COVID-19 pandemic, population aging, prevalent obesity, diabetes and autoimmune diseases, environmental pollution, mass migrations and new potential pandemic threats. In our article we showed sophisticated and complex regulations of iron metabolism. We discussed the impact of iron metabolism on heart diseases, treatment of heart failure, diabetes and obesity. We faced the problems of constant stress, climate change, environmental pollution, migrations and epidemics and showed that iron is really essential for heart metabolism in the 21st century.

Daprodustat for anaemia in patients with heart failure and chronic kidney disease: A randomized controlled study

AIMS

Hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors have been developed for the treatment of renal anaemia; however, no study has evaluated the safety and efficacy of HIF-PH inhibitors in patients with heart failure (HF). This study was designed to evaluate the safety and efficacy of daprodustat, a HIF-PH inhibitor, in patients with HF and renal anaemia.

METHODS AND RESULTS

We designed a pilot, multi-centre, open-label, randomized controlled study, in which 50 patients with HF complicated with chronic kidney disease and anaemia will be randomized 1:1 to either the daprodustat or control group at seven sites in Japan. Study entry requires New York Heart Association Class II HF symptoms or a history of hospitalization due to HF, an estimated glomerular filtration rate of <60 mL/min/1.73 m² , and a haemoglobin level of 7.5 to <11.0 g/dl. Patients randomized to the daprodustat group will be treated with oral daprodustat, and the dose will be uptitrated according to the changes in the haemoglobin level from previous visits. In this study, we will evaluate the impact of HIF-PH inhibitors on cardiac function using advanced cardiovascular imaging modalities, including cardiac magnetic resonance imaging. The primary outcome is the haemoglobin level at 16 weeks of randomization, and all adverse events will be recorded and evaluated for any association with daprodustat treatment.

CONCLUSION

Considering the hypothetical upside and downside of using HIF-PH inhibitors in anaemic patients with HF and chronic kidney disease, and because there are virtually no safe and effective treatments for patients with anaemia not caused by iron deficiency, our study results will contribute significantly to this field.

Validation of R-hf risk score for risk stratification in ischemic heart failure patients: A prospective cohort study

Background

The aim of this study was to validate R-heart failure (R-hf) risk score in ischemic heart failure patients.

Methods

We prospectively recruited a cohort of 179 ischemic and 107 non-ischemic heart failure patients. This study mainly focused on ischemic heart failure patients. Non-ischemic heart failure patients were included for the purpose of validation of the risk score in various heart failure groups. Patients were stratified in high risk, moderate risk and low risk groups according to R-hf risk score.

Results

A total of 179 participants with ischemic heart failure were included. Based on R-hf risk score, 82 had high risk, 50 had moderate risk and 47 had low risk heart failure scores. More than half of the patients having R-hf score of <5 had renal failure (n = 91, 50.8%) and anemia (n = 99, 55.3%). Notably, HFrEF was more prevalent in patients with high risk score (74, 90.2%). Patients with high risk score had significantly higher creatinine (2.63 ± 1.96, p < 0.001), Troponin-T HS (59.9 ± 38.0, p < 0.001) and PRO BNP (17842 ± 6684, p < 0.001) when compared to patients with low and moderate risk score. Patients with low risk score had significantly higher Hb (13.2 ± 1.85, p < 0.001), Albumin (3.69 ± 0.42, p < 0.001) and GFR (90.0 ± 8.04, p < 0.001). A R-hf score of <5 was a significant predictor of mortality in ischemic (OR = 50.34; 95% CI [16.94-194.00, p < 0.001) and non-ischemic (OR = 46.34; 95% CI [12.97-225.39], p < 0.001) heart failure patients.

Conclusions

Lower R-hf risk score is a significant predictor of mortality in ischemic and non-ischemic heart failure patients. Risk score can be accessed at https://www.hfriskcalc.in.

Prognostic Effects of Changes in Right Ventricular Fractional Area Change in Patients With Heart Failure

BACKGROUND

It is still unclear whether changes in right ventricular function are associated with prognosis in heart failure (HF) patients. This study aimed to examine the prognostic effect of changes in right ventricular fractional area change (RVFAC).Methods and Results: This study enrolled 480 hospitalized patients with decompensated HF, and measured RVFAC with echocardiography at discharge (first examination) and post-discharge in the outpatient setting (second examination). RVFAC was divided into 3 categories: >35% in 314 patients, 25-35% in 108 patients, and <25% in 58 patients. Next, based on changes in RVFAC from the first to the second examination, the patients were further classed into 4 groups: (1) Preserved/Unchanged (preserved and unchanged RVFAC, n=235); (2) Reduced/Improved (improved RVFAC in at least 1 category, n=106); (3) Reduced/Unchanged (reduced and unchanged RVFAC, n=47); and (4) Preserved or Reduced/Worsened (deteriorated RVAFC in at least 1 category, n=92). Multivariate logistic regression analysis revealed that chronic kidney disease and anemia were the predictors of the preserved or reduced/worsened RVFAC. In the Kaplan-Meier analysis, changes in RVFAC were associated with the cardiac event rate and all-cause mortality. In the multivariable Cox proportional hazard analysis, the preserved or reduced/worsened RVFAC was an independent predictor of cardiac events and all-cause mortality.

CONCLUSIONS

Changes in RVFAC were associated with post-discharge prognosis in hospitalized heart failure patients.

Biomarkers in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous disorder developing from multiple aetiologies with overlapping pathophysiological mechanisms. HFpEF diagnosis may be challenging, as neither cardiac imaging nor physical examination are sensitive in this situation. Here, we review biomarkers of HFpEF, of which the best supported are related to myocardial stretch and injury, including natriuretic peptides and cardiac troponins. An overview of biomarkers of inflammation, extracellular matrix derangements and fibrosis, senescence, vascular dysfunction, anaemia/iron deficiency and obesity is also provided. Finally, novel biomarkers from -omics technologies, including plasma metabolites and circulating microRNAs, are outlined briefly. A cardiac-centred approach to HFpEF diagnosis using natriuretic peptides seems reasonable at present in clinical practice. A holistic approach including biomarkers that provide information on the non-cardiac components of the HFpEF syndrome may enrich our understanding of the disease and may be useful in classifying HFpEF phenotypes or endotypes that may guide patient selection in HFpEF trials.

Anemia warrants treatment to improve survival in patients with heart failure receiving sacubitril-valsartan

Angiotensin inhibition remains a cornerstone for pharmacologic management of heart failure (HF), despite being associated with decreased hemoglobin (Hb) levels. To investigate the effect of anemia and its treatment on patients with HF treated with sacubitril-valsartan (S/V), we conducted a retrospective study involving patients with recorded left ventricular ejection fractions (LVEFs) of < 40% between January 2017 and December 2019. We identified 677 patients, 37.7% of whom received S/V. The median follow-up period was 868 days. Anemia was associated with significantly decreased survival, increased mortality rates, and higher all-cause hospitalizations in S/V-using patients. We further analyzed 236 patients with HF who had recorded renal function, LVEF, and Hb at the initiation of S/V therapy to identify Hb patterns after S/V therapy. Of these patients, 35.6% exhibited decreasing Hb 12 months after S/V initiation, which was associated with a lower survival rate. Among the patients who were not prescribed anemia medications, Hb of ≥ 12 (vs. < 12 g/dL) was associated with a higher survival rate; this association was absent among the patients undergoing anemia treatment. These results emphasize that consistent screening and treatment for anemia should be implemented to reduce the morbidity and mortality of patients with HF receiving S/V.

Carbon dots and Methylene blue facilitated photometric quantification of Hemoglobin

Early detection and monitoring of any abnormality of Hemoglobin (Hb) concentration in whole blood samples are important as this may be related to anemia, leukemia, dengue, etc. To facilitate quantitative detection and to monitor the hemoglobin level in the blood, we attempt to develop a low-cost, portable point of care (POC) device based on the spectrophotometric principle. Optical sensitivities of carbon quantum dots (CDs) are found to be highly responsive, while there is a selective reaction between Hb and reduced form of Methylene Blue (MB_red). The interaction of Hb, MB_red, and CDs is delineated using UV-Visible (UV-Vis) spectroscopy. CDs have a characteristic UV-Vis peak at ∼ 347 nm, and it shows a gradual increase in intensity with a slight red shift (∼355 nm) on the progressive increase in Hb concentration. Simultaneously, the colorless MB_red is oxidized to its blue oxidized form MB_ox and its characteristic peak starts reappearing at ∼ 663 nm. These responses are exploited to quantify Hb concentration with a limit of detection (LOD) as low as ∼ 2 g dL^-1 in a developed POC device, and the results are validated with the clinical data obtained from a local hospital with reasonably good agreement. This photometric detection approach can be adopted for other quantitative biosensors.

5-Alpha Reductase Inhibitors and the Risk of Anemia among Men with Benign Prostatic Hyperplasia: A Population-based Cohort Study

BACKGROUND

5-alpha reductase inhibitors (5αRIs) are effective for the treatment of benign prostatic hyperplasia (BPH). However, 5αRIs could lower levels of hemoglobin, increasing the risk of anemia.

OBJECTIVE

To compare the rate of anemia between new users of 5αRIs and α-blockers in the United Kingdom (UK).

METHODS

We conducted a matched, active comparator, new-user cohort study using the Clinical Practice Research Datalink. The study population consisted of men aged 40+ years with incident BPH who initiated 5αRIs between 1998 and 2019 and were matched 1:1 on propensity score to new users of α-blockers. Anemia was defined by a measured hemoglobin < 130 g/l. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for anemia.

RESULTS

Our study cohort included 9,429 new users of 5αRIs and 9,429 matched new users of α-blockers. Their median durations of follow-up were 136 days (interquartile range [IQR]: 54-336 days) and 77 days (IQR: 58-236), respectively. A total of 2,865 5αRIs users and 2,407 α-blocker users developed incident anemia, representing rates of 37.3 (95% CI: 33.6-41.3) and 42.0 (95% CI: 38.1-46.2) per 100 person-years, respectively. The use of 5αRIs was not associated with an increased risk of anemia compared to the use of α-blockers (HR: 0.95, 95% CI: 0.90-1.00). Similarly, we did not observe an increased risk of mild, moderate, or severe anemia.

CONCLUSION

The use of 5αRIs was not associated with an increased risk of anemia compared to the use of α-blockers among men with BPH.

Anemia and outcomes following left ventricular assist device implantation

BACKGROUND

Patients with concomitant anemia and congestive heart failure have poor outcomes. The prevalence and clinical risk of anemia in patients receiving durable left ventricular assist devices (LVAD) remain unknown.

METHODS

We retrospectively analyzed patients who underwent LVAD implantation between 2014 and 2018. The association between hemoglobin level at the time of index discharge and the one-year composite endpoint of heart failure readmissions or hemocompatibility-related adverse events was investigated.

RESULTS

A total of 168 patients (57 [48, 66] years old, 123 males) were included and stratified into a classification of anemia (hemoglobin <9.7 g/dl, N = 99) or non-anemia (N = 69). The anemia group had a higher one-year incidence of the composite endpoint (56% vs 36%, p = .013) with an adjusted hazard ratio of 1.83 (95% confidence interval 1.08-2.82). Patients with anemia also experienced suboptimal bi-ventricular unloading.

CONCLUSIONS

Anemia was prevalent in LVAD patients and associated with a greater risk of heart failure and hemocompatibility-related adverse events. The optimal threshold for therapeutic intervention in response to post-LVAD anemia needs further investigation.

The Prognostic Value of Anemia in Patients with Preserved, Mildly Reduced and Recovered Ejection Fraction

Data on the relevance of anemia in heart failure (HF) patients with an ejection fraction (EF) > 40% by subgroup-preserved (HFpEF), mildly reduced (HFmrEF) and the newly defined recovered EF (HFrecEF)-are scarce. Patients with HF symptoms, elevated NT-proBNP, EF ≥ 40% and structural abnormalities were registered in the HFpEF-HFmrEF database. We described the outcome of our HFpEF-HFmrEF cohort by the presence of anemia. Additionally, HFrecEF patients were also selected from HFrEF patients who underwent resynchronization and, as responders, reached 40% EF. Using propensity score matching (PSM), 75 pairs from the HFpEF-HFmrEF and HFrecEF groups were matched by their clinical features. After PMS, we compared the survival of the HFpEF-HFmrEF and HFrecEF groups. Log-rank, uni-and multivariate regression analyses were performed. From 375 HFpEF-HFmrEF patients, 42 (11%) died during the median follow-up time of 1.4 years. Anemia (HR 2.77; 95%CI 1.47-5.23; p < 0.01) was one of the strongest mortality predictors, which was also confirmed by the multivariate analysis (aHR 2.33; 95%CI 1.21-4.52; p = 0.01). Through PSM, the outcomes for HFpEF-HFmrEF and HFrecEF patients with anemia were poor, exhibiting no significant difference. In HFpEF-HFmrEF, anemia was an independent mortality predictor. Its presence multiplied the mortality risk in those with EF ≥ 40%, regardless of HF etiology.

Relationship between the Amount of Menstrual Flow and Cardiac Status in Women with Fontan Circulation

A high prevalence of heavy menstrual bleeding (HMB) has been reported in women with Fontan circulation. Cyanosis has been reported to contribute to HMB, and menstruation has been suggested to affect cardiac status in women with congenital heart disease. This study aimed to evaluate the relationship between the amount of menstrual flow and cardiac status in women with Fontan circulation.Twenty women who had undergone the Fontan procedure were prospectively investigated and the amount of their menstrual flow was evaluated using a questionnaire. Participants were divided into two groups-small and large menstrual bleeding groups-and their clinical data, including the results of hematological tests and echocardiographic findings, were evaluated.One (5%) woman showed primary amenorrhea. Eight of the remaining 19 (42%) women were included in the large menstrual bleeding group. Women with large menstrual bleeding showed a significantly higher hematocrit level (47.1% [36.2%-50.3%] versus 42.1% [35.3%-44.9%], P = 0.006) and longer QRS duration (106 [92-172] ms versus 88 [78-140] ms, P = 0.008), as well as a lower fractional area change (37.4% [35.6%-47.2%] versus 47.0% [38.2%-55.7%], P = 0.010) and global longitudinal strain (-10.5% [-14.9% to -6.6%] versus -13.9% [-20.5% to -7.8%], P = 0.041) of the dominant ventricle on echocardiography, than women with small bleeding.Erythrocytosis, longer QRS duration, and reduced ventricular function were related to increased menstrual bleeding in women with Fontan circulation. These functions may be interrelated with the amount of menstrual flow in such women.

Effect of Anemia on the Prognosis of Patients with Ventricular Tachyarrhythmias

This study evaluates the prognostic impact of anemia in patients presenting with ventricular tachyarrhythmias. The present longitudinal, observational, registry-based, monocentric cohort study included retrospectively all consecutive patients presenting with ventricular tachyarrhythmias on admission from 2002 to 2016. Anemic patients (hemoglobin levels <12.0 g/dl) were compared with non-anemic patients (hemoglobin levels ≥12.0 g/dl). The primary endpoint was all-cause mortality at 2.5 years. Secondary endpoints were cardiac death at 24 hours, all-cause mortality at index hospitalization, and the composite endpoint of cardiac death at 24 hours, recurrent ventricular tachyarrhythmias, and appropriate ICD therapies at 2.5 years. A total of 2,184 consecutive patients were included, of whom 30% were anemic and 70% non-anemic. Anemia was associated with the primary endpoint of all-cause mortality at 2.5 years (65% vs 29%, p = 0.001; HR = 2.441; 95% CI 2.086 to 2.856), cardiac death at 24 hours (26% vs 11%, p = 0.001), all-cause mortality at index hospitalization (45% vs 20%, p = 0.001), and the composite endpoint (35% vs 27%, p = 0.001; HR = 2.923; 95% CI 2.564 to 4.366). After multivariable adjustment, anemia was no longer associated with the composite endpoint. Predictors of adverse prognosis for anemics were CKD (HR = 2.191), LVEF <35% (HR = 1.651), cardiogenic shock (HR = 1.591), CPR (HR = 1.460), male gender (HR = 1.379), and age (HR = 1.017). In conclusion, anemic patients presenting with ventricular tachyarrhythmias were associated with increased long-term mortality at 2.5 years but not with the composite arrhythmic endpoint at 2.5 years. Predictors of adverse prognosis at 2.5 years were CKD, LVEF <35%, cardiogenic shock, CPR, male gender, and age.

Anemia in heart failure: still an unsolved enigma

BACKGROUND

Anemia affects one-third of heart failure patients and is associated with increased morbidity and mortality. Despite being one of the commonest comorbidities associated with heart failure, there is a significant knowledge gap about management of anemia in the setting of heart failure due to conflicting evidence from recent trials.

MAIN BODY

The etiology of anemia in heart failure is multifactorial, with absolute and functional iron deficiency, decreased erythropoietin levels and erythropoietin resistance, inflammatory state and heart failure medications being the important causative factors. Anemia adversely affects the already compromised hemodynamics in heart failure, besides being commonly associated with more comorbidities and more severe disease. Though low hemoglobin levels are associated with poor outcomes, the correction of anemia has not been consistently associated with improved outcomes. Parenteral iron improves the functional capacity in iron deficient heart failure patients, the effects are independent of hemoglobin levels, and also the evidence on hard clinical outcomes is yet to be ascertained.

CONCLUSION

Despite all the research, anemia in heart failure remains an enigma. Perhaps, anemia is a marker of severe disease, rather than the cause of poor outcome in these patients. In this review, we discuss the current understanding of anemia in heart failure, its management and the newer therapies being studied.

Anemia in Cardiovascular Disease: Marker of Disease Severity or Disease-modifying Therapeutic Target?

PURPOSE OF THE REVIEW

In this review paper, we examine the latest evidence regarding the use of iron supplementation, erythropoiesis-stimulating agents (ESAs), and blood transfusions as therapeutic targets for anemia to mitigate morbidity and mortality in patients with cardiovascular disease.

RECENT FINDINGS

Intravenous ferric carboxymaltose (FC) injections in heart failure (HF) have resulted in improved self-reported patient symptoms; higher exercise capacity, as measured by 6-min walk test distance in anemic patients; and lower re-hospitalization rates in iron deficient patients. Darbepoetin alfa has shown evidence of improved Kansas City Cardiomyopathy Questionnaire scores. No mortality benefits have been noted thus far with FC injections or darbepoetin in HF, with an increase in adverse events with darbepoetin. Aggressive transfusions (Hg < 10 g/dL) are not associated with improved outcomes in cardiovascular disease. Quality of life metrics, rather than mortality, appear to improve with IV FC and ESA use in HF. More studies are required to see if these treatments have a role in coronary artery disease. Current evidence suggests that anemia is a marker of underlying disease severity, with a limited role in disease modification. Further studies are required to solidify our understanding of this topic.

Prognostic Value of Fractional Excretion of Urea Nitrogen at Discharge in Acute Decompensated Heart Failure

Background

Maintaining euvolemia is crucial for improving prognosis in acute decompensated heart failure (ADHF). Although fractional excretion of urea nitrogen (FEUN) is used as a body fluid volume index in patients with acute kidney injury, the clinical impact of FEUN in patients with ADHF remains unclear. This study aimed to investigate whether FEUN can determine the long‐term prognosis in patients with ADHF.

Methods and Results

We retrospectively identified 466 patients with ADHF who had FEUN measured at discharge between April 2011 and December 2018. The primary endpoint was post‐discharge all‐cause death. Patients were divided into two groups according to a FEUN cut‐off value of 35%, commonly used in pre‐renal failure. The FEUN <35% (low‐FEUN) group included 224 patients (48.1%), and the all‐cause mortality rate for the total cohort was 37.1%. The log‐rank test revealed that the low‐FEUN group had a significantly higher rate of all‐cause death compared to the FEUN equal to or greater than 35% (high‐FEUN) group (P<0.001). Multivariate Cox proportional hazards model analysis revealed that low‐FEUN was associated with post‐discharge all‐cause death, independently of other heart failure risk factors (hazard ratio, 1.467; 95% CI, 1.030–2.088, P=0.033). The risk of low‐FEUN compared to high‐FEUN in post‐discharge all‐cause death was consistent across all subgroups; however, the effects tended to be modified by renal function (threshold: 60 mL/min/1.73 m², interaction P=0.069).

Conclusions

Our study suggests that FEUN may be a novel surrogate marker of volume status in patients with ADHF requiring diuretics.

The Risk Factors for Child Anemia Are Consistent across 3 National Surveys in Nepal

BACKGROUND

Anemia is an etiologically heterogeneous condition affecting over half of preschool-aged children in South Asia. An urgent need exists to elucidate context-specific causes of anemia to effectively address this issue.

OBJECTIVES

This study investigated national trends and stability in the prevalence of child anemia and associated risk factors from 2013 to 2016 in Nepal.

METHODS

Same-season national surveys were administered in 2013, 2014, and 2016 in 63 sites across 21 districts, selected using multistage random sampling, representing the mountains, hills, and Tarai (plains). Among consenting households with children aged 6-59 mo, a random sample of capillary blood was selected each year for anemia assessment using an Hb 201+ hemoglobinometer, with n = 835, 807, and 881 children assessed, respectively. Prevalence of child anemia, defined as hemoglobin <11.0 g/dL with adjustment for altitude, was estimated each year and disaggregated by region and child age. Prevalence ratios were estimated using log-binomial regression models with robust SE or robust Poisson regression when models failed to converge. Interaction terms between each risk factor and year were created to test for consistencies in associations over time.

RESULTS

The national prevalence of child anemia decreased from 63.3% (95% CI: 59.0%, 67.5%) in 2013 to 51.9% (95% CI: 46.5%, 57.2%) in 2014 and increased to 59.3% (95% CI: 54.7%, 63.8%) in 2016. Across years, prevalence was highest in the Tarai (58.4-70.2%), followed by the mountains (53.0-61.1%) and hills (37.5-51.4%). Nationally and across time, child age and maternal anemia were significantly associated with child anemia. Child diarrhea and stunting, maternal thinness, and poor water and sanitation conditions also showed consistent trends toward higher anemia prevalence.

CONCLUSIONS

Anemia affects more than half of Nepalese children aged 6-59 mo. Although prevalence varies year to year, the stability of observed risk factors suggests the need to focus on reducing gastrointestinal infection, promoting adequate household sanitation, and improving maternal and child health.

Pathophysiology and Therapeutic Approaches to Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.

The Prognostic Significance of Anemia in Patients With Heart Failure: A Meta-Analysis of Studies From the Last Decade

Background: Anemia is a commonly occurring comorbidity in patients with heart failure (HF). Although there are a few reports of a higher prevalence of mortality and hospitalization-related outcomes due to accompanying anemia, other studies suggest that anemia does not have an adverse impact on the prognostic outcomes of HF. Two meta-analyses in the past decade had reported the adverse impact of anemia on both mortality and hospitalization- related outcomes. However, only one of these studies had evaluated the outcome while using multivariable adjusted hazard ratios. Moreover, several studies since then reported the prognostic influence of anemia in HF. In this present study, we evaluate the prognostic impact of anemia on mortality and hospitalization outcomes in patients with HF.

Methods: We carried out a systematic search of the academic literature in the scientific databases EMBASE, CENTRAL, Scopus, PubMed, Cochrane, ISI Web of Science, clinicaltrial.gov, and MEDLINE based on the PRISMA guidelines. Meta-analysis was then performed to evaluate the effect (presented as risk ratio) of anemia on the overall mortality and hospitalization outcome in patients with HF.

Results: Out of 1,397 studies, 11 eligible studies were included with a total of 53,502 (20,615 Female, 32,887 Male) HF patients (mean age: 71.6 ± 8.3-years, Hemoglobin: 11.9 ± 1.5 g/dL). Among them, 19,794 patients suffered from anemia (Hb: 10.5 ± 1.6), and 33,708 patients did not have anemia (Hb: 13.2 ± 1.7 g/dL). A meta-analysis revealed a high-odds ratio (OR) for the overall mortality in patients with anemia (OR: 1.43, 95% CI: 1.29–1.84). A high-risk ratio was also reported for hospitalization as the outcome in patients with anemia (1.22, 1.0–1.58).

Conclusion: This systematic review and meta-analysis provide evidence of the high risk of mortality and hospitalization-related outcomes in patients with HF and anemia. The study confirms the findings of previously published meta-analyses suggesting anemia as an important and independent risk factor delineating the prognostic outcome of chronic HF.

Epidemiological and clinical boundaries of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and is associated with relevant morbidity and mortality. However, an evidence-based treatment is still absent. The heterogeneous definitions, differences in aetiology/pathophysiology, and diagnostic challenges of HFpEF made it difficult to define its epidemiological landmarks so far. Several large registries and observational studies have recently disclosed an increasing incidence/prevalence, as well as its prognostic significance. An accurate definition of HFpEF epidemiological boundaries and phenotypes is mandatory to develop novel effective and rational therapeutic approaches.

How I treat anemia in heart failure

Anemia is a very common comorbidity in patients with heart failure (HF), affecting ∼30% of stable ambulatory patients and 50% patients with acute decompensated HF. Absolute or functional iron deficiency (ID) is seen in ∼50% patients with HF. Both of these comorbidities often coexist and are independently associated with increased mortality and hospitalizations. These findings led several investigators to test the hypotheses that treatment of anemia and ID in HF would improve symptoms and long-term outcomes. Small studies showed that erythropoiesis-stimulating agents (ESAs) improve subjective measures of HF. However, a large pivotal outcome trial found that the ESA darbepoetin alfa did not improve long-term outcomes in patients with HF with reduced ejection fraction and instead was associated with adverse effects. Studies using IV iron have had somewhat greater success, showing improvements in subjective and some objective measures of HF. However, more research is needed to establish the best treatment options for these high-risk patients. We present 5 common scenarios of patients with HF and anemia and describe our personal approach on how we might treat them based on objective evidence where available. An algorithm that offers guidance in regard to personalized therapy for such patients is also presented.

Revisiting the treatment of anemia in the setting of chronic kidney disease, hematologic malignancies, and cancer: perspectives with opinion and commentary

INTRODUCTION

Anemia has and will continue to be a central theme in medicine particularly as clinicians are treating a burgeoning population of complex multi-organ system processes. As a result of multiple randomized controlled trials (RCTs), meta-analyses, and societal recommendations overly restrictive paradigms and under-administration of erythropoiesis stimulating agents (ESAs) have likely been followed by clinicians among all specialties.

AREAS COVERED

A review of anemia in the context of chronic kidney disease, hematologic malignancies, and cancer is presented with focus on the establishment of ESAs as integral in the treatment of anemia. Multiple RCTs and meta-analyses studying the use of ESAs are presented with focus upon their application to clinical practice. A 'compendium' is proffered describing the evolution, establishment, and implications of ESA administration initially among those with CKD with rapid subsequent application to the Hematology-Oncology population of patients. Literature search methodologies have included MEDLINE (1985-2020), PubMed (1996-2020), Cochrane Central Trials (1985-2020), EMBASE (2000-2020), and ClinicalTrials.gov (2000-2020).

EXPERT OPINION

Upon evaluation of risks and benefits of ESAs focused opinion and commentary is made supporting more liberal use of these agents and strongly suggesting that the current underlying treatment 'pendulum' has perhaps shifted too far to the 'under-treatment' side in many cases.

Growth differentiation factor 15 in adverse cardiac remodelling: from biomarker to causal player

Heart failure is a growing health issue as a negative consequence of improved survival upon myocardial infarction, unhealthy lifestyle, and the ageing of our population. The large and complex pathology underlying heart failure makes diagnosis and especially treatment very difficult. There is an urgent demand for discriminative biomarkers to aid disease management of heart failure. Studying cellular pathways and pathophysiological mechanisms contributing to disease initiation and progression is crucial for understanding the disease process and will aid to identification of novel biomarkers and potential therapeutic targets. Growth differentiation factor 15 (GDF15) is a proven valuable biomarker for different pathologies, including cancer, type 2 diabetes, and cardiovascular diseases. Although the prognostic value of GDF15 in heart failure is robust, the biological function of GDF15 in adverse cardiac remodelling is not fully understood. GDF15 is a distant member of the transforming growth factor-β family and involved in various biological processes including inflammation, cell cycle, and apoptosis. However, more research is suggesting a role in fibrosis, hypertrophy, and endothelial dysfunction. As GDF15 is a pleiotropic protein, elucidating the exact role of GDF15 in complex disease processes has proven to be a challenge. In this review, we provide an overview of the role GDF15 plays in various intracellular and extracellular processes underlying heart failure, and we touch upon crucial points that need consideration before GDF15 can be integrated as a biomarker in standard care or when considering GDF15 for therapeutic intervention.

Trends of Clinical Outcomes and Health Care Resource Use in Heart Failure in the United States

Background Heart failure (HF) imparts a significant clinical and economic burden on the health system in the United States. Methods and Results We used the National Inpatient Sample database between September 2002 and December 2016. We examined trends of comorbidities, inpatient mortality, and healthcare resource use in patients admitted with acute HF. Outcomes were adjusted for demographic variables, comorbidities, and inflation. A total of 11 806 679 cases of acute HF hospitalization were identified. The burden of coronary artery disease, peripheral vascular disease, valvular heart disease, diabetes mellitus, hypertension, anemia, cancer, depression, and chronic kidney disease among patients admitted with acute HF increased over time. The adjusted mortality decreased from 6.8% in 2002 to 4.9% in 2016 (P-trend<0.001; average annual decline, 1.99%), which was consistent across age, sex, and race. The adjusted mean length of stay decreased from 8.6 to 6.5 days (P<0.001), but discharge disposition to a long-term care facility increased from 20.8% to 25.6% (P<0.001). The adjusted mean cost of stay increased from $51 548 to $72 075 (P<0.001; average annual increase, 2.78%), which was partially explained by the higher proportion of procedures (echocardiogram, right heart catheterization, use of ventricular assist devices, coronary artery bypass grafting) and the higher incidence of HF complications (cardiogenic shock, respiratory failure, ventilator, and renal failure requiring dialysis). Conclusions This national data set showed that despite increasing medical complexities, there was significant reduction in inpatient mortality and length of stay. However, these measures were counterbalanced by a higher proportion of discharge disposition to long-term care facilities and expensive cost of care.

Coexisting Morbidities in Heart Failure: No Robust Interaction with the Left Ventricular Ejection Fraction

PURPOSE OF REVIEW

Heart failure (HF) patients often present with multiple coexisting morbidities. In this review, we contend that coexisting morbidities are highly prevalent and clinically important regardless of the left ventricular ejection fraction (LVEF).

RECENT FINDINGS

Multimorbidity is prevalent in the ambulatory subjects of the community and increases with age. Differences in the prevalence of coexisting morbidities between HF with preserved LVEF (> 50%), mid-range LVEF (40-50%), and reduced LVEF (< 40%) are either not demonstrable or whenever present are small and unrelated to morbidity and mortality. The constellation of coexisting morbidities together with the disease modifiers (age, sex, genes, other) defines the HF phenotype and outcome. There is no robust evidence supporting an interaction in HF patients between the prevalence and clinical significance of coexisting morbidities and the LVEF.

Clinical relationship between anemia and atrial fibrillation recurrence after catheter ablation without genetic background

Background

Anemia is a known adverse prognostic factor among patients with cardiovascular diseases. We investigated whether the hemoglobin level was associated with the rhythm outcome after atrial fibrillation (AF) catheter ablation (AFCA).

Methods

We included 2627 patients who underwent AFCA and a guidelines-based rhythm follow-up (age 58 ± 10.9 years, 73% men, 30.6% with persistent AF), and evaluated the association of pre-AFCA anemia (haemoglobin <13 g/dL in men and <12 g/dL in women) and rhythm outcomes. We studied the mechanistic relationship between anemia and AF recurrence using a Mendelian randomization analysis (1775 subjects with genome-wide association study) after reviewing already proven 12 hemoglobin-associated genetic polymorphisms.

Results

The body mass index, paroxysmal AF, warfarin use, and baseline red cell distribution width were independently associated with anemia in patients with AF. During a 23-month follow-up (interval OR 9–48 months), the clinical AF recurrence rate was significantly higher in patients with than without anemia (log-rank p = 0.001; propensity score-matched log-rank p = 0.004). This pattern was more significant in male patients (Log-rank p < 0.001) or patients with paroxysmal AF (Log-rank p < 0.001). Anemia (hazard ratio [HR] 1.45 [1.17–1.80], p = 0.001), left atrial diameter (HR 1.03 [1.01–1.04], p < 0.001), a female sex (HR 1.17 [1.00–1.36], p = 0.047), and persistent AF (HR 1.58 [1.36–1.84], p < 0.001) were independently associated with post-AFCA clinical recurrence. In the Mendelian randomization, we could not find a significant direct causal relationship between anemia and AF recurrence at the genetic level.

Conclusions

Pre-AFCA anemia is an independent predictor of post-AFCA clinical recurrence, especially in male patients, without a genetically direct causal relationship.

Causes and predictors of early mortality in patients treated with left ventricular assist device implantation in the European Registry of Mechanical Circulatory Support (EUROMACS)

PURPOSE

The aim of the study was to analyze early mortality after continuous-flow left ventricular assist device (LVAD) implantation which remains high.

METHODS

We analyzed consecutive (n = 2689) patients from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) undergoing continuous-flow LVAD implantation. The primary outcome was early (< 90 days) mortality. Secondary outcomes were differential causes of early post-operative death following LVAD implantation.

RESULTS

Univariable and multivariable analysis as well as regression analysis were used to examine determinants and differential causes of early (< 90 days) mortality after LVAD implantation. During the first 90 days, 2160 (80%) patients were alive with ongoing LVAD support, 40(2%) patients underwent heart transplantation, and 487(18%) deceased. The main causes of early death were MOF (36%), sepsis (28%), cardiopulmonary failure (CPF; 10%), CVA (9%), and right-sided heart failure (RHF, 8%). Furthermore, MOF and sepsis are 70% of causes of death in the first week. Independent clinical predictors of early death were age, female sex, INTERMACS profile 1 to 3, and ECMO. Laboratory predictors included elevated serum creatinine, total bilirubin, lactate, and low hemoglobin. Furthermore, hemodynamic predictors included elevated RA-to-PCWP ratio, pulmonary vascular resistance, and low systemic vascular resistance. Longer total implantation time was also independent predictor of early mortality. A simple model of 12 variables predicts early mortality following LVAD implantation with a good discriminative power with area under the curve of 0.75.

CONCLUSIONS

In the EUROMACS registry, approximately one out of five patients die within 90 days after LVAD implantation. Early mortality is primarily dominated by multiorgan failure followed by sepsis. A simple model identifies important parameters which are associated with early mortality following LVAD implantation.