Anaemia is an independent predictor of poor outcome in patients with chronic heart failure

Predictors of lower exercise capacity in patients with cancer

Maintaining cancer patients' exercise capacity and therefore patients' ability to live a self-determined life is of huge importance, but little is known about major determinants. We sought to identify determinants of exercise capacity in patients with a broad spectrum of cancer types, who were already receiving cancer treatment or about to commence such therapy. Exercise capacity was assessed in 253 consecutive patients mostly suffering from advanced cancer using the 6-min walk test (6-MWT). All patients underwent echocardiography, physical examination, resting electrocardiogram, hand grip strength (HGS) measurement, and laboratory assessments. Patients were divided into two groups according to the median distance in the 6-MWT (459 m). Patients with lower exercise capacity were older, had significantly lower HGS and haemoglobin and higher values of high sensitive (hs) Troponin T and NT-proBNP (all p < 0.05). Whilst the co-morbidity burden was significantly higher in this group, no differences were detected for sex, body mass index, tumor type, or cachexia (all p > 0.2). Using multivariable logistic regression, we found that the presence of anaemia (odds ratio (OR) 6.172, 95% confidence interval (CI) 1.401-27.201, p = 0.016) as well as an increase in hs Troponin T (OR 3.077, 95% CI 1.202-5.301, p = 0.019) remained independent predictors of impaired exercise capacity. Increasing HGS was associated with a reduced risk of a lower exercise capacity (OR 0.896, 95% CI 0.813-0.987, p = 0.026). Screening patients for elevated hs troponin levels as well as reduced HGS may help to identify patients at risk of lower exercise capacity during cancer treatment.

Relationship Between Canagliflozin, Sodium Glucose Cotransporter 2 Inhibitor, and Hematopoietic Effects in Patients With Diabetes and Mild Heart Failure: Results From the CANDLE Trial

ABSTRACT

There were few clinical studies on the relationship between sodium glucose cotransporter 2 inhibitors (SGLT2i) and hematopoiesis in patients with diabetes (DM) and heart failure (HF) with consideration of systemic volume status. A total of 226 DM patients with HF enrolled in the CANDLE trial, a multicenter, prospective, randomized open-label blinded-endpoint trial, were studied. Estimated plasma volume status (ePVS) was calculated based on a weight- and hematocrit-based formula. At baseline, there was no significant difference in hematocrit and hemoglobin between the canagliflozin (n = 109) and glimepiride (n = 116) groups. Hematocrit and hemoglobin at 24 weeks, changes in hematocrit and hemoglobin difference (24 weeks-baseline), and hematocrit and hemoglobin ratio (24 weeks/baseline) were significantly higher in the canagliflozin than in the glimepiride group, respectively. There was no significant difference in ePVS at baseline and 24 weeks between the 2 groups. After adjustment for baseline parameters, canagliflozin correlated positively with changes in hematocrit and hemoglobin difference, and hematocrit and hemoglobin ratio by multivariate linear regression analyses. The difference in hematocrit and hemoglobin between the 2 groups became statistically significant at 3 and 6 months after randomization. There was no heterogeneity between canagliflozin and the characteristics of the patients for hematocrit and hemoglobin difference and ratio. A correlation of the changes in hematocrit and hemoglobin with cardiac and renal improvement was not observed. In conclusion, canagliflozin was associated with an increased hematocrit and hemoglobin in patients with diabetes and HF regardless of their volume status and characteristics.

Iron deficiency in cardiac surgical patients

Iron is an essential element and involved in a variety of metabolic processes including oxygen transport, cellular energy production, energy metabolism of heart muscles, brain function, cell growth and cell differentiation. Preoperative anaemia is an independent risk factor for poor outcome. Recently, iron deficiency was considered only in the context of anaemia. However, negative consequences of iron deficiency in the absence of anaemia have been described for patients undergoing cardiac surgery. To date, the benefit of intravenous iron supplementation in these patients has been controversially debated. In this review, we discuss the latest progress in studies of intravenous iron supplementation in iron deficient cardiac surgical patients.

Understanding main pregnancy complications through animal models

Since human pregnancy is an inefficient process, achieving desired and pleasant outcome of pregnancy - the birth of a healthy and fit baby - is the main goal in any pregnancy. Spontaneous pregnancy failure is actually the most common complication of pregnancy and Most of these pregnancy losses are not known. Animal models have been utilized widely to investigate the system of natural biological adaptation to pregnancy along with increasing our comprehension of the most important hereditary and non-hereditary factors that contribute to pregnancy disorders. We use model organisms because their complexity better reproduces the human condition. A useful animal model for the disease should be pathologically similar to the disease conditions in humans. Animal models deserve a place in research because of the ethical limitations that apply to pregnant women's experiments. The present review provides insights into the overall risk factors involved in recurrent miscarriage, recurrent implant failure and preeclampsia and animal models developed to help researchers identify the source of miscarriage and the best research and treatment strategy for women with Repeated miscarriage and implant failure.

Prognostic value of packed cell volume and blood glucose concentration in 954 client-owned chelonians

OBJECTIVE

To evaluate the prognostic value of PCV and blood glucose concentration in chelonians presented for veterinary care and to develop risk categories on the basis of the interaction of these analytes.

ANIMALS

954 client-owned chelonians (34 genera).

PROCEDURES

Medical records of 1,059 client-owned chelonians presented to 2 veterinary institutions between 2014 and 2018 were reviewed. Logistic regression models were developed to evaluate factors associated with death, including PCV and blood glucose concentrations.

RESULTS

There were 954 chelonians (34 genera) for which the data required to be included in the analysis were available. Both PCV and blood glucose concentration were significant prognostic indicators of death. Odds of death for chelonians with severe anemia (PCV, < 10%) and moderate anemia (PCV, 11% to 20%) were 6.8 times (adjusted odds ratio [aOR], 6.8; 95% CI, 3.8 to 12.3) and 1.6 times (aOR, 1.6; 95% CI, 1.01 to 2.7), respectively, the odds of death for chelonians with PCV within reference range. Odds of death for chelonians with severe hypoglycemia (< 30 mg/dL), moderate hyperglycemia (91 to 150 mg/dL), and severe hyperglycemia (> 181 mg/dL) were 5.3 times (aOR, 5.3; 95% CI; 2.4 to 11.4), 3 times (aOR, 3.0;95% CI, 1.4 to 6.3), and 4.3 times (aOR, 4.3; 95% CI, 2.4 to 7.6), respectively, the odds of death for chelonians with blood glucose concentration within reference range. Five risk categories were identified on the basis of PCV and blood glucose concentration.

CONCLUSIONS AND CLINICAL RELEVANCE

Derangements in PCV and blood glucose concentration in client-owned chelonians were associated with increased odds of death. On the basis of these results, more aggressive diagnostic testing and treatments may be indicated in chelonians with similar alterations.

Socio-economic assessment of patient blood management practical implementation in surgical treatment of coronary heart disease (I20-I25)

Aim    To evaluate possible social and economic benefits of correcting preoperative iron deficiency /iron deficiency anemia as a comorbidity in a model population in the process of transition from the routine practice to the optimized preparation of patients to elective surgery (as exemplified by several circulatory diseases: I20 - I25, class IX ICD 10).Material and methods    By building imitation models depending on the patient blood management (PBM) practice, changes in years of life lost/saved adjusted for disability were evaluated, including in monetary terms, in relation to the annual number of operations performed for ischemic heart disease (IHD) (I20 - I25) in the age group of 17 years and older, as well as a potential effect of PBM on the applied health economics.Results    With implementation of the PBM systemic measures in cardiac surgery, the potentially prevented annual social and economic damage will amount to more than 38 thousand years of life saved and more than 20.2 billion rubles in monetary terms. Furthermore, it will be possible to exclude 9435 hemotransfusion from the cardiosurgical practice, which will annually save more than 2.3 thousand liters of blood with a total cost of 77.7 million rubles in favor of clinical situations that have no alternative.Conclusion    The implementation of PBM in cardiac surgery, the discipline with the highest levels of preoperative iron deficiency/anemia and the use of blood components, will not only improve the clinical outcomes and cost-effectiveness of surgical interventions, but will also prevent social and economic damage to the country.

Clinical Implications of the Coexistence of Anemia and Diabetes Mellitus in the Elderly Population

Diabetes mellitus (DM) and also anemia are common in the elderly and have a negative impact on the clinical outcomes of patients. The coexistence of anemia and DM seems to be insufficiently recognized; therefore, the aim of our study is to analyze the incidence and clinical consequences of this coexistence, including mortality, in the population of people aged ≥60. A retrospective study was conducted on 981 primary care clinic patients aged ≥60 during 2013-2014. The prevalence of coexistence of DM and anemia (defined in accordance with WHO) and data on the incidence of comorbidities, hospitalization, medical procedures, and all-cause mortality were analyzed. In the study population, 25% had DM, while 5.4% had both DM and anemia. Peripheral artery disease (PAD) was found in 48 patients (4.89%) of the entire study population, more often in men (p < 0.001). Diabetic patients with anemia compared to nonanemic diabetics had more comorbidities (median 4 (4, 5) vs. 3 (2-4); p < 0.001)-PAD more often (p = 0.004), more hospitalization (median 2 (0-11) vs. 0 (0-11); p < 0.001), and more frequent medical procedures (e.g., percutaneous coronary intervention (p < 0.001), coronary artery bypass surgery (p = 0.027), arteriography (p < 0.001), and bypass surgery or endovascular treatments of lower limb ischemia (p < 0.001)). The cumulative survival of patients with both DM and anemia vs. nonanemic diabetics at 36 months was 86.4% vs. 99.3% (p < 0.001). A multivariate logistic regression model showed anemia to be a significant risk factor for death in diabetic patients (p = 0.013). Patients with both DM and anemia have more comorbidities than nonanemic diabetic patients; they are more often hospitalized, require medical procedures more frequently, and are at a higher risk of death. Effective treatment of anemia in patients with DM is advisable and may well improve the prognosis of patients.

The Interplay between Preoperative Anemia and Postoperative Blood Transfusion on Survival following Fenestrated Aortic Aneurysm Repair

BACKGROUND

Anemia is associated with a higher mortality following standard endovascular aortic repair (EVAR). This study evaluates the impact of anemia on fenestrated endovascular aneurysm repair (FEVAR) for complex aneurysm (AAA) repair.

METHODS

All elective FEVARs performed between 2010 and 2018 at a tertiary vascular center were analyzed. Anemia was defined as a preoperative hemoglobin (Hb) of <120 g/L for women and <130 g/L for men (World Health Organization definition). Primary outcome was overall survival by Kaplan-Meier. Secondary outcomes included length of hospital stay (LOS) and myocardial infarction (MI). Cox proportional hazard analyses were conducted.

RESULTS

In total, 132 FEVAR patients were followed up for 3.7 (2.2) years. Thirty-eight patients were anemic [average Hb of 112 (13) g/L]. Groups were comparable for age, AAA diameter, body mass index, and comorbidity. Anemic patients had a lower baseline estimated glomerular filtration rate [64.1 (23.2) vs. 70.9 (18.8) mL/min/1.73 m², P = 0.022] and a longer procedural time [242 (103) vs. 195.4 (88) min, P = 0.009] with no difference in the number of fenestrations (P = 0.696). Kaplan-Meier analysis demonstrated a higher mortality (log-rank P = 0.03) with 40% deceased versus 21% nonanemic (P = 0.04) at the end of follow-up. Anemic patients had more postoperative myocardial infarctions (MIs) (4 vs. 2, P = 0.037) and a longer LOS [9.2 (7.1) vs. 6.3 (6.8) days, P = 0.001]. Increasing Hb increased the likelihood of survival [hazard ratio, HR -0.8 (0.65-0.94), P = 0.038]. Postoperative transfusion was adversely associated with survival [HR 3.65 (1.05-12.8), P = 0.043].

CONCLUSIONS

Anemia appears to be associated with an increased rate of postoperative MI, LOS, frequency of blood transfusion, and mortality rate following FEVAR but this surpassed by postoperative blood transfusion. Optimization of preoperative Hb should be considered as a potential target for improvements in clinical outcomes and hypothetically a consequential reduction in postoperative red blood cell transfusion need.

Anaemia, iron status, and gender predict the outcome in patients with chronic heart failure

Aims

Anaemia and iron deficiency (ID) are frequently found in patients with chronic heart failure (CHF) and associated with adverse outcome. However, it is unclear whether absolute [transferrin saturation (TSAT) <20%, ferritin <100 μg/L] or inflammation‐driven functional ID (TSAT <20%, ferritin >100 μg/L) with and without anaemia had similar or different consequences for such patients.

Methods and results

Within this retrospective cohort study, 2223 patients (1601 men and 622 women) with CHF, referred to our department, between 2000 and 2018, were followed for a median time of 84 months. Anaemia was found in 393 patients and was an independent predictor for an adverse outcome [HR 2.164 (95% CI 1.865–2.512), P < 0.001]. In 674 patients with available parameters of iron metabolism, ID was present in 228 patients and was associated with an unfavourable outcome [HR 1.499 (95% CI 1.158–1.940), P = 0.002]. ID was best predicting an adverse outcome in men ≤59 years, with heart failure with reduced ejection fraction, preserved kidney function, no inflammation, and a body mass index (BMI) ≥25.5 kg/m². Functional ID in women and absolute ID in men were associated with poor prognosis. Of note, TSAT <20% but not low ferritin levels were predictive for an adverse outcome. Anaemic patients with high ferritin levels, advanced inflammation, older age, low BMI, male gender, and reduced glomerular filtration rate had the worst prognosis.

Conclusions

Anaemia and low tissue iron availability as reflected by TSAT <20% are negative predictors of outcome in patients with CHF. Systemic inflammation, renal function, BMI, age, and gender are important contributors for the clinical course.

Troponin in critical care patients and outcomes

Myocardial infarction is common in the critically unwell population with pre-existing cardiovascular disease and is associated with a greater overall mortality. This article explores guidelines for diagnosing myocardial infarction, and research into the use of troponin as both a diagnostic and prognostic tool. Currently, the majority of patients in the intensive care unit with acute myocardial infarction go unrecognised. The underlying cause is predominantly oxygen supply-demand imbalance, therefore identifying those at risk is important as there is the potential to modify elements of their care and reduce their overall mortality.

Impacts of non-recovery of trastuzumab-induced cardiomyopathy on clinical outcomes in patients with breast cancer

OBJECTIVES

The impacts of non-recovery of trastuzumab-induced left ventricular dysfunction (LVD) on clinical outcomes in breast cancer have been poorly studied. We investigated the predictors of LV-functional non-recovery and its impacts on clinical outcomes in breast cancer patients with trastuzumab-induced LVD.

METHODS AND RESULTS

A total of 243 patients with trastuzumab-induced LVD were divided into the recovered LVD group (n = 195) and non-recovered LVD group (n = 48). Major adverse clinical events (MACEs) including death, symptomatic heart failure (HF), and HF hospitalization (HHF) were compared. Hemoglobin and albumin levels were significantly lower in non-recovered LVD than in recovered LVD group. Non-recovered LVD group showed significantly larger LV end-diastolic and systolic dimension, higher pulmonary artery systolic pressure, lower LV ejection fraction (EF), and decreased global longitudinal strain than in recovered LVD group. Decreased LVEF, enlarged LV size, pulmonary hypertension, and anemia were independent predictors of LV-functional non-recovery. During 45.9 ± 23.5 months of follow-up, MACEs were developed in 32 patients: 15 deaths, 28 symptomatic HF, and 22 HHF. In Kaplan-Meier survival analysis, MACE free survival was significantly lower in non-recovered LVD group than in recovered LVD group (log rank p = 0.002).

CONCLUSION

LV-functional non-recovery was not uncommon in breast cancer patients with trastuzumab-induced cardiomyopathy, and non-recovered LVD was significantly associated with MACEs. Decreased LVEF, enlarged LV size, pulmonary hypertension, and anemia were independent predictors of LV-functional non-recovery. Careful monitoring for MACEs and intensive medical management should be considered in trastuzumab-induced cardiomyopathy with these characteristics.

Intravenous Iron Therapy in Heart Failure

Iron deficiency anemia is both a comorbid condition and an indicator of poor prognosis in heart failure. The mechanisms by which this occurs are multiple and complex. Recent robust randomized clinical trials have shown significant improvements in quality of life and rates of hospitalization with intravenous repletion of iron. In this article, we review the mechanisms by which iron deficiency impacts heart failure and the evidence behind repletion. There remains a good deal to learn about long-term effects of intravenous iron repletion, and clinical trials are ongoing in this regard.

Hemoglobin Kinetics and Long-term Prognosis in Heart Failure

INTRODUCTION AND OBJECTIVES

The influence of hemoglobin kinetics on outcomes in heart failure has been incompletely established.

METHODS

Hemoglobin was determined at the first visit and at 6 months. Anemia was defined according to World Health Organization criteria (hemoglobin < 13g/dL for men and hemoglobin < 12g/dL for women). Patients were classified relative to their hemoglobin values as nonanemic (both measurements normal), transiently anemic (anemic at the first visit but not at 6 months), newly anemic (nonanemic initially but anemic at 6 months), or permanently anemic (anemic in both measurements).

RESULTS

A total of 1173 consecutive patients (71.9% men, mean age 66.8±12.2 years) were included in the study. In all, 476 patients (40.6%) were considered nonanemic, 170 (14.5%) had transient anemia, 147 (12.5%) developed new-onset anemia, and 380 (32.4%) were persistently anemic. During a follow-up of 3.7±2.8 years after the 6-month visit, 494 patients died. On comprehensive multivariable analyses, anemia (P < .001) and the type of anemia (P < .001) remained as independent predictors of all-cause mortality. Compared with patients without anemia, patients with persistent anemia (hazard ratio [HR] = 1.62; 95% confidence interval [95%CI], 1.30-2.03; P < .001) and new-onset anemia (HR = 1.39; 95%CI, 1.04-1.87, P = .03) had higher mortality, and even transient anemia showed a similar trend, although without reaching statistical significance (HR = 1.31; 95%CI, 0.97-1.77, P = .075).

CONCLUSIONS

Anemia, especially persistent and of new-onset, and to a lesser degree, transient anemia, is deleterious in heart failure.

Comprehensive therapeutic approach for patients with heart failure and comorbidity

The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype». Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.

Prognostic role of echocardiographic and hematologic parameters in heart failure patients complicated with incidental pleural effusion diagnosed during echocardiographic evaluation

We aimed to determine long-term prognostic role of echocardiographic and hematologic parameters in heart failure patients complicated with incidental pleural effusion (PE) diagnosed during echocardiographic evaluation. The study was performed by evaluating patient records in which PE was incidentally detected during echocardiographic examination in a tertiary teaching hospital between Jan 2002 and Dec 2012. Total 151 patients with heart failure complicated with PE were analyzed. All patients' mortality data were collected from registry center of Social Insurance Institution which is officially responsible for recording all mortality data in Turkey. Detailed echocardiographic and hematologic parameters including creatinine, uric acid, albumin, sodium, potassium, hemoglobin at the time of hospital admission were analyzed. Data from 151 eligible patients were analyzed. We compared patients who died (n = 51) during follow-up with the survivors (n = 100) in terms of patients' echocardiographic and hematological features. Mean duration of follow-up was 71.5 ± 45.6 months. Fifty-one patients (33.8 %) died during this follow-up period. From all echocardiographic parameters only dilated left atrium (LA) diameter was found to be associated with a poor prognosis (p = 0.034). Low albumin, sodium and hemoglobin levels were associated with poor prognosis (p < 0.001, p = 0.002 and p = 0.007, respectively). We showed that dilated LA, as well as low albumin, low sodium and low hemoglobin levels had a worse prognostic significance than patients with normal LA size, within normal limits of albumin, sodium and hemoglobin levels in patients with heart failure complicated with PE determined incidentally by echocardiography.

Do optimal prognostic thresholds in continuous physiological variables really exist? Analysis of origin of apparent thresholds, with systematic review for peak oxygen consumption, ejection fraction and BNP

Background

Clinicians are sometimes advised to make decisions using thresholds in measured variables, derived from prognostic studies.

Objectives

We studied why there are conflicting apparently-optimal prognostic thresholds, for example in exercise peak oxygen uptake (pVO₂), ejection fraction (EF), and Brain Natriuretic Peptide (BNP) in heart failure (HF).

Data Sources and Eligibility Criteria

Studies testing pVO₂, EF or BNP prognostic thresholds in heart failure, published between 1990 and 2010, listed on Pubmed.

Methods

First, we examined studies testing pVO₂, EF or BNP prognostic thresholds. Second, we created repeated simulations of 1500 patients to identify whether an apparently-optimal prognostic threshold indicates step change in risk.

Results

33 studies (8946 patients) tested a pVO₂ threshold. 18 found it prognostically significant: the actual reported threshold ranged widely (10–18 ml/kg/min) but was overwhelmingly controlled by the individual study population's mean pVO₂ (r = 0.86, p<0.00001). In contrast, the 15 negative publications were testing thresholds 199% further from their means (p = 0.0001). Likewise, of 35 EF studies (10220 patients), the thresholds in the 22 positive reports were strongly determined by study means (r = 0.90, p<0.0001). Similarly, in the 19 positives of 20 BNP studies (9725 patients): r = 0.86 (p<0.0001).

Second, survival simulations always discovered a “most significant” threshold, even when there was definitely no step change in mortality. With linear increase in risk, the apparently-optimal threshold was always near the sample mean (r = 0.99, p<0.001).

Limitations

This study cannot report the best threshold for any of these variables; instead it explains how common clinical research procedures routinely produce false thresholds.

Key Findings

First, shifting (and/or disappearance) of an apparently-optimal prognostic threshold is strongly determined by studies' average pVO₂, EF or BNP. Second, apparently-optimal thresholds always appear, even with no step in prognosis.

Conclusions

Emphatic therapeutic guidance based on thresholds from observational studies may be ill-founded. We should not assume that optimal thresholds, or any thresholds, exist.

Anemia, heart failure and evidence-based clinical management

Anemia is a prevalent comorbidity and marker of a poorer prognosis in patients with heart failure (HF). Its clinical relevance, as well as its pathophysiology and the clinical management of these patients are important subjects in the specialized literature. In the present review, we describe the current concepts on the pathophysiology of anemia in HF, its diagnostic criteria, and the recommendations for iron supplementation. Also, we make a critical analysis of the major studies showing evidences on the benefits of this supplementation. The four main components of anemia are addressed: chronic disease, dilutional, "renal" and malabsorption. In patients with HF, the diagnostic criteria are the same as those used in the general population: serum ferritin levels lower than 30 mcg/L in patients without kidney diseases and lower than 100 mcg/L or serum ferritin levels between 100-299 mcg/L with transferring saturation lower than 20% in patients with chronic kidney diseases. Finally, the therapeutic possibilities for anemia in this specific patient population are discussed.

Anemia in chronic heart failure: can we treat? What to treat?

Even though anemia is a significant comorbidity regularly observed in patients with chronic heart failure (HF), only in recent years systematic therapeutic research has been started. This article aims to review the aspects of anemia in chronic HF that are relevant for making treatment decisions, beginning with the definition of anemia and its incidence and prevalence of anemia in patients with chronic HF. Considering the etiology and prognostic impact of anemia in chronic HF, several treatment options will be considered. The latter are the application of erythropoiesis-stimulating agents (erythropoietin or darbepoetin alfa) or in the application of intravenous iron (e.g., iron carboxymaltose). According to the results seen in the FAIR-HF trial, iron supplementation should be particularly considered to improve symptoms and quality of life. Intravenous iron application may result in higher compliance and much faster treatment response than oral iron. The RED-HF study will show whether use of darbepoetin alfa in anemic patients with chronic HF will reduce the combined endpoint of death for any reason or hospitalization for heart failure.

Iron deficiency and heart failure: diagnostic dilemmas and therapeutic perspectives

Iron is a micronutrient essential for cellular energy and metabolism, necessary for maintaining body homoeostasis. Iron deficiency is an important co-morbidity in patients with heart failure (HF). A major factor in the pathogenesis of anaemia, it is also a separate condition with serious clinical consequences (e.g. impaired exercise capacity) and poor prognosis in HF patients. Experimental evidence suggests that iron therapy in iron-deficient animals may activate molecular pathways that can be cardio-protective. Clinical studies have demonstrated favourable effects of i.v. iron on the functional status, quality of life, and exercise capacity in HF patients. It is hypothesized that i.v. iron supplementation may become a novel therapy in HF patients with iron deficiency.

Iron supplementation for the treatment of chronic heart failure and iron deficiency: systematic review and meta-analysis

AIMS

Over half of chronic heart failure (CHF) patients are anaemic, and iron deficiency is common. Iron replacement therapy (oral or i.v.) might improve exercise capacity and quality of life (QOL).

METHODS AND RESULTS

We carried out a systematic review and meta-analysis of all randomized control trials that compared iron with no therapy for CHF patients with iron deficiency, whether or not they were anaemic. We searched electronic databases as well as haematology and cardiology conferences up to August 2011. The primary outcome was the effect of iron on QOL parameters such as New York Heart Association (NYHA) class and the Minnesota Living With Heart Failure Questionnaire (MLHWFQ). Secondary outcomes included all-cause mortality, mean ejection fraction, 6 min walk distance (6MWD), hospitalizations due to any cause, iron indices, C-reactive protein levels, and adverse events. Four trials performed fulfilled the inclusion criteria. A total of 370 patients were treated with i.v. iron, compared with 224 control patients. There was significant improvement in QOL in the iron arm according to the MLWHFQ score at 26 weeks, with a weighted mean difference of -18.00 (-22.54, -13.46, I(2) = 0%]. The point estimate for improvement in NYHA class was in favour of iron. Iron reduced the number of hospitalizations and C-reactive protein levels, and increased the 6MWD and mean ejection fraction. Iron indices were significantly improved without a change in haemoglobin levels. No increase in the rate of adverse events was found.

CONCLUSION

Intravenous iron therapy is associated with improved QOL parameters, reduction in hospitalizations, and increased 6MWD. Treatment with i.v. iron is safe, with no increased rate of adverse events. The results of our analysis are limited by the paucity of trials, and significant heterogeneity between trials.

Treatment of anemia in heart failure: potential risks and benefits of intravenous iron therapy in cardiovascular disease

Iron-deficiency anemia is common in patients with heart failure (HF), but the optimum diagnostic tests to detect iron deficiency and the treatment options to replete iron have not been fully characterized. Recent studies in patients with HF indicate that intravenous iron can rapidly replenish iron stores in patients having iron-deficiency anemia, with resultant increased hemoglobin levels and improved functional capacity. Preliminary data from a subgroup analysis also suggest that supplemental intravenous iron therapy can improve functional capacity even in those subjects without anemia. The mechanisms responsible for this observation are not fully characterized, but may be related to beneficial effects of iron supplementation on mitochondrial respiration in skeletal muscle. The long-term safety of using intravenous iron supplementation in HF populations is not known. Iron is a known pro-oxidant factor that can inhibit nitric oxide signaling and irreversibly injury cells. Increased iron stores are associated with vascular endothelial dysfunction and increased risk of coronary heart disease events. Additional clinical trials are needed to more fully characterize the therapeutic potential and safety of intravenous iron in HF patients.

Iron deficiency: an ominous sign in patients with systolic chronic heart failure

AIMS

Beyond erythropoiesis, iron is involved in numerous biological processes crucial for maintenance of homeostasis. Patients with chronic heart failure (CHF) are prone to develop iron deficiency (ID), and iron supplementation improves their functional status and quality of life. We sought to examine the relationship between ID and survival in patients with systolic CHF.

METHODS AND RESULTS

In a prospective observational study, we evaluated 546 patients with stable systolic CHF [age: 55 +/- 11 (mean +/- standard deviation) years, males: 88%, left ventricular ejection fraction: 26 +/- 7%, New York Heart Association (NYHA) class (I/II/III/IV): 57/221/226/42]. Iron deficiency was defined as: ferritin <100 microg/L, or 100-300 microg/L with transferrin saturation <20%. The prevalence of ID was 37 +/- 4% [+/-95% confidence intervals (CI)] in the entire CHF population (32 +/- 4 vs. 57 +/- 10%-in subjects without vs. with anaemia defined as haemoglobin level <12 g/dL in women and <13 g/dL in men, P < 0.001). In a multiple logistic model, ID was more prevalent in women, those in the advanced NYHA class, with higher plasma N-terminal pro-type B natriuretic peptide and higher serum high-sensitivity C-reactive protein (all P < 0.05). At the end of follow-up (mean duration: 731 +/- 350 days), there were 153 (28%) deaths and 30 (6%) heart transplantations (HTX). In multivariable models, ID (but not anaemia) was related to an increased risk of death or HTX (adjusted hazard ratio 1.58, 95% CI 1.14-2.17, P < 0.01).

CONCLUSION

In patients with systolic CHF, ID is common and constitutes a strong, independent predictor of unfavourable outcome. Iron supplementation may be considered as a therapeutic approach in these patients to improve prognosis.

Association of anemia and long-term survival in patients with pulmonary hypertension

BACKGROUND

Anemia is a marker of worsened clinical outcome in patients with heart failure from left ventricular dysfunction. Pulmonary hypertension often results in right ventricular dysfunction. Accordingly we sought to examine the association of hemoglobin levels and long-term all-cause mortality in a cohort of patients with pulmonary hypertension.

METHODS

Baseline demographic information, clinical characteristics and fasting blood work were obtained in a cohort of 145 patients with pulmonary hypertension referred for pulmonary vasodilator testing. Data was retrospectively analyzed with Cox-proportional hazards analysis.

RESULTS

Baseline characteristics of the cohort included age (mean±SD) 55.8±14.6 years, 75% women, 50% with idiopathic pulmonary hypertension, mean pulmonary artery pressure 46.1±14.2 mm Hg and arterial O(2) saturation 91±6 %. The most commonly utilized pulmonary hypertension specific therapeutic agents in descending order of frequency were epoprostenol (27%), sildenafil (21%), bosentan (17%), and treprostinil (6%). Over a median follow-up of 2.1 years, there were 39 deaths (26.9%). Patients who died had significantly lower hemoglobin levels than those survived (12.2±2.3 vs. 13.7±2.0, p<0.001). After adjustment for known predictors of death and pulmonary hypertension etiology, anemic patients were 3.3 times more likely to die than non-anemic patients (95% CI [1.43-7.51], p=0.005).

CONCLUSIONS

Hemoglobin levels closely parallel survival in pulmonary hypertension. Modification of anemia in this disorder could alter the clinical course and calls for further research in this area.

The economic burden of anemia in heart failure

Anemia is a complex issue in patients with heart failure (HF). In past years, clinicians accepted anemia as a given or an "accessory" diagnosis in HF patients. This attitude has changed since understanding of the causes and morbidity of anemia in HF has improved and with the introduction of targeted treatments. Increasing health care costs have stimulated vigorous debate about the cost-effectiveness of such treatments. It behooves clinicians to understand the effectiveness of specific treatments, risks and benefits, and costs. This review addresses the impact of anemia's prevalence, etiology, associated outcomes, and treatments on the economic burden of HF patients.

Managing anemia in patients with chronic heart failure: what do we know?

Anemia is common in patients with chronic heart failure (HF) with an incidence ranging from 4% to 55% depending on the studied population. Several studies have highlighted that the prevalence of anemia increases with worsening heart failure as reflected by New York Heart Association classification. Additionally, several epidemiological studies have highlighted its role as a prognostic marker, linking it to worse outcomes including; malnutrition, increased hospitalizations, refractory heart failure and death. The pathophysiology of anemia is multifactorial and related to various factors including; hemodilution, iron losses from anti-platelet drugs, activation of the inflammatory cascade, urinary losses of erythropoietin and associated renal insufficiency. There are a host of epidemiological studies examining HF outcomes and anemia, but only a few randomized trials addressing this issue. The purpose of this article is to review the literature that examines the interrelationship of anemia and congestive HF, analyzing its etiology, impact on outcomes and also the role of associated kidney disease as well as cardiorenal syndrome both as a marker of morbidity and mortality.

Rationale and design of Ferinject assessment in patients with IRon deficiency and chronic Heart Failure (FAIR-HF) study: a randomized, placebo-controlled study of intravenous iron supplementation in patients with and without anaemia

Aims

Iron deficiency (ID) and anaemia are common in patients with chronic heart failure (CHF). The presence of anaemia is associated with increased morbidity and mortality in CHF, and ID is a major reason for the development of anaemia. Preliminary studies using intravenous (i.v.) iron supplementation alone in patients with CHF and ID have shown improvements in symptom status. FAIR-HF (Clinical Trials.gov NCT00520780) was designed to determine the effect of i.v. iron repletion therapy using ferric carboxymaltose on self-reported patient global assessment (PGA) and New York Heart Association (NYHA) in patients with CHF and ID.

Methods and results

This is a multi-centre, randomized, double-blind, placebo-controlled study recruiting ambulatory patients with symptomatic CHF with LVEF ≤ 40% (NYHA II) or ≤45% (NYHA III), ID [ferritin <100 ng/mL or ferritin 100–300 ng/mL when transferrin saturation (TSAT) < 20%], and haemoglobin 9.5–13.5 g/dL. Patients were randomized in a 2:1 ratio to receive ferric carboxymaltose (Ferinject^®) 200 mg iron i.v. or saline i.v. weekly until iron repletion (correction phase), then monthly until Week 24 (maintenance phase). Primary endpoints are (i) self-reported PGA at Week 24 and (ii) NYHA class at Week 24, adjusted for baseline NYHA class.

Conclusion

This study will provide evidence on the efficacy and safety of iron repletion with ferric carboxymaltose in CHF patients with ID with and without anaemia.

A secondary analysis of the CHOIR trial shows that comorbid conditions differentially affect outcomes during anemia treatment

The CHOIR trial in anemic patients with chronic kidney disease compared epoetin-alfa treatment with low (11.3 g/l) and high (13.5 g/l) hemoglobin targets on the composite end point of death, hospitalization for heart failure, stroke, and myocardial infarction. However, other anemia management trials in patients with chronic kidney disease found there was increased risk when hemoglobin is targeted above 13 g/dl. In this secondary analysis of the CHOIR trial, we compared outcomes among the subgroups of patients with diabetes and heart failure to describe the comparative relationship of treatment to these two different hemoglobin goals. By Cox regression analysis, there was no increased risk associated with the higher hemoglobin target among patients with heart failure. In patients without heart failure, however, the hazard ratio (1.86) associated with the higher target was significant. Comparing survival curves in an unadjusted model, patients with diabetes did not have a greater hazard associated with the higher target. Subjects without diabetes had a significantly greater hazard in the high as compared to the low target, but the interaction between diabetes and the target was not significant. We suggest that the increased risks associated with higher hemoglobin targets are not clinically apparent among subgroups with greater mortality risk. These differential outcomes underscore the need for dedicated trials in these subpopulations.

[Anemia in congestive heart failure]

Anemia is a common disorder in congestive heart failure and an independant prognostic factor. The aims of this study are to evaluate the prevalence of anemia among a population of in-hospital congestive heart failure patients, to compare anemic patients (A) with non anemic patients (NA) and to study their cares.

RESULTS

One hundred and thirty-two patients, 70 men (53%), et 62 women (47%) are enrolled. Mean age is 76.4+/-13.5 years. The prevalence of anemia (WHO criteria) is 49%. Patients A are older than NA: 79.1+/-13.8 years versus 73.8+/-12.9 years (p=0.025), renal function is more altered in A than in NA, creatinine clearance is 56.5 ml/min (A) versus 76.2 ml/min (NA) (p=0.003). Ejection fraction (EF) is lower in A than in NA: 35.1+/-15.3% versus 50.9+/-15.9%, (p<0.0001.) Anemia is less frequent in preserved EF (28%) than in low EF (63%) (p<0.0001). Hospitalization duration is longer in A than in NA: 10.7+/-10.1 days versus 6.9+/-3.7 days (p=0.005). There are more re hospitalized patients among A than NA: 38 versus 10 (p=0.0001). There is a significant difference of survival of NA versus A at day 614 (p=0.03).

CONCLUSION

Anemia is frequent in our population, and is associated with others prognostic factors and comorbidity.

[Percutaneous aortic valve replacement - pro]

Percutaneous aortic valve replacement is presently on its way to revolutionize the current treatment practice for patients with degenerative aortic valve stenosis. Two different techniques are available: the balloon-expandable Edwards valve prosthesis and the self-expanding CoreValve ReValving prosthesis. After an initial learning curve as well as device modifications, use of the current generations has a > 95% success rate with a low peri- and post-interventional complication rate. In this article, an overview on the current status of this technique will be provided.

Anemia: an independent predictor of death and hospitalizations among elderly patients with atrial fibrillation

BACKGROUND

Anemia and atrial fibrillation (AF) are common among the elderly. Anemia is an independent predictor of mortality and morbidity for numerous cardiovascular and noncardiovascular diseases, but the association of anemia with mortality and hospitalizations in patients with AF requires clarification.

METHODS

Subjects were 13,067 Medicare beneficiaries hospitalized with AF and included in the National Registry of Atrial Fibrillation II data set. Index hospitalization hematocrit (Hct) was obtained by structured chart abstraction. Cox proportional hazards models quantified the association of Hct with mortality and re-hospitalizations during a median follow-up period of 12 months.

RESULTS

The mean age was 79.8 years, 58% were women, and the mean Hct was 39.2%. Hematocrit was significantly (P < .0001) associated with risk of death and of rehospitalization even after adjustment for demographic information, comorbid conditions, and use of cardiovascular medications. As compared to a Hct of 40% to 44.9%, the adjusted hazard ratios for mortality were 1.66 for Hct <25%, 1.50 for 25% to 29.9%, 1.28 for 30% to 34.9%, 1.07 for 35% to 39.9%, 1.03 for 45% to 49.9%, and 1.10 for > or = 50%. The association between anemia and mortality was significant in men and women but stronger in men (P = .006 for interaction). Compared to the category 40% to 44.9%, the risk of rehospitalization was increased to 28% (adjusted hazard ratio 1.28, 95% CI 1.15-1.43) in the Hct category 25% to 29.9%.

CONCLUSION

Anemia is an independent predictor of mortality and of hospitalizations in elderly patients with AF. Studies are needed to assess the effect of treatment of anemia on clinical outcomes.

The impact of anemia on the prognosis of chronic heart failure: a meta-analysis and systemic review

The aim of this study was to assess the impact of anemia on the clinical outcomes of chronic heart failure (CHF) by a meta-analysis and systemic review of published literatures. Twenty published English-language articles were selected from Medline, PubMed, and ISI Database. Clinical data were extracted, pooled, and analyzed with a fixed- or random-effects model. A total of 97,699 patients with CHF were identified from the published studies. Meta-analysis of these studies indicated that anemia is associated with a higher risk for death (relative risk [RR], 1.66; P<.0001). In addition, anemic patients had more advanced New York Heart Association class (III or IV; RR, 1.35; P<.0001) and lower left ventricular ejection fraction (weight mean difference, -0.53; P<.0001) than nonanemic patients. Systemic review also revealed that the severity of anemia is closely related to the rate of mortality and hospitalization for heart failure. Anemia is associated with an increased risk of mortality and rate of hospitalization for heart failure. Anemia is an independent risk factor for adverse outcomes in patients with CHF.

Prevalence, incidence, and prognostic value of anaemia in patients after an acute myocardial infarction: data from the OPTIMAAL trial

AIMS

The prevalence, incidence, and prognostic value of anaemia in patients with an acute myocardial infarction (AMI) complicated by heart failure is unclear.

METHODS AND RESULTS

We analysed the relationship between haemoglobin (Hb) and outcome in 5010 patients with AMI complicated by heart failure in the OPTIMAAL study. In 3921 patients, follow-up Hb levels were available at 365 (+/-90) days. In a subgroup of 224 patients, iron-related haematinics were assessed at baseline and during follow-up. At baseline, mean Hb was 12.6 +/- 1.3 g/dL in women and 13.7 +/- 1.4 g/dL in men. Hb < 11.5 g/dL was found in 9.3% of patients (women: 18.2%, men: 5.8%). Lower haemoglobin at baseline was clearly associated with female gender and the presence of diabetes, higher age and Killip class, lower body mass index, systolic blood pressure, total cholesterol, and the absence of current smoking (all P < 0.05). Higher Hb [per one standard deviation (SD)] related to lower mortality [adjusted hazard ratios (HR) 0.88; 95% confidence interval (CI) 0.83-0.93], CHF hospitalizations [HR 0.85 (0.77-0.93)], and all-cause hospitalizations [HR 0.96 (0.92-0.99), all P < 0.05]. In patients without anaemia at baseline, the anaemia incidence after 1 year of follow-up was 10.1% in women and 10.0% in men. Of patients with anaemia at baseline, 65% did not have anaemia at 12 months and 46% did not have anaemia at any time during follow-up (median 3.0 years, inter-quartile range, Q1-Q3 = 2.7-3.3 years). At 12 months, an increase in Hb (per SD) was related to lower mortality [HR 0.73 (0.63-0.85; P < 0.0001)] independent of baseline Hb and other clinical characteristics.

CONCLUSION

In patients with complicated AMIs, anaemia on admission and/or reductions in haemoglobin during follow-up are independent risk factors for mortality and hospitalization. Studies are warranted to determine whether correcting anaemia after a complicated AMI improves outcome.

Prevalence of anemia in heart failure and its effects on prognosis

Anemia is common in heart failure patients but its prevalence varies widely according to various sources. There is no agreement regarding the definition of anemia to be used and several risk factors have been found to be associated with higher prevalence of anemia in heart failure patients. The prevalence of anemia depends on its definition and the clinical characteristics of the patients included in the studies. Anemia is associated with adverse prognosis in the general population, in patients with end-stage renal disease, chronic diseases, coronary artery disease and also in patients with heart failure; however, despite all the information available, the issue of whether anemia is an independent predictor of mortality and the nature of the risk between anemia and mortality in heart failure patients are not yet fully understood.

[Etiology and clinical management of anemia in heart failure. GESAIC Study]

BACKGROUND AND OBJECTIVE

Studies about anemia in heart failure (HF) tend to link the anemia to a cardio-renal dysfunction, and its syndromic value is seldom evaluated. Our objective was to assess the etiology and clinical management of anemia in HF patients in a hospital setting.

PATIENTS AND METHOD

Initial cross-sectional analysis of a multi-center and prospective cohort of patients with HF and anemia. Anemia was defined according to the WHO criteria; the Modification of Diet in Renal Disease equation was used to assess glomerular filtration and the etiology of anemia was defined according to common criteria.

RESULTS

We evaluated 228 patients, with a median age of 79.1 years and 59.65% women. Iron deficiency anemia was present in 36,8% of patients and anemia of chronic disease in 30.3%. Of note, 12.7% cases did not meet any etiological criteria. The main factor associated with iron deficiency was anti-platelet therapy (OR=1.99; 95% CI, 1.16-1.68) and the main factors associated with anemia of chronic disease were the use of angiotensin converting enzyme inhibitors (ACEI) or angiotensin II receptor antagonists (ARA-II) (OR=3.29; 95% CI, 1.36-7.94). The main factor associated with undefined anemia was initial heart failure (OR=5.41; 95% CI, 1.65-17.65). On the other hand, 8.1% of patients required transfusion, 6% were treated with erythropoietin and 25.3% were treated with iron. Both age (OR=1.04; 95% CI, 1-1.08) and hemoglobin level at admission (OR=1.81; 95% CI, 1.46-2.25) were associated with active treatment for anemia.

CONCLUSIONS

A clinical study of anemia in patients with HF can establish an etiological diagnosis in 70% of cases, resulting in a more effective treatment.