Management of Iron Deficiency in Heart Failure

Non-cardiac comorbidities in heart failure: an update on diagnostic and management strategies

Managing non-cardiac comorbidities in heart failure (HF) requires a tailored approach that addresses each patient's specific conditions and needs. Regular communication and coordination among healthcare providers is crucial to providing the best possible care for these patients. Poorly controlled hypertension contributes to left ventricular remodeling and diastolic dysfunction, emphasizing the importance of optimal blood pressure control while avoiding adverse effects. Among HF patients with diabetes, SGLT2 inhibitors and mineralocorticoid receptor antagonists have shown promise in reducing HF-related morbidity and mortality. Chronic kidney disease exacerbates HF and vice versa, forming the vicious cardiorenal syndrome, so disease-modifying therapies should be maintained in HF patients with comorbid CKD, even with transient changes in kidney function. Anemia in HF patients may be multifactorial, and there is growing evidence for the benefit of intravenous iron supplementation in HF patients with iron deficiency with or without anemia. Obesity, although a risk factor for HF, paradoxically offers a better prognosis once HF is established, though developing treatment strategies may improve symptoms and cardiac performance. In HF patients with stroke and atrial fibrillation, anticoagulation therapy is recommended. Among HF patients with sleep-disordered breathing, continuous positive airway pressure may improve sleep quality. Chronic obstructive pulmonary disease often coexists with HF, and many patients can tolerate cardioselective beta-blockers. Cancer patients with comorbid HF require careful consideration of cardiotoxicity risks associated with cancer therapies. Depression is underdiagnosed in HF patients and significantly impacts prognosis. Cognitive impairment is prevalent in HF patients and impacts their self-care and overall quality of life.

[The effect of the treatmet of iron on patients with failure heart and insufficient of iron. An Meta-analisis of randomized clinical trials]

INTRODUCTION

Approximately 45% of patients with heart failure had iron deficiency for the rest of their lives.

OBJECTIVE

To determine the effect of iron treatment in patients with heart failure and iron deficiency or anemia.

MATERIALS AND METHODS

The studies were selected in: PubMed, Scopus, Cochrane and Google Scholar, from the beginning of June to July 2023. The selected articles that met the inclusion criteria, the relevant information of the studies were collected according to the selection variables and were recorded in the Revman 5.0 program of the Cochrane collaboration. The primary outcome was composed of hospitalization for heart failure or cardiovascular death.

RESULTS

Of the 7 included studies, 6717 patients were obtained, the average age was 70 years with a predominance of the male gender (57%). The primary outcome was lower in patients in the control group compared to the placebo group (OR, 0.62; 95%CI, 0.54-0.70). The 6-minute walk test (6-MWT) was improved in the iron-supplemented group compared to the placebo group (OR, 0.79; 95%CI, 0.64-0.98). Adverse events were fewer in the iron supplement group compared to the placebo group (OR, 0.78; 95%CI, 0.67-0.91).

CONCLUSION

In this meta-analysis of randomized controlled trials, the effect of iron supplementation is found to reduce the incidence rate of hospitalization for heart failure or cardiovascular death. In addition to a reduction in adverse events, such as gastrointestinal and neurological disorders, it also improves 6-MWT.

Effect of Ferric Carboxymaltose Supplementation in Patients with Heart Failure with Preserved Ejection Fraction: Role of Attenuated Oxidative Stress and Improved Endothelial Function

Both clinical and experimental evidence shows that iron deficiency (ID) correlates with an increased incidence of heart failure (HF). Moreover, data on iron supplementation demonstrating a beneficial effect in subjects with HF have mostly been collected in patients undergoing HF with reduced ejection fraction (HFrEF). Relatively poor data, however, exist on the potential of iron supplementation in patients with HF with preserved ejection fraction (HFpEF). Here, we report on data emerging from a multicentric, double-blind, randomized, placebo-controlled study investigating the effect of IV supplementation with a placebo or ferric carboxymaltose (FCM) on 64 subjects with HFpEF. ID was detected by the measurement of ferritin levels. These data were correlated with cardiac performance measurements derived from a 6 min walking test (6MWT) and with echocardiographic determinations of diastolic function. Moreover, an EndoPAT analysis was performed to correlate cardiac functionality with endothelial dysfunction. Finally, the determination of serum malondialdehyde (MDA) was performed to study oxidative stress biomarkers. These measurements were carried out before and 8 weeks after starting treatment with a placebo (100 mL of saline given i.v. in 10 min; n = 32) or FCM at a dose of 500 mg IV infusion (n = 32), which was given at time 0 and repeated after 4 weeks. Our data showed that a condition of ID was more frequently associated with impaired diastolic function, worse 6MWT and endothelial dysfunction, an effect that was accompanied by elevated MDA serum levels. Treatment with FCM, compared to the placebo, improved ferritin levels being associated with an improved 6MWT, enhanced cardiac diastolic function and endothelial reactivity associated with a significant reduction in MDA levels. In conclusion, this study confirmed that ID is a frequent comorbidity in patients with HFpEF and is associated with reduced exercise capacity and oxidative stress-related endothelial dysfunction. Supplementation with FCM determines a significant improvement in diastolic function and the exercise capacity of patients with HFpEF and is associated with an enhanced endothelial function and a reduced production of oxygen radical species.

Cardiovascular and metabolic determinants of quality of life in patients with cancer

AIMS

Maintaining quality of life (QoL) in patients with cancer has gathered significant interest, but little is known about its major determinants. We sought to identify determinants of QoL in patients undergoing cancer treatment as well as in treatment-naïve patients about to commence such therapy.

METHODS AND RESULTS

QoL was assessed in 283 patients with cancer using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 questionnaire. All patients underwent a battery of tests including physical examination, resting electrocardiogram, hand grip strength, and biochemistry assessment. Using multivariable logistic regression, we found that age [odds ratio (OR) 0.954, 95% confidence interval (CI) 0.916-0.994], resting heart rate (OR 1.036, 95% CI 1.004-1.068), hand grip strength (OR 0.932, 95% CI 0.878-0.990), and the presence of cachexia (OR 4.334, 95% CI 1.767-10.631) and dyspnoea (OR 3.725, 95% CI 1.540-9.010; all P < 0.05) remained independently predictive of reduced QoL.

CONCLUSIONS

Therefore, it may be reasonable to address circumstances that are affecting muscle mass, body weight, and heart rate to maintaining QoL; however, prospective studies to test these endpoints are required.

Iron replacement therapy in heart failure: a literature review

Background

Heart failure (HF) is a major global challenge, emphasised by its designation as the leading cause of hospitalisation in those aged 65 and above. Approximately half of all patients with HF have concurrent iron deficiency (ID) regardless of anaemia status. In HF, iron deficiency is independently associated with higher rates of hospitalisation and death, lower exercise capacity, and poorer quality-of-life than in patients without iron deficiency. With such consequences, several studies have investigated whether correcting ID can improve HF outcomes.

Main body.

As of 1st June 2021, seven randomised controlled trials have explored the use of intravenous (IV) iron in patients with HF and ID, along with various meta-analyses including an individual patient data meta-analysis, all of which are discussed in this review. IV iron was well tolerated, with a comparable frequency of adverse events to placebo. In the context of heart failure with reduced ejection fraction (HFrEF), IV iron reduces the risk of hospitalisation for HF, and improves New York Heart Association (NYHA) functional class, quality-of-life, and exercise capacity (as measured by 6-min walk test (6MWT)) distance and peak oxygen consumption. However, the effect of IV iron on mortality is uncertain. Finally, the evidence for IV iron in patients with acute decompensated heart failure, or heart failure with preserved ejection fraction (HFpEF) is limited.

Conclusions

IV iron improves some outcomes in patients with HFrEF and ID. Patients with HFrEF should be screened for ID, defined as ferritin < 100 µg/L, or ferritin 100–299 µg/L if transferrin saturation < 20%. If ID is found, IV iron should be considered, although causes of ID other than HF must not be overlooked.

Anemia and Management of Heart Failure Patients

Anemia is common in heart failure with preserved and reduced ejection fraction. It is independently associated with poor functional status, hospitalization, and reduced survival. Its etiology is complex and multifactorial. Hemodynamic and nonhemodynamic compensatory mechanisms have been discussed as a response to chronic anemia. Whether anemia is a risk marker of advanced disease or a risk factor for progressive heart failure is debated. Current guidelines recommend a diagnostic workup as a part of standard management. Studies investigating intravenous iron administration reported beneficial effects on clinical outcomes. This article reviews current information on anemia.

Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes?

Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.

The association of anemia as a risk of heart failure

AIM

The present study was conducted to assess the presence of anemia in patients with advanced heart failure (HF) and compared the clinical characteristics of patients with anemia and without anemia.

METHODOLOGY

The present study was conducted on 102 patients (60 males, 42 females) with advanced HF admitted in hospital. In all, general physical and clinical examinations were performed. All were subjected to complete blood count (CBC), hematocrit, and assessment of urea, creatinine, sodium, potassium, and brain natriuretic peptide (BNP). The levels of serum iron, ferritin, iron saturation, and iron-binding capacity were also evaluated. The causes of HF were assessed.

RESULTS

Mean age was 48.2 ± 5.7 and 42.2 ± 6.2 years in males and females patients, respectively. Left ventricular ejection fraction (LVEF) was 0.26 ± 0.8 in males and 0.24 ± 0.5 in females. 71.5% males and 76.3% females were on inotropic support. The etiology of HF was ischemia in 29% males and 27% females, high blood pressure in 15% males and 12% females, obesity in 18% males and 19% females, valvular heart disease in 7% males and 5% females, diabetes in 11% males and 6% females, and idiopathy in 20% males and 31% females. There was a significant difference in mean age, initial HB, final HB, hypertension, creatinine, BNP, and initial hematocrit level in patients with anemia and without anemia (P < 0.05). Deaths in hospital were also significant (P < 0.05).

CONCLUSION

Anemia was seen in one-third of the patients with HF. Anemia was an independent marker with poor prognosis. Anemic patients were older than non-anemic patients.

Subclinical Iron Deficiency in Non-Anemic Individuals: A Retrospective Analysis of Korean Health Examinees

OBJECTIVES

Non-anemic individuals may have undetected subclinical iron deficiency (SID). The aims of this study were to determine the prevalence of SID and identify the associated factors for SID. In addition, the screening performance of red blood cell (RBC) indices for SID in health check-ups was assessed.

METHODS

This study was conducted with 16,485 non-anemic health examinees (3,567 males and 12,918 females) who underwent tests for iron variables (serum iron, total iron-binding capacity, ferritin, and iron saturation) at 16 health-promotion centers in 13 cities in Korea between January 2017 and June 2018. SID was defined as a decreased ferritin level (<24 µg/L in males and <15 µg/L in females) and either a decreased serum iron level (<44 µg/dL in males and <29 µg/dL in females) or a transferrin saturation of <20%.

RESULTS

The prevalence rates of SID were 0.6 and 3.3% in males and females, respectively. In terms of age and sex, SID was most prevalent in males aged ≥70 years (7.8%) and females aged 15-49 years (7.6%). There were significant differences in the hemoglobin (Hb) level, white blood cell count, platelet count, mean corpuscular volume, mean corpuscular Hb (MCH), and RBC distribution width (RDW) between the SID and non-SID groups (p < 0.001). The factors associated with SID in males were older age (odds ratio, OR, 1.069, 95% confidence interval, CI, 1.03-1.109, p = 0.004), lower Hb (OR 0.58, 95% CI 0.345-0.976, p = 0.04), lower MCH (OR 0.433, 95% CI 0.298-0.629, p < 0.001), and higher RDW (OR 1.374, 95% CI 1.001-1.887, p = 0.049), while in females they were lower body mass index (BMI; OR 0.929, 95% CI 0.895-0.963, p < 0.001) and younger age (OR 0.954, 95% CI 0.945-0.963, p < 0.001), as well as lower Hb, lower MCH, and higher RDW. The AUC for the MCH (0.877, 95% CI 0.793-0.960 in males; 0.872, 95% CI 0.853-0.890 in females) indicates that the MCH at cut-offs of 29.2 and 29.3 pg are the best discriminators of SID in males and females, respectively (p < 0.001).

CONCLUSIONS

Reproductive-age females with a lower BMI and elderly males are high-risk groups for SID. MCH is a reliable RBC index for the screening of SID. For the population with defined risk factors, including females with lower BMI and elderly males, screening for SID is needed to prevent the development of anemia.