Iron Deficiency • Common • Related to - Poor quality of life - Heart failure symptoms - Poor prognosis • Consider screening patients - Who are symptomatic - Whose prognosis is declining
Iron deficiency is much more common than anemia.
Iron Deficiency: More Common Than Anemia Klip IT, et al. Am Heart J. 2013;165(4):575 ‐ 582.
…screen for iron deficiency independently of hemoglobin level...
CONFIRM-HF: IV Iron Improves Exercise Capacity in HFrEF 6 ‐ Min Walk Test FCM = ferric carboxymaltose 6MWT = 6 ‐ minute walk test Adapted from: Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al. Eur Heart J . 2015;36(11):657-668.
FAIR-HF • 50.3% of patients in the ferric carboxymaltose group reported “much” or ”moderate” improvement on the patient global assessment vs. 27.5% of the placebo group. • OR 2.51 (95% CI, 1.75-3.61; P <0.001) Anker SD, et al. N Engl J Med . 2009;361(25)2436-2448.
IRONOUT • Oral iron vs. placebo • 225 patients with HFrEF (<40%) • No significant effect on heart failure symptoms • Oral iron is not well absorbed Lewis GD, et al. JAMA . 2017;317(19):1958-1966.
ESC Guidelines • Recommend only intravenous iron supplementation for iron deficiency in patients with HFrEF Ponikowski P, et al. Eur J Heart Fail . 2016;18(8):891-975.
Iron Deficiency • Ferritin <100 g/L or • Ferritin 100-299 g/L with TSAT <20% Ponikowski P, et al. Eur J Heart Fail . 2016;18(8):891-975.
Treatment of Iron Deficiency in HFrEF Consider ferric carboxymaltose as 500 − 1000 mg single doses of iron to correct iron deficiency Dosing calculations according to hemoglobin levels and body weight Hemoglobin Patient body weight g/dL mmol/L <35 kg 35 kg − <70 kg ≥ 70 kg <10 <6.2 500 mg 1500 mg 2000 mg 10 − 14 6.2–8.7 500 mg 1000 mg 1500 mg >14 >8.7 500 mg 500 mg 500 mg Check ferritin + TSAT at next scheduled visit (preferably at 3 months) Check ferritin + TSAT 1 − 2 � mes per year or if change in clinical picture or if hemoglobin decreases HFrEF = heart failure with reduced ejection fraction; McDonagh T, et al. Eur J Heart Fail. 2018;20(12):1664 ‐ 1672.
Side Effects of Intravenous Iron • Itching or rash at the injection site • Anaphylactoid reaction • Iron infusion staining
…[ferric carboxymaltose] is allowed to be administered both in inpatients but also in outpatients…
Effect of Ferric Carboxymaltose in HFrEF: Meta-analysis HFrEF = heart failure with reduced ejection fraction; Anker SD, et al. Eur J Heart Fail. 2018;20(1):125-133.
Select Ongoing Large HFrEF Trials Study Name AFFIRM ‐ AHF FAIR ‐ HF ‐ 2 IRONMAN HEART ‐ FID # of Patients 1,100 1,200 1,300 3,014 Acute HF Chronic HF Chronic HF Chronic HF Diagnosis EF<50% EF ≤ 45% <45% EF ≤ 40% Blinding Double blind Double blind Open label Double blind Iron (III) Study Arm FCM FCM FCM isomaltoside Event driven + Event driven + 12 mos Duration 52 weeks at least 12 120 weeks last patient mos f/u All ‐ cause mortality + Primary HF hosp + total HF hosp through HF hosp + CVD CVD or HF hosp Endpoint CVD 12 mos and 6 ‐ month 6MWD HFrEF = heart failure with reduced ejection fraction; von Haehling S, et al. JACC Heart Fail. 2019;7(1):36-46.
Iron Deficiency in HFpEF: Reduced Functional Capacity and QOL 6MWT = 6-minute walk test; HFrEF = heart failure with preserved ejection fraction ID = iron deficiency, MLHFQ = Minnesota Living with Heart Failure Questionnaire, QOL = quality of life; Alcaide-Aldeano A, Garay A, Alcoberro L, et al. J Clin Med . 2020;9(4):1199.
Take Home Message • The most important clinical pearl is to screen for iron deficiency and diagnose it in symptomatic patients.
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