Abstract
Aims: This study assessed the impact of acute hemoglobin (Hb) falls in heart failure (HF) patients. Methods: HF patients with repeated Hb values over time were included. Falls in Hb greater than 30% were considered to represent an acute episode of anemia and the risk of hospitalization and all-cause mortality after the first episode was assessed. Results: In total, 45,437 HF patients (54.9% female, mean age 74.3 years) during a follow-up average of 2.9 years were analyzed. A total of 2892 (6.4%) patients had one episode of Hb falls, 139 (0.3%) had more than one episode, and 342 (0.8%) had concomitant acute kidney injury (AKI). Acute heart failure occurred in 4673 (10.3%) patients, representing 3.6/100 HF patients/year. The risk of hospitalization increased with one episode (Hazard Ratio = 1.30, 95% confidence interval (CI) 1.19–1.43), two or more episodes (HR = 1.59, 95% CI 1.14–2.23, and concurrent AKI (HR = 1.61, 95% CI 1.27–2.03). A total of 10,490 patients have died, representing 8.1/100 HF patients/year. The risk of mortality was HR = 2.20 (95% CI 2.06–2.35) for one episode, HR = 3.14 (95% CI 2.48–3.97) for two or more episodes, and HR = 3.20 (95% CI 2.73–3.75) with AKI. In the two or more episodes and AKI groups, Hb levels at the baseline were significantly lower (10.2–11.4 g/dL) than in the no episodes group (12.8 g/dL), and a higher and significant mortality in these subgroups was observed. Conclusions: Hb falls in heart failure patients identified those with a worse prognosis requiring a more careful evaluation and follow-up.
Highlights
The relevance of anemia in the history and prognosis of heart failure (HF) has been recognized [1,2,3]
The baseline glomerular filtration rate (GFR) was significantly lower in subjects with episodes mainly in the group in which decreased Hb levels occurred with acute kidney injury (AKI)
Anticoagulant use, but not antiplatelet use, increased the risk of Hb fall episodes, with values of relative risk (RR) = 2.33 (95% confidence interval (CI) 2.17–2.51) and RR = 0.75, respectively
Summary
The relevance of anemia in the history and prognosis of heart failure (HF) has been recognized [1,2,3]. Well-established as a prognostic factor, the prevalence is more than 25% in all patients with HF and even greater in older adults [4]. A progressive reduction of hemoglobin (Hb) implies a poor prognosis [5,6]. The origin of anemia in HF is multifactorial and includes fluid retention, chronic kidney disease, undernutrition, relatively low levels of erythropoietin, inflammation, and drugs blocking the renin-angiotensin system that reduce erythropoietin, erythroid progenitors, and the degradation of an inhibitor of erythropoiesis [3,7]. The Hb fall impacts the comorbidities frequently present in HF patients, and increases the myocardial workload [10]
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