Iron deficiency in heart failure

Abstract

Abstract Abstract: Iron deficiency (ID) is an ominous non-cardiovascular co-morbidity highly prevalent in patients with heart failure (HF). The presence of ID in patients with HF, regardless of concomitant anaemia, translates into exaggerated HF symptoms, impaired exercise capacity, poor quality of life, frequent recurrent HF hospitalizations, high mortality and increased healthcare costs. ID is diagnosed in patients with HF when serum ferritin is < 100 ng/mL (ng/mL = μg/L), or when serum ferritin is between 100 and 299 ng/mL combined with a transferrin saturation (TSAT) of < 20% (TSAT = (iron/TIBC) × 100%). According to the ESC guidelines on HF (2016, 2021), all patients with HF are recommended to be screened for ID using serum ferritin and TSAT, regardless of left ventricular ejection fraction (LVEF), haemoglobin level and kidney function. The results of the FAIR-HF, CONFIRM-HF, and AFFIRM-AHF trials along with meta-analyses have established the basis for the ESC recommendation that intravenous iron supplementation with ferric carboxymaltose (FCM) should be considered in symptomatic patients with LVEF <45% and ID (defined as above) in order to alleviate HF symptoms, improve exercise capacity and quality of life. The major results of the AFFIRM-AHF trial have led the foundations for the recommendation that intravenous iron supplementation with FCM should be considered in symptomatic HF patients recently hospitalized for HF and with LVEF < 50% and ID (defined as above) in order to reduce the risk of HF hospitalization. Therapy with FCM has been demonstrated to be effective and safe. Cost-effectiveness analysis has confirmed that intravenous iron supplementation with FCM in iron deficient patients after an episode of acute HF is dominant in the UK, USA, and Switzerland, and is highly cost-effective in Italy. Ongoing clinical trials are expected to provide further evidence on the effect of this therapy on long-term cardiovascular mortality in iron deficient patients with HF (FAIR-HF2, IRONMAN, HEART-FID) and on exercise capacity and quality of life in iron deficient patients with HF with preserved ejection fraction (FAIR-HFpEF).