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Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
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Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
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Mhanna M, Sauer MC, Al-Abdouh A, Jabri A, Beran A, Barbarawi M, Mansour S, Hanna EB. Intravenous iron therapy for patients with iron deficiency and heart failure: a systematic review and meta-analysis of randomized controlled trials. Proc AMIA Symp 2024; 37:466-476. [PMID: 38628339 PMCID: PMC11018061 DOI: 10.1080/08998280.2024.2326387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 02/19/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Heart failure (HF) presents a significant health challenge, with intravenous (IV) iron therapy considered a potential treatment avenue. Method We assessed IV iron therapy's efficacy in HF patients with concurrent iron deficiency versus standard of care. Primary outcomes included the composite of HF hospitalizations or cardiovascular-related mortality, HF hospitalizations, and all-cause, HF, and cardiovascular mortality rates. Secondary measures encompassed improvements in New York Heart Association functional classification, quality of life, 6-minute walk test, left ventricular ejection fraction, and adverse events. We used a random-effects model to compute relative risk (RR) or mean difference (MD) with 95% confidence intervals (CIs). Results Based on an analysis of 14 randomized controlled trials involving 6614 patients, IV iron therapy significantly reduced composite outcome (RR: 0.84, 95% CI: 0.73, 0.96; P = 0.01) and HF hospitalizations (RR: 0.74, 95% CI: 0.61, 0.89; P = 0.002) compared to standard of care. Mortality rates showed no significant difference. IV iron therapy improved New York Heart Association functional classification, quality of life, and 6-minute walk test, with no major impact on left ventricular ejection fraction. Adverse events remained stable. Conclusions IV iron therapy holds promise for diminishing HF hospitalizations and enhancing quality of life and 6-minute walk test in HF patients. Yet, its effect on all-cause or cardiovascular mortalities appears limited.
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Affiliation(s)
- Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Ahmad Al-Abdouh
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Ahmad Jabri
- Department of Cardiology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH, USA
| | - Azizullah Beran
- Department of Gastroenterology, Indiana University, Indianapolis, IN, USA
| | - Mahmoud Barbarawi
- Department of Cardiology, University of Connecticut, Farmington, CT, USA
| | - Shareef Mansour
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - Elias B. Hanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA, USA
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3
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Sephien A, Dayto DC, Reljic T, Prida X, Joly JM, Tavares M, Katz JN, Kumar A. Efficacy of Intravenous Iron in Patients with Heart Failure with Reduced Ejection Fraction and Iron Deficiency: A Systematic Review and Meta-Analysis of Randomized Control Trials. Am J Cardiovasc Drugs 2024; 24:285-302. [PMID: 38519808 DOI: 10.1007/s40256-024-00635-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The European Society of Cardiology (ESC) provided a focused update to the 2021 Guideline for the Management of Heart Failure, now providing a 1A recommendation for intravenous iron in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency (ID). However, the findings from randomized controlled trials (RCT) are mixed. This systematic review of RCTs aims to provide an update and synthesize the evidence addressing the association of intravenous iron with patient-based outcomes in patients with HFrEF and ID. METHODS Any RCT evaluating the effect of intravenous iron in patients with HFrEF and ID was eligible for inclusion. A complete search of the EMBASE and PubMed databases was conducted from inception until 15 September 2023. The primary outcome was the composite of the quality of life (QoL) questionnaires, while the secondary outcomes included first heart failure (HF) hospitalizations and all-cause mortality. Data extraction was performed independently by two reviewers. Data were pooled using a random-effects model. RESULTS Of the 1035 references, 15 RCTs enrolling 6649 patients were included in this study. Intravenous iron was associated with significant improvement in the composite of QoL (standardized mean difference - 1.36, 95% confidence interval [CI] - 2.24 to - 0.48; p = 0.002), a significant reduction in first HF hospitalizations (hazard ratio [HR] 0.73, 95% CI 0.56-0.95; p = 0.02), and with no change in all-cause mortality (HR 0.90, 95% CI 0.79-1.03; p = 0.12). The certainty of the evidence ranged from moderate to very low. CONCLUSION Intravenous iron is possibly associated with improved QoL and reduced HF hospitalizations, without impacting all-cause mortality. These findings not only support the use of intravenous iron in patients with HFrEF but also emphasize the need for well-designed and executed RCTs with granular outcome reporting and powered sufficiently to address the impact of intravenous iron on mortality in patients with HFrEF and ID. REGISTRATION PROSPERO identifier number CRD42023389.
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Affiliation(s)
- Andrew Sephien
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Denisse Camille Dayto
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA
| | - Tea Reljic
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida, Tampa, FL, USA
| | - Joanna M Joly
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew Tavares
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
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Bhatia K, Sabharwal B, Gupta K, Lopez PD, Kaur A, Bhatia HK, Gandhi KD, Niroula S, Correa A, Birati EY, Argulian E, Fox A, Mahmood K. Clinical outcomes of intravenous iron therapy in patients with heart failure and iron deficiency: Meta-analysis and trial sequential analysis of randomized clinical trials. J Cardiol 2024; 83:105-112. [PMID: 37380069 DOI: 10.1016/j.jjcc.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Iron deficiency in patients with heart failure (HF) is underdiagnosed and undertreated. The role of intravenous (IV) iron is well-established to improve quality of life measures. Emerging evidence also supports its role in preventing cardiovascular events in patients with HF. METHODOLOGY We conducted a literature search of multiple electronic databases. Randomized controlled trials that compared IV iron to usual care among patients with HF and reported cardiovascular (CV) outcomes were included. Primary outcome was the composite of first heart failure hospitalization (HFH) or CV death. Secondary outcomes included HFH (first or recurrent), CV death, all-cause mortality, hospitalization for any cause, gastrointestinal (GI) side effects, or any infection. We performed trial sequential and cumulative meta-analyses to evaluate the effect of IV iron on the primary endpoint, and on HFH. RESULTS Nine trials enrolling 3337 patients were included. Adding IV iron to usual care significantly reduced the risk of first HFH or CV death [risk ratio (RR) 0.84; 95 % confidence interval (CI) 0.75-0.93; I2 = 0 %; number needed to treat (NNT) 18], which was primarily driven by a reduction in the risk of HFH of 25 %. IV iron also reduced the risk of the composite of hospitalization for any cause or death (RR 0.92; 95 % CI 0.85-0.99; I2 = 0 %; NNT 19). There was no significant difference in the risk of CV death, all-cause mortality, adverse GI events, or any infection among patients receiving IV iron compared to usual care. The observed benefits of IV iron were directionally consistent across trials and crossed both the statistical and trial sequential boundaries of benefit. CONCLUSION In patients with HF and iron deficiency, the addition of IV iron to usual care reduces the risk of HFH without affecting the risk of CV or all-cause mortality.
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Affiliation(s)
- Kirtipal Bhatia
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Basera Sabharwal
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Kartik Gupta
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Persio D Lopez
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Arpanjeet Kaur
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, NY, USA
| | - Harsimran K Bhatia
- Department of Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | | | - Shailesh Niroula
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Ashish Correa
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine, Poriya Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Tel Aviv, Israel
| | - Edgar Argulian
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Arieh Fox
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiran Mahmood
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Doumani G, Spanos G, Theofilis P, Vordoni A, Kalaitzidis RG. Cardiorenal syndrome and iron supplementation-more benefits than risks: a narrative review. Int Urol Nephrol 2024; 56:597-606. [PMID: 37606747 DOI: 10.1007/s11255-023-03741-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Intravenous iron administration has emerged as a crucial intervention for managing patients with cardiorenal syndrome (CRS) and iron deficiency, with or without the presence of anemia. Multiple studies have demonstrated the benefits of intravenous iron supplementation in improving anemia, symptoms, and functional capacity in patients with HF and iron deficiency. Furthermore, iron supplementation has been associated with a reduction in hospitalizations for HF exacerbation and the improvement of patients' quality of life and clinical outcomes. In addition to its effects on HF management, emerging evidence suggests a potential positive impact on kidney function in patients with CRS. Studies have shown an increase in estimated glomerular filtration rate and improvements in renal function markers in patients receiving intravenous iron therapy, highlighting the potential of this intervention in patients with CRS. This paper reviews the existing literature on the impact of intravenous iron therapy in these patient populations and explores its effects on various clinical outcomes. Future research endeavors are eagerly awaited to further improve our understanding of its clinical implications and optimize patient outcomes.
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Affiliation(s)
- Georgia Doumani
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece
| | - Georgios Spanos
- Department of Nephrology, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | - Panagiotis Theofilis
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece
| | - Aikaterini Vordoni
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece
| | - Rigas G Kalaitzidis
- Center for Nephrology "G. Papadakis", General Hospital of Nikaia, Piraeus "Agios Panteleimon", 18454, Piraeus, Nikaia, Greece.
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6
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Phillips L, Richmond M, Neunert C, Jin Z, Brittenham GM. Iron Deficiency in Chronic Pediatric Heart Failure: Overall Assessment and Outcomes in Dilated Cardiomyopathy. J Pediatr 2023; 263:113721. [PMID: 37673205 DOI: 10.1016/j.jpeds.2023.113721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To evaluate the frequency of iron status assessment in pediatric heart failure and the prevalence and adverse effects of absolute iron deficiency in dilated cardiomyopathy-induced heart failure. STUDY DESIGN We retrospectively reviewed records of children with chronic heart failure at our center between 2010 and 2020. In children with dilated cardiomyopathy, we analyzed baseline cardiac function, hemoglobin level, and subsequent risk of composite adverse events (CAE), including death, heart transplant, ventricular assist device (VAD) placement, and transplant registry listing. Absolute iron deficiency and iron sufficiency were defined as transferrin saturations <20% and ≥30%, respectively; and indeterminant iron status as 20%-29%. RESULTS Of 799 patients with chronic heart failure, 471 (59%) had no iron-related laboratory measurements. Of 68 children with dilated cardiomyopathy, baseline transferrin saturation, and quantitative left ventricular ejection fraction (LVEF), 33 (49%) and 14 (21%) were iron deficient and sufficient, respectively, and 21 (31%) indeterminant. LVEF was reduced to 23.6 ± 12.1% from 32.9 ± 16.8% in iron deficiency and sufficiency, respectively (P = .04), without a significant difference in hemoglobin. After stratification by New York Heart Association classification, in advanced class IV, hemoglobin was reduced to 10.9 ± 1.3 g/dL vs 12.7 ± 2.0 g/dL in iron deficiency and sufficiency, respectively (P = .01), without a significant difference in LVEF. CONCLUSIONS In this single-center study, iron deficiency was not monitored in most children with chronic heart failure. In pediatric dilated cardiomyopathy-induced heart failure, absolute iron deficiency was prevalent and associated with clinically consequential and possibly correctable decreases in cardiac function and hemoglobin concentration.
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Affiliation(s)
- Lia Phillips
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY.
| | - Marc Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Cindy Neunert
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Gary M Brittenham
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
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7
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Techasatian W, Nishimura Y, Tanariyakul M, Morihara C, Arayangkool C, Settle A, Aiumtrakul N, Kewcharoen J. Intravenous Iron for Heart Failure: Updated Systematic Review and Meta-Analysis. Angiology 2023:33197231213181. [PMID: 37916421 DOI: 10.1177/00033197231213181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
While the administration of intravenous (IV) iron to those with heart failure has been implicated to be associated with a possible reduction in hospitalizations and improvement in symptoms, a recent large multicenter trial only showed modest benefits in reducing hospitalization, necessitating the updated systematic review. We conducted a systematic review and meta-analysis, searching the MEDLINE and EMBASE database until January 9, 2023. Outcomes included total heart failure hospitalizations, first heart failure hospitalization, six-minute walk test (6MWT) distance, and incidence of infection. There were 13 studies with 3410 participants (1,790 with IV iron). Pooled analysis that reported the incidence of cardiovascular death showed that patients with IV iron did not have significantly lower odds of cardiovascular death or first heart failure hospitalization. In contrast, those who received IV iron had significantly lower total heart failure hospitalization (pooled odds ratio (OR) 0.63, 95% confidence interval (CI) 0.44-0.90, I2 59.0%, P = .017) and a composite of cardiovascular death and first heart failure hospitalization (pooled OR 0.55, 95% CI 0.47-0.64, I2 0%, P = .656). While the efficacy is modest, IV iron therapy could be associated with reduced hospitalization for heart failure without significant adverse events.
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Affiliation(s)
- Witina Techasatian
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Manasawee Tanariyakul
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Clarke Morihara
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Chinnawat Arayangkool
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Alexander Settle
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Noppawit Aiumtrakul
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
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Jankowska EA, Ponikowski P. Iron Deficiency in Heart Failure: A Korea-Oriented Review. INTERNATIONAL JOURNAL OF HEART FAILURE 2023; 5:173-183. [PMID: 37937204 PMCID: PMC10625879 DOI: 10.36628/ijhf.2023.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 11/09/2023]
Abstract
Iron deficiency (ID) occurs at high frequency across the spectrum of heart failure (HF), with HF severity and race being potentially important predictors for its development. ID, irrespective of anaemia status, leads to poor outcomes in patients with HF, including exacerbated reduction in exercise capacity, poor quality of life (QoL) and increased risk of HF hospitalisation. As ID has a large public health and economic burden in Asia, and patients hospitalised with acute HF in the Asia Pacific vs. other regions commonly present with more severe clinical symptoms, there is a clear need to identify and treat ID promptly in Asian patients with HF. The biomarkers serum ferritin and transferrin saturation are used for ID diagnosis, and periodic screening is recommended in all patients with HF. The intravenous iron treatments, ferric carboxymaltose (FCM) and ferric derisomaltose, have demonstrated efficacy and tolerability in patients with acute or chronic HF and ID, with FCM shown to be cost-effective (and in some cases cost-saving). Meta-analyses support the likely benefits of intravenous FCM for improving QoL and reducing HF hospitalisation, without reducing mortality risk in patients with HF and ID. Accordingly, European Society of Cardiology guidelines recommend considering intravenous FCM for patients with symptomatic HF with left ventricular ejection fraction ≤50% who were recently hospitalised for HF and have ID. Although analyses of Asian patients with HF and ID are limited, the effects of intravenous iron would be expected to be similar to that in White populations; further clarifying studies may be of interest.
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Affiliation(s)
- Ewa A. Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, 10 University Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, 10 University Hospital, Wroclaw, Poland
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9
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Graham FJ, Pellicori P, Masini G, Cuthbert JJ, Clark AL, Cleland JGF. Influence of serum transferrin concentration on diagnostic criteria for iron deficiency in chronic heart failure. ESC Heart Fail 2023; 10:2826-2836. [PMID: 37400990 PMCID: PMC10567655 DOI: 10.1002/ehf2.14438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/23/2023] [Accepted: 05/29/2023] [Indexed: 07/05/2023] Open
Abstract
AIMS Transferrin saturation (TSAT), a marker of iron deficiency, reflects both serum concentrations of iron (SIC) and transferrin (STC). TSAT is susceptible to changes in each of these biomarkers. Little is known about determinants of STC and its influence on TSAT and mortality in patients with heart failure. Accordingly, we studied the relationship of STC to clinical characteristics, to markers of iron deficiency and inflammation and to mortality in chronic heart failure (CHF). METHODS AND RESULTS Prospective cohort of patients with CHF attending a clinic serving a large local population. A total of 4422 patients were included (median age 75 (68-82) years; 40% women; 32% with left ventricular ejection fraction ≤40%). STC ≤ 2.3 g/L (lowest quartile) was associated with older age, lower SIC and haemoglobin and higher high-sensitivity C-reactive protein, ferritin and N-terminal pro-brain natriuretic peptide compared with those with STC > 2.3 g/L. In the lowest STC quartile, 624 (52%) patients had SIC ≤13 μmol/L, of whom 38% had TSAT ≥20%. For patients in the highest STC quartile, TSAT was <20% when SIC was >13 μmol/L in 185 (17%) patients. STC correlated inversely with ferritin (r = -0.52) and high-sensitivity C-reactive protein (r = -0.17) and directly with albumin (r = 0.29); all P < 0.001. In models adjusted for age, N-terminal pro-brain natriuretic peptide and haemoglobin, both higher SIC (hazard ratio 0.87 [95% CI: 0.81-0.95]) and STC (hazard ratio 0.82 [95% CI: 0.73-0.91]) were associated with lower mortality. SIC was more strongly associated with both anaemia and mortality than either STC or TSAT. CONCLUSIONS Many patients with CHF and a low STC have low SIC even when TSAT is >20% and serum ferritin >100 μg/L; such patients have a high prevalence of anaemia and a poor prognosis and might have iron deficiency but are currently excluded from clinical trials of iron repletion.
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Affiliation(s)
- Fraser J. Graham
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Pierpaolo Pellicori
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Gabriele Masini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | | | | | - John G. F. Cleland
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
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10
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Hamza M, Sattar Y, Manasrah N, Patel NN, Rashdi A, Khanal R, Naveed H, Zafar M, Khan AM, Alharbi A, Aamir M, Gonuguntla K, Raina S, Balla S. Meta-Analysis of Efficacy and Safety of Intravenous Iron in Patients With Iron Deficiency and Heart Failure With Reduced Ejection Fraction. Am J Cardiol 2023; 202:119-130. [PMID: 37429060 DOI: 10.1016/j.amjcard.2023.06.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
Iron deficiency is an independent risk factor for heart failure (HF) exacerbation. We aim to study the safety and efficacy of intravenous (IV) iron therapy in patients with HF with reduced ejection fraction (HFrEF). A literature search was conducted on MEDLINE (Embase and PubMed) using a systematic search strategy by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) until October 2022. CRAN-R software (The R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias and Newcastle-Ottawa Scale. We included 12 studies with a total of 4,376 patients (IV iron n = 1,985 [45.3%]; standard of care [SOC] n = 2,391 [54.6%]). The mean age was 70.37 ± 8.14 years and 71.75 ± 7.01 years in the IV iron and SOC groups, respectively. There was no significant difference in all-cause mortality and cardiovascular mortality (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74 to 1.04, p <0.15). However, HF readmissions were significantly lower in the IV iron group (RR 0.73, 95% CI 0.56 to 0.96, p = 0.026). Non-HF cardiac readmissions were not significantly different between the IV iron and SOC groups (RR 0.92, 95% CI 0.82 to 1.02, p = 0.12). In terms of safety, there was a similar rate of infection-related adverse events in both arms (RR 0.86, 95% CI 0.74 to 1, p = 0.05). IV iron therapy in patients with HFrEF is safe and shows a significant reduction in HF hospitalizations compared with SOC. There was no difference in the rate of infection-related adverse events. The changing landscape of HFrEF pharmacotherapy in the last decade may warrant a re-demonstration of the benefit of IV iron with current SOC. The cost-effectiveness of IV iron use also needs further study.
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Affiliation(s)
- Mohammad Hamza
- Department of Internal Medicine, Albany Medical Center, Albany, New York
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Nouraldeen Manasrah
- Department of Internal Medicine, Detroit Medical Center, Sinai Grace Hospital, Wayne State University, Detroit, Michigan
| | - Neel Navinkumar Patel
- Neel Navinkumar Patel Department of Internal Medicine, New York Medical College/Landmark Medical Center, Woonsocket, Rhode Island
| | - Amna Rashdi
- Department of Cardiology, Windsor Heart Institute, Windsor, Ontario, Canada
| | - Resha Khanal
- Department of Internal Medicine, Promedica Physician Group, Toledo, Ohio
| | - Hamza Naveed
- Department of Internal Medicine HCA Houston Healthcare/ University of Houston, Kingwood Medical Center, Houston, Texas
| | - Maha Zafar
- Department of Internal Medicine, Arkansas College of Osteopathic Medicine Mercy Program, Mercy Hospital Fort Smith, Arkansas
| | - Ahsan Mahmood Khan
- Department of Internal Medicine, Pakistan Ordnance Factories Hospital, Wah Cantonment, Pakistan
| | - Anas Alharbi
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Muhammad Aamir
- Department of Cardiology, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Karthik Gonuguntla
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Sameer Raina
- Department of Cardiology, West Virginia University, Morgantown, West Virginia
| | - Sudarshan Balla
- Department of Cardiology, West Virginia University, Morgantown, West Virginia.
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11
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Ras-Jiménez MDM, Ramos-Polo R, Francesch Manzano J, Corbella Santano M, Morillas Climent H, Jose-Bazán N, Jiménez-Marrero S, Garcimartin Cerezo P, Yun Viladomat S, Moliner Borja P, Torres Cardús B, Verdú-Rotellar JM, Diez-López C, González-Costello J, García-Romero E, de Frutos Seminario F, Triguero-Llonch L, Enjuanes Grau C, Tajes Orduña M, Comin-Colet J. Soluble Transferrin Receptor as Iron Deficiency Biomarker: Impact on Exercise Capacity in Heart Failure Patients. J Pers Med 2023; 13:1282. [PMID: 37623532 PMCID: PMC10455097 DOI: 10.3390/jpm13081282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/05/2023] [Accepted: 08/18/2023] [Indexed: 08/26/2023] Open
Abstract
The soluble transferrin receptor (sTfR) is a marker of tissue iron status, which could indicate an increased iron demand at the tissue level. The impact of sTfR levels on functional capacity and quality of life (QoL) in non-anemic heart failure (HF) patients with otherwise normal systemic iron status has not been evaluated. We conducted an observational, prospective, cohort study of 1236 patients with chronic HF. We selected patients with normal hemoglobin levels and normal systemic iron status. Tissue iron deficiency (ID) was defined as levels of sTfR > 75th percentile (1.63 mg per L). The primary endpoints were the distance walked in the 6 min walking test (6MWT) and the overall summary score (OSS) of the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The final study cohort consisted of 215 patients. Overall QoL was significantly worse (51 ± 27 vs. 39 ± 20, p-value = 0.006, respectively), and the 6 MWT distance was significantly worse in patients with tissue ID when compared to patients without tissue ID (206 ± 179 m vs. 314 ± 155, p-value < 0.0001, respectively). Higher sTfR levels, indicating increased iron demand, were associated with a shorter distance in the 6 MWT (standardized β = -0.249, p < 0.001) and a higher MLHFQ OSS (standardized β = 0.183, p-value = 0.008). In this study, we show that in patients with normal systemic iron parameters, higher levels of sTfR are strongly associated with an impaired submaximal exercise capacity and with worse QoL.
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Affiliation(s)
- Maria del Mar Ras-Jiménez
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Department of Internal Medicine, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Raúl Ramos-Polo
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Josep Francesch Manzano
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
| | - Miriam Corbella Santano
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
| | - Herminio Morillas Climent
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Núria Jose-Bazán
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Santiago Jiménez-Marrero
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Paloma Garcimartin Cerezo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Advanced Practice Nurses, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain
- Biomedical Research in Heart Diseases, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Escuela Superior de Enfermería del Mar, Parc de Salut Mar, 08003 Barcelona, Spain
| | - Sergi Yun Viladomat
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Department of Internal Medicine, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Pedro Moliner Borja
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Blanca Torres Cardús
- Primary Care Service Delta del Llobregat, Institut Català de la Salut, 08820 Barcelona, Spain
| | - José Maria Verdú-Rotellar
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Primary Care Service Litoral, Institut Català de la Salut, 08023 Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Department of Medicine, Universitat Pompeu Fabra, 08002 Barcelona, Spain
| | - Carles Diez-López
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Advanced Heart Failure and Heart Trasplant Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - José González-Costello
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Advanced Heart Failure and Heart Trasplant Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Elena García-Romero
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Advanced Heart Failure and Heart Trasplant Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Fernando de Frutos Seminario
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Advanced Heart Failure and Heart Trasplant Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Laura Triguero-Llonch
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Advanced Heart Failure and Heart Trasplant Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
| | - Cristina Enjuanes Grau
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Marta Tajes Orduña
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
| | - Josep Comin-Colet
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), 08907 L’Hospitalet de Llobregat, Spain
- Community Heart Failure Program, Cardiology Department, Bellvitge University Hospital, 08907 L’Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
- Department of Clinical Sciences, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
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12
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Graham FJ, Friday JM, Pellicori P, Greenlaw N, Cleland JG. Assessment of haemoglobin and serum markers of iron deficiency in people with cardiovascular disease. Heart 2023; 109:1294-1301. [PMID: 37130747 PMCID: PMC10423540 DOI: 10.1136/heartjnl-2022-322145] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/07/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The prevalence of anaemia and iron deficiency and their prognostic association with cardiovascular disease have rarely been explored at population level. METHODS National Health Service records of the Greater Glasgow region for patients aged ≥50 years with a broad range of cardiovascular diagnoses were obtained. During 2013/14, prevalent disease was identified and results of investigations collated. Anaemia was defined as haemoglobin <13 g/dL for men or <12 g/dL for women. Incident heart failure, cancer and death between 2015 and 2018 were identified. RESULTS The 2013/14 dataset comprised 197 152 patients, including 14 335 (7%) with heart failure. Most (78%) patients had haemoglobin measured, especially those with heart failure (90%). Of those tested, anaemia was common both in patients without (29%) and with heart failure (prevalent cases in 2013/14: 46%; incident cases during 2013/14: 57%). Ferritin was usually measured only when haemoglobin was markedly depressed; transferrin saturation (TSAT) even less often. Incidence rates for heart failure and cancer during 2015-18 were inversely related to nadir haemoglobin in 2013/14. A haemoglobin of 13-15 g/dL for women and 14-16 g/dL for men was associated with the lowest mortality. Low ferritin was associated with a better prognosis and low TSAT with a worse prognosis. CONCLUSION In patients with a broad range of cardiovascular disorders, haemoglobin is often measured but, unless anaemia is severe, markers of iron deficiency are usually not. Low haemoglobin and TSAT, but not low ferritin, are associated with a worse prognosis. The nadir of risk occurs at haemoglobin 1-3 g/dL above the WHO definition of anaemia.
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Affiliation(s)
- Fraser J Graham
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK
| | - Jocelyn M Friday
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK
| | - John Gf Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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13
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Gerhardt LMS, Kordsmeyer M, Sehner S, Güder G, Störk S, Edelmann F, Wachter R, Pankuweit S, Prettin C, Ertl G, Wanner C, Angermann CE. Prevalence and prognostic impact of chronic kidney disease and anaemia across ACC/AHA precursor and symptomatic heart failure stages. Clin Res Cardiol 2023; 112:868-879. [PMID: 35648270 PMCID: PMC10293329 DOI: 10.1007/s00392-022-02027-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The importance of chronic kidney disease (CKD) and anaemia has not been comprehensively studied in asymptomatic patients at risk for heart failure (HF) versus those with symptomatic HF. We analysed the prevalence, characteristics and prognostic impact of both conditions across American College of Cardiology/American Heart Association (ACC/AHA) precursor and HF stages A-D. METHODS AND RESULTS 2496 participants from three non-pharmacological German Competence Network HF studies were categorized by ACC/AHA stage; stage C patients were subdivided into C1 and C2 (corresponding to NYHA classes I/II and III, respectively). Overall, patient distribution was 8.1%/35.3%/32.9% and 23.7% in ACC/AHA stages A/B/C1 and C2/D, respectively. These subgroups were stratified by the absence ( - ) or presence ( +) of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2) and anaemia (haemoglobin in women/men < 12/ < 13 g/dL). The primary outcome was all-cause mortality at 5-year follow-up. Prevalence increased across stages A/B/C1 and C2/D (CKD: 22.3%/23.6%/31.6%/54.7%; anaemia: 3.0%/7.9%/21.7%/33.2%, respectively), with concordant decreases in median eGFR and haemoglobin (all p < 0.001). Across all stages, hazard ratios [95% confidence intervals] for all-cause mortality were 2.1 [1.8-2.6] for CKD + , 1.7 [1.4-2.0] for anaemia, and 3.6 [2.9-4.6] for CKD + /anaemia + (all p < 0.001). Population attributable fractions (PAFs) for 5-year mortality related to CKD and/or anaemia were similar across stages A/B, C1 and C2/D (up to 33.4%, 30.8% and 34.7%, respectively). CONCLUSIONS Prevalence and severity of CKD and anaemia increased across ACC/AHA stages. Both conditions were individually and additively associated with increased 5-year mortality risk, with similar PAFs in asymptomatic patients and those with symptomatic HF.
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Affiliation(s)
- Louisa M S Gerhardt
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Maren Kordsmeyer
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, St Josefs-Hospital Wiesbaden, Wiesbaden, Germany
| | - Susanne Sehner
- Medical Centre Hamburg-Eppendorf, Institute of Medical Biometry and Epidemiology, Hamburg, Germany
| | - Gülmisal Güder
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Frank Edelmann
- Department of Internal Medicine, Cardiology, Charité - Campus Virchow Klinikum, Universitätsmedizin Berlin, and German Centre for Cardiovascular Research, Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology and Pneumology, University Hospital Leipzig, Leipzig, Germany
| | - Sabine Pankuweit
- Department of Cardiology, Philips-University Marburg, Marburg, Germany
| | | | - Georg Ertl
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
| | - Christoph Wanner
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I (Nephrology), University Hospital Würzburg, Würzburg, Germany
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany.
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14
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Ogugua FM, Aguilar FA, Gamam A, Maqsood MH, Yoo TK, Kasmi F, AlKowatli O, Lo K. Treating Iron Deficiency (ID) Anemia in Heart Failure (HF) Patients with IV Iron: A Meta-Analysis. Cureus 2023; 15:e41895. [PMID: 37581143 PMCID: PMC10423640 DOI: 10.7759/cureus.41895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/16/2023] Open
Abstract
Findings on the effects of iron on heart failure (HF) hospitalizations and mortality among patients with iron deficiency (ID) and HF remain conflicting across different studies. We performed a meta-analysis of clinical trials assessing the clinical, hematic and cardiovascular benefits of treating ID in HF patients. We completed a systematic search for studies comparing IV iron to placebo in HF patients with ID. The primary outcomes were rates of HF hospitalization and all-cause mortality. Secondary outcomes included change in hematic values, New York Heart Association (NYHA) class and ejection fraction. We applied a random-effects model with planned sensitivity analyses of studies with skewed effect sizes. Nine studies were included with a total of 2,261 patients. Analysis revealed that treatment of HF patients with IV iron replacement significantly reduced the odds of HF hospitalization (odds ratio (OR): 0.44; 95% confidence interval (CI): 0.24 to 0.78; p=0.005, I2=67%),) but did not significantly impact all-cause mortality compared to placebo (OR: 0.89; 95%, CI: 0.67 to 1.19; p=0.44, I2: 0%). Analysis showed that IV iron treatment group had significantly higher serum ferritin, transferrin saturation and hemoglobin (Hb) levels. They also had lower NYHA class -1.90 (95% CI (-2.91 to -0.89); p<0.001, I2:89%) with higher ejection fraction 0.50 (95% CI (0.09 to 0.90) p=0.016, I2:86%). Treatment with IV iron in HF patients with ID is associated with a significant reduction of HF hospitalization but no effects on all-cause mortality. There were also significant increases in hematic values and ejection fraction with a reduction in NYHA class.
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Affiliation(s)
| | | | | | | | | | - Fedi Kasmi
- Internal Medicine, Sheikh Khalifa Hospital, Ajman, ARE
| | - Oubada AlKowatli
- Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, USA
| | - Kevin Lo
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
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15
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Hamed M, Elseidy SA, Ahmed A, Thakker R, Mansoor H, Khalili H, Mohsen A, Mamas MA, Banerjee S, Kumbhani DJ, Elgendy IY, Elbadawi A. Intravenous iron therapy among patients with heart failure and iron deficiency: An updated meta-analysis of randomized controlled trials. Heliyon 2023; 9:e17245. [PMID: 37383191 PMCID: PMC10293724 DOI: 10.1016/j.heliyon.2023.e17245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023] Open
Abstract
Background Randomized clinical trials (RCTs) evaluating the role of intravenous (IV) iron administration in patients with heart failure (HF) and iron deficiency (ID) have yielded inconsistent results. Methods Electronic search of MEDLINE, EMBASE and OVID databases was performed until November 2022 for RCTs that evaluated the role of IV iron administration in patients with HF and ID. The main study outcomes were the composite of HF hospitalization or cardiovascular mortality, and individual outcome of HF hospitalization. Summary estimates were evaluated using random effects model. Results The final analysis included 12 RCTs with 3,492 patients (1,831 patients in the IV iron group and 1,661 patients in the control group). The mean follow-up was 8.3 months. IV iron was associated with a lower incidence in the composite of HF hospitalization or cardiovascular mortality (31.9% vs. 45.3%; relative risk [RR] 0.72; 95% confidence interval [CI] 0.59-0.88) and individual outcome of HF hospitalization (28.4% vs. 42.2; RR 0.69; 95% CI 0.57-0.85). There was no significant difference between both groups in cardiovascular mortality (RR 0.88; 95% CI 0.75-1.04) and all-cause mortality (RR 0.95; 95% CI 0.83-1.09). IV iron was associated with lower New York Heart Association class and higher left ventricular ejection fraction (LVEF). Meta-regression analyses showed no effect modification for the main outcomes based on age, hemoglobin level, ferritin level or LVEF. Conclusion Among patients with HF and ID, IV iron administration was associated with reduction in the composite of HF hospitalization or cardiovascular mortality and driven by a reduction in HF hospitalization.
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Affiliation(s)
- Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Sheref A. Elseidy
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Asmaa Ahmed
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Ravi Thakker
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Hend Mansoor
- Department of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Houman Khalili
- Division of Cardiology, Memorial Healthcare System, Hollywood, FL, USA
| | - Amr Mohsen
- Division of Cardiology, Loma Linda University, Loma Linda, CA, USA
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
| | - Subhash Banerjee
- Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Dharam J. Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Islam Y. Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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16
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Ford I, Kalra PR. Unanswered questions from the IRONMAN trial - Authors' reply. Lancet 2023; 401:1495-1496. [PMID: 37149301 DOI: 10.1016/s0140-6736(23)00448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/27/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK.
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK; Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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17
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Graham FJ, Pellicori P, Kalra PR, Ford I, Bruzzese D, Cleland JG. Intravenous iron in patients with heart failure and iron deficiency: an updated meta-analysis. Eur J Heart Fail 2023; 25:528-537. [PMID: 36823953 PMCID: PMC10946839 DOI: 10.1002/ejhf.2810] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/04/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
AIMS For patients with heart failure (HF) and iron deficiency (ID), randomized trials suggest that intravenous (IV) iron reduces hospitalizations for heart failure (HHF), but uncertainty exists about the effects in subgroups and the impact on mortality. We conducted a meta-analysis of randomized trials investigating the effect of IV iron on clinical outcomes in patients with HF. METHODS AND RESULTS We identified randomized trials published between 1 January 2000 and 5 November 2022 investigating the effect of IV iron versus standard care/placebo in patients with HF and ID in any clinical setting, regardless of HF phenotype. Trials of oral iron or not in English were not included. The main outcomes of interest were a composite of HHF and cardiovascular death (CVD), on HHF alone and on cardiovascular and all-cause mortality. Ten trials were identified with 3373 participants, of whom 1759 were assigned to IV iron. IV iron reduced the composite of recurrent HHF and CVD (rate ratio 0.75, 95% confidence interval [CI] 0.61-0.93; p < 0.01) and first HHF or CVD (odds ratio [OR] 0.72, 95% CI 0.53-0.99; p = 0.04). Effects on cardiovascular (OR 0.86, 95% CI 0.70-1.05; p = 0.14) and all-cause mortality (OR 0.93, 95% CI 0.78-1.12; p = 0.47) were inconclusive. Results were similar in analyses confined to the first year of follow-up, which was less disrupted by the COVID-19 pandemic. Subgroup analyses found little evidence of heterogeneity for the effect on the primary endpoint, although patients with transferrin saturation <20% (OR 0.67, 95% CI 0.49-0.92) may have benefited more than those with values ≥20% (OR 0.99, 95% CI 0.74-1.30) (heterogeneity p = 0.07). CONCLUSION In patients with HF and ID, this meta-analysis suggests that IV iron reduces the risk of HHF but whether this is associated with a reduction in cardiovascular or all-cause mortality remains inconclusive.
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Affiliation(s)
- Fraser J. Graham
- Robertson Centre for BiostatisticsUniversity of GlasgowGlasgowUK
| | | | - Paul R. Kalra
- Department of CardiologyPortsmouth Hospitals University NHS TrustPortsmouthUK
- College of Medical, Veterinary & Life SciencesUniversity of GlasgowGlasgowUK
- Faculty of Science and HealthUniversity of PortsmouthPortsmouthUK
| | - Ian Ford
- Robertson Centre for BiostatisticsUniversity of GlasgowGlasgowUK
| | - Dario Bruzzese
- Department of Public HealthUniversity of Naples Federico IINaplesItaly
| | - John G.F. Cleland
- School of Cardiovascular and Metabolic HealthUniversity of GlasgowGlasgowUK
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18
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Pugliese NR, Pellicori P, Filidei F, De Biase N, Maffia P, Guzik TJ, Masi S, Taddei S, Cleland JGF. Inflammatory pathways in heart failure with preserved left ventricular ejection fraction: implications for future interventions. Cardiovasc Res 2023; 118:3536-3555. [PMID: 36004819 PMCID: PMC9897694 DOI: 10.1093/cvr/cvac133] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/26/2022] [Accepted: 08/10/2022] [Indexed: 02/07/2023] Open
Abstract
Many patients with symptoms and signs of heart failure have a left ventricular ejection fraction ≥50%, termed heart failure with preserved ejection fraction (HFpEF). HFpEF is a heterogeneous syndrome mainly affecting older people who have many other cardiac and non-cardiac conditions that often cast doubt on the origin of symptoms, such as breathlessness, or signs, such as peripheral oedema, rendering them neither sensitive nor specific to the diagnosis of HFpEF. Currently, management of HFpEF is mainly directed at controlling symptoms and treating comorbid conditions such as hypertension, atrial fibrillation, anaemia, and coronary artery disease. HFpEF is also characterized by a persistent increase in inflammatory biomarkers. Inflammation may be a key driver of the development and progression of HFpEF and many of its associated comorbidities. Detailed characterization of specific inflammatory pathways may provide insights into the pathophysiology of HFpEF and guide its future management. There is growing interest in novel therapies specifically designed to target deregulated inflammation in many therapeutic areas, including cardiovascular disease. However, large-scale clinical trials investigating the effectiveness of anti-inflammatory treatments in HFpEF are still lacking. In this manuscript, we review the role of inflammation in HFpEF and the possible implications for future trials.
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Affiliation(s)
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow G12 8QQ, UK
| | - Francesco Filidei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Pasquale Maffia
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8TA, UK
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples 80138, Italy
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
- Department of Internal and Agricultural Medicine, Jagiellonian University, Collegium Medicum, Krakow 31-008, Poland
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow G12 8QQ, UK
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Savarese G, von Haehling S, Butler J, Cleland JGF, Ponikowski P, Anker SD. Iron deficiency and cardiovascular disease. Eur Heart J 2023; 44:14-27. [PMID: 36282723 PMCID: PMC9805408 DOI: 10.1093/eurheartj/ehac569] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/11/2022] [Accepted: 09/27/2022] [Indexed: 02/07/2023] Open
Abstract
Iron deficiency (ID) is common in patients with cardiovascular disease. Up to 60% of patients with coronary artery disease, and an even higher proportion of those with heart failure (HF) or pulmonary hypertension have ID; the evidence for cerebrovascular disease, aortic stenosis and atrial fibrillation is less robust. The prevalence of ID increases with the severity of cardiac and renal dysfunction and is probably more common amongst women. Insufficient dietary iron, reduced iron absorption due to increases in hepcidin secondary to the low-grade inflammation associated with atherosclerosis and congestion or reduced gastric acidity, and increased blood loss due to anti-thrombotic therapy or gastro-intestinal or renal disease may all cause ID. For older people in the general population and patients with HF with reduced ejection fraction (HFrEF), both anaemia and ID are associated with a poor prognosis; each may confer independent risk. There is growing evidence that ID is an important therapeutic target for patients with HFrEF, even if they do not have anaemia. Whether this is also true for other HF phenotypes or patients with cardiovascular disease in general is currently unknown. Randomized trials showed that intravenous ferric carboxymaltose improved symptoms, health-related quality of life and exercise capacity and reduced hospitalizations for worsening HF in patients with HFrEF and mildly reduced ejection fraction (<50%). Since ID is easy to treat and is effective for patients with HFrEF, such patients should be investigated for possible ID. This recommendation may extend to other populations in the light of evidence from future trials.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas TX, USA
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Wellebing, University of Glasgow, Glasgow, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland
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20
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Kalra PR, Cleland JGF, Petrie MC, Thomson EA, Kalra PA, Squire IB, Ahmed FZ, Al-Mohammad A, Cowburn PJ, Foley PWX, Graham FJ, Japp AG, Lane RE, Lang NN, Ludman AJ, Macdougall IC, Pellicori P, Ray R, Robertson M, Seed A, Ford I. Intravenous ferric derisomaltose in patients with heart failure and iron deficiency in the UK (IRONMAN): an investigator-initiated, prospective, randomised, open-label, blinded-endpoint trial. Lancet 2022; 400:2199-2209. [PMID: 36347265 DOI: 10.1016/s0140-6736(22)02083-9] [Citation(s) in RCA: 94] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND For patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric carboxymaltose administration improves quality of life and exercise capacity in the short-term and reduces hospital admissions for heart failure up to 1 year. We aimed to evaluate the longer-term effects of intravenous ferric derisomaltose on cardiovascular events in patients with heart failure. METHODS IRONMAN was a prospective, randomised, open-label, blinded-endpoint trial done at 70 hospitals in the UK. Patients aged 18 years or older with heart failure (left ventricular ejection fraction ≤45%) and transferrin saturation less than 20% or serum ferritin less than 100 μg/L were eligible. Participants were randomly assigned (1:1) using a web-based system to intravenous ferric derisomaltose or usual care, stratified by recruitment context and trial site. The trial was open label, with masked adjudication of the outcomes. Intravenous ferric derisomaltose dose was determined by patient bodyweight and haemoglobin concentration. The primary outcome was recurrent hospital admissions for heart failure and cardiovascular death, assessed in all validly randomly assigned patients. Safety was assessed in all patients assigned to ferric derisomaltose who received at least one infusion and all patients assigned to usual care. A COVID-19 sensitivity analysis censoring follow-up on Sept 30, 2020, was prespecified. IRONMAN is registered with ClinicalTrials.gov, NCT02642562. FINDINGS Between Aug 25, 2016, and Oct 15, 2021, 1869 patients were screened for eligibility, of whom 1137 were randomly assigned to receive intravenous ferric derisomaltose (n=569) or usual care (n=568). Median follow-up was 2·7 years (IQR 1·8-3·6). 336 primary endpoints (22·4 per 100 patient-years) occurred in the ferric derisomaltose group and 411 (27·5 per 100 patient-years) occurred in the usual care group (rate ratio [RR] 0·82 [95% CI 0·66 to 1·02]; p=0·070). In the COVID-19 analysis, 210 primary endpoints (22·3 per 100 patient-years) occurred in the ferric derisomaltose group compared with 280 (29·3 per 100 patient-years) in the usual care group (RR 0·76 [95% CI 0·58 to 1·00]; p=0·047). No between-group differences in deaths or hospitalisations due to infections were observed. Fewer patients in the ferric derisomaltose group had cardiac serious adverse events (200 [36%]) than in the usual care group (243 [43%]; difference -7·00% [95% CI -12·69 to -1·32]; p=0·016). INTERPRETATION For a broad range of patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric derisomaltose administration was associated with a lower risk of hospital admissions for heart failure and cardiovascular death, further supporting the benefit of iron repletion in this population. FUNDING British Heart Foundation and Pharmacosmos.
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Affiliation(s)
- Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Fozia Z Ahmed
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Abdallah Al-Mohammad
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Peter J Cowburn
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul W X Foley
- Wiltshire Cardiac Centre, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alan G Japp
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rebecca E Lane
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK
| | - Ninian N Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew J Ludman
- Department of Cardiology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Robin Ray
- Cardiology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alison Seed
- Department of Cardiology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK.
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21
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McDonagh TA, Bromage DI, Cannata A. Intravenous iron passes another endurance test in heart failure. Lancet 2022; 400:2158-2159. [PMID: 36347266 DOI: 10.1016/s0140-6736(22)02180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Theresa A McDonagh
- King's College Hospital and School of Cardiovascular Sciences, King's College London, London WC2R 2LS, UK.
| | - Daniel I Bromage
- King's College Hospital and School of Cardiovascular Sciences, King's College London, London WC2R 2LS, UK
| | - Antonio Cannata
- King's College Hospital and School of Cardiovascular Sciences, King's College London, London WC2R 2LS, UK
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22
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López-Vilella R, Donoso Trenado V, Jover Pastor P, Sánchez-Lázaro I, Martínez Dolz L, Almenar Bonet L. Why Iron Deficiency in Acute Heart Failure Should Be Treated: A Real-World Clinical Practice Study. Life (Basel) 2022; 12:life12111828. [PMID: 36362983 PMCID: PMC9699465 DOI: 10.3390/life12111828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background. This study aims to determine whether the administration of ferric carboxymaltose (FCM) in patients with acute heart failure (AHF) and iron deficiency (ID) improves morbidity and mortality. Methods. We studied 890 consecutive patients admitted for AHF. Patients were divided into six groups according to reduced left ventricular ejection fraction (HFrEF) or preserved (HFpEF), presence of ID, and administration of FCM. Emergency visits, re-admissions, and all-cause mortality were assessed at 6 months. Results. The overall prevalence of ID was 91.2%. In the HFrEF group, no differences were found in isolated events when patients with untreated vs. treated ID were compared, while differences were found in the combined event rate (p = 0.049). The risk calculation showed an absolute risk reduction (ARR) of 10% and relative risk reduction (RRR) of 18%. In HFpEF there was a positive trend with regard to the combined event (p = 0.107), with an ARR of 9% and an RRR of 15%. The number of patients we needed to treat to prevent a combined event was 10.5 in HFrEF and 10.8 in HFpEF. Conclusions. FCM in AHF reduced the combined event rate of emergency visits, re-admission, and all-cause death at 6 months in HF with left ventricular ejection fraction <50%, and showed a positive trend in HFpEF.
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Affiliation(s)
- Raquel López-Vilella
- Heart Failure and Transplantation Unit, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Correspondence: ; Tel.: +34-961245851
| | - Víctor Donoso Trenado
- Heart Failure and Transplantation Unit, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Pablo Jover Pastor
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Ignacio Sánchez-Lázaro
- Heart Failure and Transplantation Unit, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Luis Martínez Dolz
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Luis Almenar Bonet
- Heart Failure and Transplantation Unit, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain
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23
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Hwang NC, Sivathasan C. Preoperative Evaluation and Care of Heart Transplant Candidates. J Cardiothorac Vasc Anesth 2022; 36:4161-4172. [PMID: 36028377 DOI: 10.1053/j.jvca.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/11/2022]
Abstract
Heart transplantation is recommended for patients with advanced heart failure refractory to medical and device therapy, and who do not have absolute contraindications. When patients become eligible for heart transplantation, they undergo comprehensive evaluation and preparation to optimize their posttransplantation outcomes. This review provides an overview of the processes that are employed to enable the candidates to be transplant-ready when donor hearts are available.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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24
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Alabdullah B, Ferreira D, Bourke E, Kamalanathan H, Elashri I, Porwal K, Tiller MJ, Gadre PH, Jones S, McGee M. The Prevalence of Iron Deficiency in Atrial Fibrillation: Low Hanging Fruit? Medicina (B Aires) 2022; 58:medicina58101492. [PMID: 36295652 PMCID: PMC9610053 DOI: 10.3390/medicina58101492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives: Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. The relationship between AF and iron deficiency is poorly understood. Materials and Methods: We conducted an observational study investigating the prevalence of iron deficiency in those with AF. Iron deficiency was defined by the American College of Cardiology (ACC) criteria for iron deficiency in heart failure. Results: Of 134 eligible subjects, 81 (60.4%) met the ACC definition of iron deficiency in heart failure. Those who were iron deficient were more likely to be female (OR 1.876, p = 0.005), have a history of diabetes mellitus (OR 3.085, p = 0.001) a history of stroke (OR 3.147, p = 0.016), and have higher CHA2DS2-VASc (p ≤ 0.0001) and Charlson Comorbidity Index scores (CCI) (p = 0.007). Conclusions: The prevalence of iron deficiency in those with AF appears high and warrants evaluation in a prospective study.
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Affiliation(s)
- Bachar Alabdullah
- Cardiology Department, Tamworth Rural Referral Hospital, Dean Street, North Tamworth, NSW 2340, Australia
| | - David Ferreira
- Cardiovascular Department, John Hunter Hospital, New Lambton Heights, Newcastle, NSW 2305, Australia
- Correspondence:
| | - Erin Bourke
- Cardiology Department, Tamworth Rural Referral Hospital, Dean Street, North Tamworth, NSW 2340, Australia
| | - Harish Kamalanathan
- Cardiovascular Department, John Hunter Hospital, New Lambton Heights, Newcastle, NSW 2305, Australia
| | - Ibrahim Elashri
- Cardiology Department, Tamworth Rural Referral Hospital, Dean Street, North Tamworth, NSW 2340, Australia
| | - Kushal Porwal
- Cardiovascular Department, John Hunter Hospital, New Lambton Heights, Newcastle, NSW 2305, Australia
| | - Michael J. Tiller
- Cardiology Department, Tamworth Rural Referral Hospital, Dean Street, North Tamworth, NSW 2340, Australia
| | - Payal H. Gadre
- Cardiovascular Department, John Hunter Hospital, New Lambton Heights, Newcastle, NSW 2305, Australia
| | - Sarah Jones
- Cardiology Department, Tamworth Rural Referral Hospital, Dean Street, North Tamworth, NSW 2340, Australia
| | - Michael McGee
- Cardiology Department, Tamworth Rural Referral Hospital, Dean Street, North Tamworth, NSW 2340, Australia
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25
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Myint PT, Nandar PP, Thet AM, Orasanu G. Cost-effective heart failure management: Meta-analysis of IV iron therapy in iron-deficient heart failure patients. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100204. [PMID: 38558909 PMCID: PMC10978398 DOI: 10.1016/j.ahjo.2022.100204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/25/2022] [Accepted: 09/06/2022] [Indexed: 04/04/2024]
Abstract
Background Iron deficiency is an important co-morbidity in heart failure patients. IV iron may improve quality of life and reduce heart failure hospitalizations, but the results of the clinical trials are varied. Objective The purpose of this meta-analysis is to assess not only the effect of IV iron in iron-deficient heart failure patients but also the quality of evidence. Methods PubMed and Cochrane databases were searched from inception to Oct 2021. Randomized clinical trials in iron-deficient, heart failure patients assessing the effect of IV iron versus placebo and with at least 12 weeks of follow-up were included. The outcomes were pooled and analyzed using a random-effect model. The quality of evidence was assessed using the GRADE approach. Results Seven studies were included in our meta-analysis. IV iron was associated with a 13.8 % decreased risk of HF hospitalizations (OR 0.59; 0.35-0.98, p = 0.040, GRADE = Low). All-cause mortality and CV mortality were not different between IV iron and placebo. But a composite outcome of HF hospitalizations or CV mortality was 17.5 % lower with IV iron (OR 0.51;0.31-0.84, p = 0.008, GRADE = Moderate). Conclusions Among heart failure patients with iron deficiency, IV iron is associated with lower HF hospitalizations. It is a relatively inexpensive regimen that can potentially improve quality of life and decrease healthcare expenditure.
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Affiliation(s)
- Phyo Thazin Myint
- Department of Hospital Medicine, Baystate Medical Center, Springfield, MA, USA
| | | | - Aye M. Thet
- Department of Hematology & Oncology, Ascension Macomb-Oakland Hospital, Warren, MI, USA
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26
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Kalra PR, Cleland JG, Petrie MC, Ahmed FZ, Foley PW, Kalra PA, Lang NN, Lane RE, Macdougall IC, Pellicori P, Pope MTB, Robertson M, Squire IB, Thomson EA, Ford I. Rationale and design of a randomised trial of intravenous iron in patients with heart failure. Heart 2022; 108:1979-1985. [PMID: 35948408 DOI: 10.1136/heartjnl-2022-321304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES For patients with a reduced left ventricular ejection fraction (LVEF) heart failure with reduced ejection fraction (HFrEF) and iron deficiency, administration of intravenous iron improves symptoms, exercise capacity and may in the following 12 months, reduce hospitalisations for heart failure. The Effectiveness of Intravenous iron treatment versus standard care in patients with heart failure and iron deficiency (IRONMAN) trial evaluated whether the benefits of intravenous iron persist in the longer term and impact on morbidity and mortality. METHODS IRONMAN is a prospective, randomised, open-label, blinded endpoint (PROBE) event-driven trial. Patients aged ≥18 years with HFrEF (LVEF ≤45%) and evidence of iron deficiency (ferritin <100 µg/L and/or TSAT <20%) were enrolled if they had either a current or recent hospitalisation for heart failure or elevated plasma concentrations of a natriuretic peptide. Participants were randomised to receive, or not to receive, intravenous ferric derisomaltose in addition to guideline-recommended therapy for HFrEF. Every 4 months, intravenous iron was administered if either ferritin was <100 µg/L or, provided ferritin was ≤400 µg/L, TSAT was <25%. The primary endpoint is a composite of total hospitalisations for heart failure and cardiovascular death. Hospitalisation and deaths due to infection are safety endpoints. RESULTS Trial recruitment was completed across 70 UK hospital sites in October 2021. Participants were followed until the end of March 2022. We plan to report the results by November 2022. CONCLUSIONS IRONMAN will determine whether repeated doses of intravenous ferric derisomaltose are beneficial and safe for the long-term treatment of a broad range of patients with HFrEF and iron deficiency. TRIAL REGISTRATION NUMBER NCT02642562.
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Affiliation(s)
- Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.,School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - John Gf Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.,Golden Jubilee National Hospital, Clydebank, UK
| | - Fozia Z Ahmed
- Division of Cardiovascular Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ninian N Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Rebecca E Lane
- Part of Guy's and St Thomas' NHS Foundation Trust, Royal Brompton and Harefield Hospitals, London, UK
| | | | | | - Michael T B Pope
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michele Robertson
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre Cardiovascular Diseases, Leicester, UK
| | - Elizabeth A Thomson
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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27
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Mei Z, Chen J, Luo S, Jin L, Liu Q, Chen Y. Comparative efficacy of intravenous and oral iron supplements for the treatment of iron deficiency in patients with heart failure: A network meta-analysis of randomized controlled trials. Pharmacol Res 2022; 182:106345. [PMID: 35810949 DOI: 10.1016/j.phrs.2022.106345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/17/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We aimed at comparing the efficacy of intravenous and oral iron supplementations for the treatment of iron deficiency (ID) in patients with heart failure (HF). METHODS We searched the PubMed, Cochrane, and Embase databases from inception to January 15, 2022. We included randomized controlled trials enrolling patients with HF who were treated for ID with intravenous iron supplements, oral iron supplements, or placebo. The primary outcomes were all-cause death, cardiovascular mortality, and hospitalization for heart failure. The secondary outcomes were evaluated through the six-minute walking test (6MWT) and the Kansas City Cardiomyopathy Questionnaire (KCCQ). RESULTS The network meta-analysis included sixteen studies. Compared to placebo/control groups, intravenous iron supplements did not decrease all-cause death (0.69, 0.39-1.23) or cardiovascular mortality (0.89, 0.66-1.20). After 12 weeks, a reduced hospitalization for heart failure was associated with the administration of intravenous iron supplementations (0.58, 0.34-0.97). The most significant improvements regarding 6MWT (44.44, 6.10-82.79) and KCCQ (5.96, 3.19-8.73) were observed with intravenous iron supplements. Oral iron supplements reduced hospitalization for heart failure (0.36, 0.14-0.96) and all-cause death (0.34, 0.12-0.95), but did not influence the 6MWT (29.74, -47.36 to 106.83) and KCCQ (0.10, -10.95 to 11.15). CONCLUSIONS Administering intravenous iron supplements for ID in patients with HF improves their exercise capacity and quality of life. In order to reduce hospitalizations for heart failure, the supplementation should be administered for more than 12 weeks. Although oral iron supplements did not improve exercise capacity and quality of life, they could reduce all-cause death and hospitalizations for heart failure.
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Affiliation(s)
- Ziwei Mei
- Lishui Municipal Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang 323000, China
| | - Jun Chen
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310000, China.
| | - Songmei Luo
- Lishui Municipal Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang 323000, China
| | - Lie Jin
- Lishui Municipal Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang 323000, China
| | - Qiang Liu
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310000, China
| | - Yijie Chen
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310000, China
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VENTURINI E, IANNUZZO G, DI LORENZO A, CUOMO G, D'ANGELO A, MERONE P, CUDEMO G, PACILEO M, D'ANDREA A, VIGORITO C, GIALLAURIA F. Short-term treatment of iron deficiency anemia after cardiac surgery. IJC HEART & VASCULATURE 2022; 40:101038. [PMID: 35514874 PMCID: PMC9066354 DOI: 10.1016/j.ijcha.2022.101038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
Iron deficiency anemia (IDA) is frequent after cardiac surgery and is associated with increased morbidity and mortality. In a retrospective study, we analyzed 106 patients with IDA (hemoglobin [Hb] ≤ 12 g/dl in women and ≤ 13 g/dl in men, transferrin saturation [TSAT] ≤ 20%) on admission to a Cardiac Rehabilitation Unit after cardiac surgery. The patients were divided into two groups, one was treated with oral sucrosomial iron (SI) and the other with intravenous ferric carboxymaltose (FCM). Patients received a single 1000 mg dose of FCM from the day after admission to rehabilitation (T1), or a 120 mg/day dose of SI from T1 until discharge (T2); after discharge, SI was reduced to 30 mg/day until the end of follow-up (T3). Hb was evaluated at T1, T2 and T3; the other hematological parameters at T1 and T3; natriuretic peptides at T1, T2 and T3; 6-minute walk test (6MWT) at T1 and T2. Folate, vitamin B12 and reticulocytes were sampled on admission. Folate deficiency was documented in 60.4% of patients. Hb increased in both groups with no significant differences between the two treatments (p = 0.397). The other iron metabolism parameters (sideremia, transferrin, TSAT) displayed similar behavior, showing a significant increase at T3 (p < 0.001) with both therapies, although the increase was faster with FCM. Ferritin – high on admission – decreased at T3 in the SI group and rose significantly in the FCM group (SI 219.5 vs. FCM 689 ng/ml p < 0.0001). The 6MWT increased significantly at T2, with an overlap between SI and FCM. In conclusion, the results of this study show that SI and FCM exhibit the same effectiveness on IDA; the response time to therapy of both treatments is also equally fast. SI and FCM induce a similar increase in functional capacity. The study shows that SI can be a viable alternative to FCM after cardiac surgery in terms of effectiveness and tolerability.
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Affiliation(s)
- Elio VENTURINI
- Cardiac Rehabilitation Unit and Department of Cardiology, Azienda USL Toscana Nord-Ovest, “Cecina Civil Hospital”, 57023 - Cecina (LI), Italy
| | - Gabriella IANNUZZO
- Department of Clinical Medicine and Surgery, “Federico II” University, 80131 – Naples, Italy
| | - Anna DI LORENZO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Gianluigi CUOMO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Andrea D'ANGELO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Pasquale MERONE
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Giuseppe CUDEMO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Mario PACILEO
- Department of Cardiology and Intensive Coronary Care, “Umberto I Hospital”, 84014 - Nocera Inferiore (SA), Italy
| | - Antonello D'ANDREA
- Department of Cardiology and Intensive Coronary Care, “Umberto I Hospital”, 84014 - Nocera Inferiore (SA), Italy
| | - Carlo VIGORITO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Francesco GIALLAURIA
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
- Corresponding author at: Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, Naples, Italy.
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Bomer N, Pavez-Giani MG, Grote Beverborg N, Cleland JGF, van Veldhuisen DJ, van der Meer P. Micronutrient deficiencies in heart failure: Mitochondrial dysfunction as a common pathophysiological mechanism? J Intern Med 2022; 291:713-731. [PMID: 35137472 PMCID: PMC9303299 DOI: 10.1111/joim.13456] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heart failure is a devastating clinical syndrome, but current therapies are unable to abolish the disease burden. New strategies to treat or prevent heart failure are urgently needed. Over the past decades, a clear relationship has been established between poor cardiac performance and metabolic perturbations, including deficits in substrate uptake and utilization, reduction in mitochondrial oxidative phosphorylation and excessive reactive oxygen species production. Together, these perturbations result in progressive depletion of cardiac adenosine triphosphate (ATP) and cardiac energy deprivation. Increasing the delivery of energy substrates (e.g., fatty acids, glucose, ketones) to the mitochondria will be worthless if the mitochondria are unable to turn these energy substrates into fuel. Micronutrients (including coenzyme Q10, zinc, copper, selenium and iron) are required to efficiently convert macronutrients to ATP. However, up to 50% of patients with heart failure are deficient in one or more micronutrients in cross-sectional studies. Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation, moving our view of the failing myocardium away from an "an engine out of fuel" to "a defective engine on a path to self-destruction." This summary of evidence suggests that supplementation with micronutrients-preferably as a package rather than singly-might be a potential therapeutic strategy in the treatment of heart failure patients.
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Affiliation(s)
- Nils Bomer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mario G Pavez-Giani
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Niels Grote Beverborg
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK.,National Heart & Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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[Prevalence of iron deficiency in patients with non-dialysis chronic kidney disease: The CARENFER national, multicentre, observational study]. Nephrol Ther 2022; 18:195-201. [PMID: 35241379 DOI: 10.1016/j.nephro.2021.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/08/2021] [Accepted: 12/19/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Iron deficiency is common and associated with worse outcomes in patients with non-dialysis chronic kidney disease. We performed a national, multicentre, observational and transversal study to assess the prevalence of iron deficiency as well as current iron deficiency screening practices in this population. PATIENTS AND METHODS A total of 25 nephrology centres in France participated in the study. All adult non-dialysis chronic kidney disease patients who met the inclusion (GFR>15mL/min/1.73m2) and exclusion criteria and provided consent were systematically recruited over a 4-week inclusion period. Investigators were asked to perform a blood test (hemoglobin concentration, serum iron, serum ferritin and transferrin saturation) and to complete a questionnaire about their iron status monitoring practices. The primary objective was to assess the prevalence of iron deficiency (serum ferritin<100μg/L and/or transferrin saturation<20%). Secondary objectives were to evaluate the prevalence of absolute iron deficiency (serum ferritin<100μg/L and transferrin saturation<20%) and functional iron deficiency (serum ferritin≥100μg/L and transferrin saturation<20%), the prevalence of iron deficiency according to haemoglobin concentration and chronic kidney disease stage, the proportion of centres that perform routine evaluation of iron status and the number of patients receiving iron supplementation. RESULTS A total of 1211 patients with non-dialysis chronic kidney disease were included in the analysis. The overall prevalence of iron deficiency was 47.1%. The rates of absolute iron deficiency and functional iron deficiency and anaemia were 13.4% and 17.1%, respectively. Among the 25 participating centres, 12 reported routine assessment of iron status in non-dialysis chronic kidney disease patients. CONCLUSION In this observational study, a high prevalence of iron deficiency was observed among non-dialysis chronic kidney disease patients. Less than half of participating centres reported routine assessment of iron status.
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Miñana G, Lorenzo M, Ramirez de Arellano A, Wächter S, de la Espriella R, Sastre C, Mollar A, Núñez E, Bodí V, Sanchis J, Bayés-Genís A, Núñez J. Incidence, Treatment and Clinical Impact of Iron Deficiency in Chronic Heart Failure: A Longitudinal Analysis. J Clin Med 2022; 11:jcm11092559. [PMID: 35566684 PMCID: PMC9100536 DOI: 10.3390/jcm11092559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with heart failure (HF), iron deficiency (ID) is a well-recognized therapeutic target; information about its incidence, patterns of iron repletion, and clinical impact is scarce. This single-centre longitudinal cohort study assessed the rates of ID testing and diagnosis in patients with stable HF, patterns of treatment with intravenous iron, and clinical impact of intravenous iron on HF rehospitalization risk. We included 711 consecutive outpatients (4400 visits) with stable chronic HF from 2014 to 2019 (median [interquartile range] visits per patient: 2 [2−7]. ID was defined as serum ferritin <100 µg/L, or 100−299 µg/L with transferrin saturation (TSAT) < 20%. During a median follow-up of 2.20 (1.11−3.78) years, ferritin and TSAT were measured at 2230 (50.7%) and 2183 visits (49.6%), respectively. ID was found at 846 (37.9%) visits, with ferritin and TSAT available (2230/4400), and intravenous iron was administered at 321/4400 (7.3%) visits; 233 (32.8%) patients received intravenous iron during follow-up. After multivariate analyses, iron repletion at any time during follow-up was associated with a lower risk of recurrent HF hospitalization (hazard ratio [HR] = 0.50, 95% confidence interval [CI] = 0.28−0.88; p = 0.016). Thus, ID was a frequent finding in patients with HF, and its repletion reduced the risk of recurrent HF hospitalizations.
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Affiliation(s)
- Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
- CIBER Cardiovascular, 28029 Madrid, Spain;
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
| | | | - Sandra Wächter
- Medical Department, Viforpharma Group, 8152 Zurich, Switzerland;
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
- CIBER Cardiovascular, 28029 Madrid, Spain;
| | - Clara Sastre
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
| | - Anna Mollar
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
- CIBER Cardiovascular, 28029 Madrid, Spain;
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
- CIBER Cardiovascular, 28029 Madrid, Spain;
| | - Antoni Bayés-Genís
- CIBER Cardiovascular, 28029 Madrid, Spain;
- Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Spain
- Department of Medicine, Autonomous University of Barcelona, 08193 Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Universitat de Valencia, INCLIVA, 46010 Valencia, Spain; (G.M.); (M.L.); (R.d.l.E.); (C.S.); (A.M.); (E.N.); (V.B.); (J.S.)
- CIBER Cardiovascular, 28029 Madrid, Spain;
- Correspondence: or ; Tel.: +34-617551562; Fax: +34-963862658
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Alnuwaysir RIS, Hoes MF, van Veldhuisen DJ, van der Meer P, Beverborg NG. Iron Deficiency in Heart Failure: Mechanisms and Pathophysiology. J Clin Med 2021; 11:125. [PMID: 35011874 PMCID: PMC8745653 DOI: 10.3390/jcm11010125] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/17/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022] Open
Abstract
Iron is an essential micronutrient for a myriad of physiological processes in the body beyond erythropoiesis. Iron deficiency (ID) is a common comorbidity in patients with heart failure (HF), with a prevalence reaching up to 59% even in non-anaemic patients. ID impairs exercise capacity, reduces the quality of life, increases hospitalisation rate and mortality risk regardless of anaemia. Intravenously correcting ID has emerged as a promising treatment in HF as it has been shown to alleviate symptoms, improve quality of life and exercise capacity and reduce hospitalisations. However, the pathophysiology of ID in HF remains poorly characterised. Recognition of ID in HF triggered more research with the aim to explain how correcting ID improves HF status as well as the underlying causes of ID in the first place. In the past few years, significant progress has been made in understanding iron homeostasis by characterising the role of the iron-regulating hormone hepcidin, the effects of ID on skeletal and cardiac myocytes, kidneys and the immune system. In this review, we summarise the current knowledge and recent advances in the pathophysiology of ID in heart failure, the deleterious systemic and cellular consequences of ID.
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Affiliation(s)
| | | | | | | | - Niels Grote Beverborg
- Department of Cardiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (R.I.S.A.); (M.F.H.); (D.J.v.V.); (P.v.d.M.)
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van Dalen DH, Kragten JA, Emans ME, van Ofwegen-Hanekamp CEE, Klaarwater CCR, Spanjers MHA, Hendrick R, van Deursen CTBM, Brunner-La Rocca HP. Acute heart failure and iron deficiency: a prospective, multicentre, observational study. ESC Heart Fail 2021; 9:398-407. [PMID: 34862747 PMCID: PMC8788059 DOI: 10.1002/ehf2.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/11/2021] [Accepted: 11/11/2021] [Indexed: 01/10/2023] Open
Abstract
Aims The prevalence and the natural course of iron deficiency (ID) in acute heart failure (AHF) are still unclear. We investigated the prevalence of ID in unselected patients admitted with AHF on admission, at discharge and up to 3 months thereafter. Methods and results In this prospective, multicentre, observational study, 742 patients admitted with AHF were enrolled. The main study outcome was the percentage of patients with ID (ferritin <100 μg/L = absolute ID or ferritin 100–299 μg/L and transferrin saturation <20% = functional ID) at admission (T0), after clinical stabilization prior to discharge (T1), and 10 ± 6 weeks after discharge (T2). At T0, ID was present in 71.8% of the patients (44.1% absolute and 27.7% functional ID). At T1 and T2, ID was present in 56.4% (32.4% absolute and 24% functional ID) and 50.3% (36.8% absolute and 13.5% functional ID), respectively. Absolute ID persisted from T0 to T2 in 66% of the patients, while functional ID resolved in 56% of the patients. Ferritin (median [interquartile range] 124 μg/L [56–247] to 150 μg/L [73–277]), transferrin saturation (15% [10–20] to 18% [12–27]), and iron levels (9 μmol/L [6–13] to 11 μmol/L [8–16]) increased significantly (all P < 0.001) from T0 to T1. Transferrin saturation (to 21% [15–29]) and iron levels (to 13 μmol/L [9–17]) also increased significantly (both P < 0.01) from T1 to T2 without iron supplementation. Conclusions Iron deficiency is highly prevalent in patients with AHF, but resolves during treatment in some patients, even without iron supplementation. Absolute ID is more likely to persist over time, whereas functional ID often resolves during treatment of AHF, representing probably a reduced iron availability rather than a true deficiency.
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Affiliation(s)
- Dirk H van Dalen
- Department of Cardiology, Jeroen Bosch Hospital, PO Box 90153, room B4.02.022, 's-Hertogenbosch, 5200ME, The Netherlands
| | - Johannes A Kragten
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mireille E Emans
- Department of Cardiology, Ikazia Hospital Rotterdam, Rotterdam, The Netherlands
| | | | | | - Mireille H A Spanjers
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rémond Hendrick
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Cees Th B M van Deursen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Cardiovascular Diseases (CARIM), University of Maastricht, Maastricht, The Netherlands
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Ismahel H, Ismahel N. Iron replacement therapy in heart failure: a literature review. Egypt Heart J 2021; 73:85. [PMID: 34568981 PMCID: PMC8473508 DOI: 10.1186/s43044-021-00211-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/15/2021] [Indexed: 08/30/2023] Open
Abstract
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.
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Affiliation(s)
- Hassan Ismahel
- University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK.
| | - Nadeen Ismahel
- University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK
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Safety and Efficacy of Intravenous Ferric Derisomaltose Compared to Iron Sucrose for Iron Deficiency Anemia in Patients with Chronic Kidney Disease With and Without Heart Failure. Am J Cardiol 2021; 152:138-145. [PMID: 34162484 DOI: 10.1016/j.amjcard.2021.04.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 11/23/2022]
Abstract
Ferric derisomaltose (FDI) is an intravenous (IV) high-dose iron formulation approved in the US for the treatment of iron deficiency anemia in adults who are intolerant of/have had an unsatisfactory response to oral iron, or who have non-dialysis-dependent chronic kidney disease (NDD-CKD). FERWON-NEPHRO was a randomized, open-label, multicenter clinical trial evaluating the safety and efficacy of a single infusion of FDI 1,000 mg versus up to 5 doses of iron sucrose (IS) 200 mg (recommended cumulative dose, 1,000 mg) over 8 weeks in patients with NDD-CKD and iron deficiency anemia. Of 1,525 patients included in the safety analysis, 244 (16%) had a history of heart failure (HF). Overall, the rate of serious or severe hypersensitivity reactions was low and did not differ between treatment groups. Cardiovascular adverse events (AEs) were reported for 9.4% of patients who had HF and 4.2% who did not. Time to first cardiovascular AE was longer following administration of FDI compared with IS (hazard ratio: 0.59 [95% CI: 0.37, 0.92]; p=0.0185), a difference that was similar in patients with or without HF (p=0.908 for interaction). Patients achieved a faster hematological response (assessed by changes in hemoglobin and ferritin concentrations, and increase in transferrin saturation) with FDI versus IS. In conclusion, in patients with NDD-CKD, a single infusion of FDI was safe, well tolerated, and was associated with fewer cardiovascular AEs and a faster hematological response, compared to multiple doses of IS. These effects were similar for patients with and without HF.
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36
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Rush CJ, Cleland JG, Veldtman G. The emerging burden of heart failure in adults with congenital heart disease. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Graham FJ, Pellicori P, Cleland JGF, Clark AL. Reply to the letter regarding the article 'Natural history and prognostic significance of iron deficiency and anaemia in ambulatory patients with chronic heart failure'. Eur J Heart Fail 2021; 23:1800-1801. [PMID: 34263510 DOI: 10.1002/ejhf.2304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/10/2021] [Indexed: 01/15/2023] Open
Affiliation(s)
- Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | | | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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Graham FJ, Masini G, Pellicori P, Cleland JGF, Greenlaw N, Friday J, Kazmi S, Clark AL. Natural history and prognostic significance of iron deficiency and anaemia in ambulatory patients with chronic heart failure. Eur J Heart Fail 2021; 24:807-817. [PMID: 34050582 DOI: 10.1002/ejhf.2251] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/21/2021] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
AIMS Iron deficiency (ID) and anaemia are common in heart failure; less is known about changes over time. METHODS AND RESULTS We investigated prevalence, incidence and resolution of ID and anaemia in 906 patients with chronic heart failure (median age 73 (65-79) years, 70% men, 51% with heart failure with reduced ejection fraction) 1 year apart. ID was defined as serum iron ≤13 µmol/L and anaemia as haemoglobin <13.0 g/dL for men or <12.0 g/dL for women. FAIR-HF criteria for ID were also considered. At baseline, 10% had anaemia without ID, 23% had ID without anaemia, 20% had both, and 47% had neither. Percentages changed little over 1 year, but 157 (30%) patients had new-onset ID, 104 (16%) new-onset anaemia, whilst ID resolved in 173 (44%) and anaemia in 63 (23%). Compared to those who remained iron replete (iron >13 µmol/L), mortality was higher in those with persistent or incident ID at 1 year [hazard ratio (HR) 1.81 (1.23-2.67), and HR 1.40 (0.91-2.14), respectively] in multivariable models (P = 0.02). Compared to persistent ID, resolution of ID was associated with a lower mortality [HR 0.61 (0.44-0.86); P = 0.004]. Changes in ID defined by FAIR-HF criteria were not similarly associated with mortality. Anaemia was associated with a poor outcome even if it resolved. CONCLUSIONS The prevalence and incidence of ID and anaemia are high in chronic heart failure but so is the rate of resolution. Persistent or incident ID, defined by a serum iron ≤13 µmol/L, is associated with higher mortality and resolution of ID with lower mortality.
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Affiliation(s)
- Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Gabriele Masini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Jocelyn Friday
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Syed Kazmi
- Hull University Teaching Hospitals NHS Trust, Hull, UK
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