Angiotensin-converting enzyme inhibitor as a risk factor for the development of anemia, and the impact of incident anemia on mortality in patients with left ventricular dysfunction

The effect of the four pharmacological pillars of heart failure on haemoglobin level

Anaemia, a condition characterized by low levels of haemoglobin, is frequently observed in patients with heart failure (HF). Guideline-directed medical therapy improves HF outcomes by using medications like beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, along with mineralocorticoid receptor antagonists and sodium-glucose cotransporter 2 inhibitors. In this study, we aimed to review the pathophysiology of anaemia in patients with HF and present the current evidence regarding the relationship between the main recommended medications for these patients and haemoglobin levels. The authors conducted a comprehensive search in the medical literature for relevant original clinical articles in which the four pharmacological pillars of HF were given to the patients; we, then, assessed whether the association of use of these medications and haemoglobin level or development of anaemia was provided. These common medications have been shown in the literature that may exacerbate or ameliorate anaemia. Besides, it has been shown that even in the case that they result in the development of anaemia, their use is associated with positive effects that outweigh this potential harm. The literature also suggests that among patients receiving medications with negative effects on the level of haemoglobin, there was no difference in the rate of mortality between anaemic and non-anaemic patients when both were on treatment for anaemia; this point highlights the importance of the detection and treatment of anaemia in these patients. Further research is needed to explore these relationships and identify additional strategies to mitigate the risk of anaemia in this population.

Prevalent and Incident Anemia in PARADIGM-HF and the Effect of Sacubitril/Valsartan

BACKGROUND

Anemia is common in patients with heart failure with reduced ejection fraction and is associated with poor clinical outcomes. Renin-angiotensin system blockers lower hemoglobin and may induce anemia.

OBJECTIVES

The authors investigated whether concomitant neprilysin inhibition might ameliorate this effect of renin-angiotensin system blockers in PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure).

METHODS

Anemia was defined as hemoglobin <120 g/L in women and <130 g/L in men at screening. The authors investigated the effect of randomized treatment on clinical outcomes according to anemia status, change in hemoglobin from baseline, and the incidence of anemia.

RESULTS

Of 8,239 participants with a baseline hemoglobin measurement, 1,677 (20.4%) were anemic. Patients with anemia had a more severe heart failure profile, worse kidney function, greater neurohormonal derangement, and worse clinical outcomes. Sacubitril/valsartan, compared with enalapril, decreased the risk of cardiovascular death or heart failure hospitalization similarly in patients with (HR: 0.84; 95% CI: 0.71-1.00) and without anemia (HR: 0.78 [95% CI: 0.71-0.87]; P value for interaction = 0.478). Between baseline and 12 months, hemoglobin decreased by 1.5 g/L (95% CI: 1.2-1.7 g/L) with sacubitril/valsartan compared with 2.3 g/L (95% CI: 2.0-2.6 g/L) with enalapril: mean difference 0.8 g/L (95% CI: 0.5-1.2 g/L; P < 0.001). Patients assigned to sacubitril/valsartan were less likely to develop anemia at 12 months (321 of 2,806 [11.4%]) compared with patients randomized to enalapril (440 of 2,824 [15.6%]) (OR: 0.70 [95% CI: 0.60-0.81]; P < 0.001). These findings were similar in PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) (sacubitril/valsartan vs valsartan). There was biomarker evidence of increased iron utilization with sacubitril/valsartan.

CONCLUSIONS

Irrespective of anemia status, sacubitril/valsartan compared with enalapril, decreased mortality and hospitalization. Hemoglobin decreased less with sacubitril/valsartan and the incidence of new anemia was lower with sacubitril/valsartan. (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure [PARADIGM-HF] trial; NCT01035255).

Hematological abnormalities and associated factors among metabolic syndrome patients at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia

BACKGROUND

Metabolic Syndrome (MetS) is a cluster of interconnected metabolic diseases. Hematological abnormalities are common but neglected complications of MetS. Thus, this study aimed to determine the magnitude of hematological abnormalities and their associated factors among MetS patients at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia.

METHOD

A hospital-based cross-sectional study was conducted at the University of Gondar comprehensive specialized hospital from March to May 2022. A total of 384 MetS patients were selected using a systematic random sampling technique. Data were collected using pre-tested structured questionnaires and checklists. Anthropometric and blood pressure measurements were taken, and blood sample was collected for complete blood count determination. Stool and blood film examinations were performed to detect intestinal and malaria parasites, respectively. Data were entered into EpiData 3.1 and analyzed by Stata 14.0 software. Bivariate and multivariate logistic regression models were fitted to identify factors associated with hematological abnormalities. A p-value of < 0.05 was considered statistically significant.

RESULTS

The magnitude of anemia, leukopenia, leukocytosis, thrombocytopenia, and thrombocytosis was found to be 13.3%, 0.5%, 2.9%, 1.6%, and 2.3%, respectively. Being male (AOR = 2.65, 95% CI: 1.14, 6.20), rural residency (AOR = 5.79, 95% CI: 1.72, 19.51), taking antihypertensive medications (AOR = 3.85, 95% CI: 1.16, 12.78), having elevated triglyceride level (AOR = 2.21, 95% CI: 1.03, 4.75), and being overweight or obese (AOR = 0.32, 95% CI: 0.16, 0.64) were significantly associated with anemia.

CONCLUSIONS

Anemia was the most prevalent hematological abnormality identified in the present study, followed by leukocytosis and thrombocytosis. Anemia was a mild public health problem among MetS patients in the study area. Routine anemia screening for all MetS patients, especially for those with significant associated factors, may help in the early detection and effective management of anemia, which subsequently improves the patients' quality of life.

Update on cardiogenic shock: from detection to team management

PURPOSE OF REVIEW

The following review is intended to provide a summary of contemporary cardiogenic shock (CS) profiling and diagnostic strategies, including biomarker and hemodynamic-based (invasive and noninvasive) monitoring, discuss clinical differences in presentation and trajectory between acute myocardial infarction (AMI)-CS and heart failure (HF)-CS, describe transitions to native heart recovery and heart replacement therapies with a focus on tailored management and emerging real-world data, and emphasize trends in team-based initiatives and interventions for cardiogenic shock including the integration of protocol-driven care.

RECENT FINDINGS

This document provides a broad overview of contemporary scientific consensus statements as well as data derived from randomized controlled clinical trials and observational registry working groups focused on cardiogenic shock management.

SUMMARY

This review highlights the increasingly important role of pulmonary artery catheterization in AMI-CS and HF-CS cardiogenic shock and advocates for routine application of algorithmic approaches with interdisciplinary care pathways. Cardiogenic shock algorithms facilitate the integration of clinical, hemodynamic, and imaging data to determine the most appropriate patient hemodynamic support platform to achieve adequate organ perfusion and decongestion.

Anemia prevalence time trends and disparities in the US population: examination of NHANES 1999-2020

While a rising prevalence of anemia in the United States was reported in older studies, recent data are lacking. To estimate the prevalence and time trends of anemia in the United States and to examine how these estimates differ by gender, age, race, and household income to poverty threshold ratio (HIPR), we used the National Health and Nutrition Examination Surveys from 1999 to 2020. The presence of anemia was determined using the World Health Organization criteria. Survey-weighted raw and adjusted prevalence ratios (PRs) were determined using generalized linear models for the overall population and by gender, age, race, and HIPR. In addition, an interaction between gender and race was explored. Complete data on anemia, age, gender, and race were available on 87,554 participants (mean age = 34.6 years, women = 49.8%, Whites = 37.3%). Anemia prevalence increased from 4.03% during the 1999-2000 survey cycle to 6.49% during 2017-2020. In adjusted analyses, anemia prevalence was higher in >65 than in 26-45 years old (PR = 2.14, 95% confidence interval (CI) = 1.95, 2.35), in Blacks than Whites (PR = 3.97, 95% CI = 3.63, 4.35), in women than men (PR = 1.98, 95% CI = 1.83, 2.13), and in those with HIPR ≤ 1 than >4 (PR = 0.68, 95% CI = 0.61, 0.75). Gender modified the relationship between anemia and race; when compared to their male counterparts, Black, Hispanic, and other women had higher anemia prevalence than White women (all interaction p values <0.05). The anemia prevalence in the United States has risen from 1999 to 2020 and remains high among the elderly, minorities, and women. The difference in anemia prevalence between men and women is larger in non-Whites.

Role of Iron Deficiency in Heart Failure-Clinical and Treatment Approach: An Overview

BACKGROUND

The association of chronic heart failure (CHF) and iron deficiency (ID) with or without anemia is frequently encountered in current medical practice and has a negative prognostic impact, worsening patients' exercise capacity and increasing hospitalization costs. Moreover, anemia is common in patients with chronic kidney disease (CKD) and CHF, an association known as cardio-renal anemia syndrome (CRAS) possessing a significantly increased risk of death.

AIM

This review aims to provide an illustrative survey on the impact of ID in CHF patients-based on physiopathological traits, clinical features, and the correlation between functional and absolute ID with CHF-and the benefit of iron supplementation in CHF.

METHOD

We selected the most recent publications with important scientific content covering the association of CHF and ID with or without anemia.

DISCUSSIONS

An intricate physiopathological interplay is described in these patients-decrease in erythropoietin levels, activation of the renin-angiotensin-aldosterone system, systemic inflammation, and increases in hepcidin levels. These mechanisms amplify anemia, CHF, and CKD severity and worsen patients' outcomes.

CONCLUSIONS

Anemia is frequently encountered in CHF and represents a negative prognostic factor. Data from randomized controlled trials have underlined the administration of intravenous iron therapy (ferric carboxymaltose) as the only viable treatment option, with beneficial effects on quality of life and exercise capacity in patients with ID and systolic heart failure.

Anemia is a risk factor for rapid eGFR decline in type 2 diabetes

OBJECTIVE

To investigate the association between anemia and progression of diabetic kidney disease (DKD) in type 2 diabetes.

METHODS

This was a retrospective study. A total of 2570 in-patients with type 2 diabetes hospitalized in Jinan branch of Huashan hospital from January 2013 to October 2017 were included, among whom 526 patients were hospitalized ≥ 2 times with a median follow-up period of 2.75 years. Annual rate of eGFR decline was calculated in patients with multiple admissions. A rate of eGFR decline exceeding -5 ml/min per 1.73 m² per year was defined as rapid eGFR decline. The prevalence of DKD and clinical characteristics were compared between anemia and non-anemia patients. Correlation analysis was conducted between anemia and clinical parameters. Comparison of clinical features were carried out between rapid eGFR decline and slow eGFR decline groups. The risk factors for rapid DKD progression were analyzed using logistic regression analysis.

RESULTS

The prevalence of anemia was 28.2% among the 2570 diabetic patients, while in patients with DKD, the incidence of anemia was 37.8%. Patients with anemia had greater prevalence of DKD, higher levels of urinary albumin-to-creatinine ratio (UACR), serum creatinine, BUN, urine α1-MG, urine β2-MG, urine NAG/Cr, hsCRP, Cystatin C, homocysteine and lower eGFR, as compared to the patients without anemia. Anemia was correlated with age, UACR, eGFR, urinary NAG/Cr, hsCRP and diabetic retinopathy (DR). Logistic regression analysis of 526 patients with type 2 diabetes during the follow-up period showed that anemia was an independent risk factor for rapid eGFR decline.

CONCLUSION

Anemia is associated with worse renal function and is an independent risk factor for rapid eGFR decline in type 2 diabetes.

A systematic review on sex differences in adverse drug reactions related to psychotropic, cardiovascular, and analgesic medications

Background and objective: Adverse drug reactions (ADRs) are the main safety concerns of clinically used medications. Accumulating evidence has shown that ADRs can affect men and women differently, which suggests sex as a biological predictor in the risk of ADRs. This review aims to summarize the current state of knowledge on sex differences in ADRs with the focus on the commonly used psychotropic, cardiovascular, and analgesic medications, and to aid clinical decision making and future mechanistic investigations on this topic. Methods: PubMed search was performed with combinations of the following terms: over 1,800 drugs of interests, sex difference (and its related terms), and side effects (and its related terms), which yielded over 400 unique articles. Articles related to psychotropic, cardiovascular, and analgesic medications were included in the subsequent full-text review. Characteristics and the main findings (male-biased, female-biased, or not sex biased ADRs) of each included article were collected, and the results were summarized by drug class and/or individual drug. Results: Twenty-six articles studying sex differences in ADRs of six psychotropic medications, ten cardiovascular medications, and one analgesic medication were included in this review. The main findings of these articles suggested that more than half of the ADRs being evaluated showed sex difference pattern in occurrence rate. For instance, lithium was found to cause more thyroid dysfunction in women, and amisulpride induced prolactin increase was more pronounced in women than in men. Some serious ADRs were also found to exert sex difference pattern, such as clozapine induced neutropenia was more prevalent in women whereas simvastatin/atorvastatin-related abnormal liver functions were more pronounced in men.

Can Iron Play a Crucial Role in Maintaining Cardiovascular Health in the 21st Century?

In the 21st century the heart is facing more and more challenges so it should be brave and iron to meet these challenges. We are living in the era of the COVID-19 pandemic, population aging, prevalent obesity, diabetes and autoimmune diseases, environmental pollution, mass migrations and new potential pandemic threats. In our article we showed sophisticated and complex regulations of iron metabolism. We discussed the impact of iron metabolism on heart diseases, treatment of heart failure, diabetes and obesity. We faced the problems of constant stress, climate change, environmental pollution, migrations and epidemics and showed that iron is really essential for heart metabolism in the 21st century.

Anemia warrants treatment to improve survival in patients with heart failure receiving sacubitril-valsartan

Angiotensin inhibition remains a cornerstone for pharmacologic management of heart failure (HF), despite being associated with decreased hemoglobin (Hb) levels. To investigate the effect of anemia and its treatment on patients with HF treated with sacubitril-valsartan (S/V), we conducted a retrospective study involving patients with recorded left ventricular ejection fractions (LVEFs) of < 40% between January 2017 and December 2019. We identified 677 patients, 37.7% of whom received S/V. The median follow-up period was 868 days. Anemia was associated with significantly decreased survival, increased mortality rates, and higher all-cause hospitalizations in S/V-using patients. We further analyzed 236 patients with HF who had recorded renal function, LVEF, and Hb at the initiation of S/V therapy to identify Hb patterns after S/V therapy. Of these patients, 35.6% exhibited decreasing Hb 12 months after S/V initiation, which was associated with a lower survival rate. Among the patients who were not prescribed anemia medications, Hb of ≥ 12 (vs. < 12 g/dL) was associated with a higher survival rate; this association was absent among the patients undergoing anemia treatment. These results emphasize that consistent screening and treatment for anemia should be implemented to reduce the morbidity and mortality of patients with HF receiving S/V.

Anaemia in Heart Failure Patients, Associated with Angiotensin - Renin - Aldosterone System Altering Medications

Heart failure (HF) remains one of the most common diseases and one of the major causes of death worldwide. HF is often associated with other chronic diseases, most commonly with anemia. Anemia increases patients' mortality and lowers their quality of life. There are a few pathophysiological mechanisms that explain anemia in patients with HF - hemodilution, absolute or functional iron deficiency, activation of the inflammatory cascade, chronic kidney disease, and impaired erythropoietin production and activity. Moreover, congestive HF is often treated with angiotensin-converting enzyme inhibitors and aldosterone receptors blockers, which could be linked to the development of anemia.

Conversion from Aranesp® to NESP® in dialysis patients-Exploration of dosing strategies and the feasibility of extending the dosing interval

AIM

Darbepoetin alpha is available as Aranesp® and NESP®, which differ in the inactive component and maximum dose-strength of prefilled syringes. We conducted an observational cohort study to investigate optimal conversion strategies and the feasibility of extending dosing intervals with higher-dose preparations in dialysis patients converting from Aranesp® to NESP®.

METHODS

Adult dialysis patients on Aranesp® with stable haemoglobin of 9-12 g/dL were converted to NESP® at the same monthly total dose according to one of three conversion regimens. Group A included patients on ≤80 mcg/month of Aranesp® who converted with dosing regimen unchanged. Group B patients converted to NESP® with extended dosing intervals using higher individual dose preparations. Group C were patients on 100 mcg Aranesp® who converted to NESP® 120 mcg with extended dosing intervals. Patients were observed for 6 months.

RESULTS

Fifty patients were included. All 24 Group A patients maintained stable haemoglobin. In Group B, 10 patients (50%) maintained stable haemoglobin with extension of dosing interval from 1.04 ± 0.14 to 3.03 ± 1.28 weeks. Factors associated with success in extending dosing interval included a lower prevalence of cardiovascular disease and a higher Kt/V_urea in peritoneal dialysis patients. Four patients (80%) in Group C maintained stable haemoglobin after conversion to NESP® 120 mcg with extended dosing interval. The use of NESP® 120 mcg was well tolerated, and was associated with reduced patient-reported pain score and 38% reduction of drug cost.

CONCLUSION

Dialysis patients on Aranesp® can be successfully converted to NESP® and the dosing interval can be extended successfully in a significant proportion of patients, which could reduce discomfort and drug cost.

Anemia and Management of Heart Failure Patients

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

Discontinuation of the renin-angiotensin system inhibitors improves erythropoiesis in patients with lower-risk myelodysplastic syndromes

Renin–angiotensin system (RAS) blockade by angiotensin-converting enzyme inhibitors (ACEis) or angiotensin-receptor blockers (ARBs) has been related to anemia in various situations. We aimed to investigate whether discontinuation of RAS inhibitors improves erythropoiesis in patients with lower-risk myelodysplastic syndromes (LR-MDSs). Seventy-four patients with LR-MDS were divided into three groups matched for gender and age. Group A consisted of 20 hypertensive patients who discontinued RAS inhibitors and received alternative medications. Group B consisted of 26 patients who continued to receive ACEi/ARB and Group C included 28 patients (50% hypertensive) never exposed to ACEi/ARB. Half of the patients in each group were under treatment with recombinant human erythropoietin (rHuEPO). Data were collected at baseline and after 3, 6 and 12 months. Group A showed a significant increase in hemoglobin from 10.4 ± 1g/dL at baseline to 12.6 ± 1.2 g/dL after 12 months (p = 0.035) and in hematocrit (31.4 ± 3% versus 37.9 ± 4%, p = 0.002). Incident anemia decreased from 100% at baseline to 60% at 12 months (p = 0.043) despite a concomitant dose reduction in rHuEPO by 18% (p = 0.035). No changes in hemoglobin and hematocrit were observed in both Group B and Group C. In the subset of patients not treated with rHuEPO, improvement of erythropoiesis was found only in Group A, as measured by changes in hemoglobin (11.5 ± 1 g/dL versus 12.4 ± 1.3 g/dL, p = 0.041) and hematocrit (34.5 ± 3% versus 37.1 ± 4%, p = 0.038) after 12 months. In contrast, Group B and Group C decreased hemoglobin and hematocrit after 12 months (p < 0.05). In conclusion, discontinuation of ACEi/ARB in LR-MDS patients is followed by a significant recovery of erythropoiesis after 12 months.

Different age-related impacts of lean and obesity on cardiovascular prognosis in Japanese patients with cardiovascular risks: The J-HOP (Japan Morning Surge-Home Blood Pressure) Study

The relationship between lean and cardiovascular events has been shown to vary with age, but the relationship between age‐related lean and cardiovascular events in Asia has not been established. We divided patients enrolled in the J‐HOP (Japan Morning Surge‐Home Blood Pressure) study with one or more cardiovascular disease risks into three groups based on their body mass index (BMI): lean (BMI < 21), normal‐weight (21 ≤ BMI <27), and obese (BMI ≥ 27). We stratified the risk of cardiovascular events of lean and obesity compared to normal weight into the patients < 65 years old and those aged ≥ 65 years. A total of 286 cardiovascular disease events were observed during the follow‐up period (73 ± 46 months). Regarding the relationship between BMI and cardiovascular disease risk, both lean and obesity were independent prognostic factors: lean: hazard ratio (HR) 1.43, 95% confidence interval (CI): 1.02‐2.01, p = .040; obesity: HR 1.55, 95%CI: 1.13‐2.12, p = .006. In patients < 65 years old, the risk of cardiovascular disease of the lean patients was lower than that of the normal‐weight patients (HR 0.39, 95%CI: 0.12‐1.29, p = .124) and the risk of obesity patients was significantly higher (HR 1.77, 95%CI: 1.08‐2.92, p = .024). In the patients aged ≥ 65 years, lean was a significant independent factor of cardiovascular events compared to normal‐weight (lean: HR 1.70, 95%CI: 1.18‐2.47, p = .005). In conclusion, lean was an independent predictor of cardiovascular events in patients aged ≥ 65 years.

Incident anaemia in older adults with heart failure: rate, aetiology, and association with outcomes

AIMS

Limited data exist on the epidemiology, evaluation, and prognosis of otherwise unexplained anaemia of the elderly in heart failure (HF). Thus, we aimed to determine the incidence of anaemia, to characterize diagnostic testing patterns for potentially reversible causes of anaemia, and to evaluate the independent association between incident anaemia and long-term morbidity and mortality.

METHODS AND RESULTS

Within the Cardiovascular Research Network (CVRN), we identified adults age ≥65 years with diagnosed HF between 2005 and 2012 and no anaemia at entry. Incident anaemia was defined using World Health Organization (WHO) haemoglobin thresholds (<13.0 g/dL in men; <12.0 g/dL in women). All-cause death and hospitalizations for HF and any cause were identified from electronic health records. Among 38 826 older HF patients, 22 163 (57.1%) developed incident anaemia over a median (interquartile range) follow-up of 2.9 (1.2-5.6) years. The crude rate [95% confidence interval (CI)] per 100 person-years of incident anaemia was 26.4 (95% CI 26.0-26.7) and was higher for preserved ejection fraction (EF) [29.2 (95% CI 28.6-29.8)] compared with borderline EF [26.5 (95% CI 25.4-27.7)] or reduced EF [26.6 (95% CI 25.8-27.4)]. Iron indices, vitamin B12 level, and thyroid testing were performed in 20.9%, 14.9%, and 40.2% of patients, respectively. Reduced iron stores, vitamin B12 deficiency, and/or hypothyroidism were present in 29.7%, 3.2%, and 18.6% of tested patients, respectively. In multivariable analyses, incident anaemia was associated with excess mortality [hazard ratio (HR) 2.14, 95% CI 2.07-2.22] as well as hospitalization for HF (HR 1.80, 95% CI 1.72-1.88) and any cause (HR 1.77, 95% CI 1.72-1.83).

CONCLUSION

Among older adults with HF, incident anaemia is common and independently associated with substantially increased risks of morbidity and mortality. Additional research is necessary to clarify the value of routine evaluation and treatment of potentially reversible causes of anaemia.

The effect of initiation of renin-angiotensin system inhibitors on haemoglobin: A national cohort study

AIMS

To determine whether initiation of treatment with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers (ACEI/ARBs) is associated with a subsequent reduction in haemoglobin in the general population.

METHODS

We undertook a national cohort study over a 13-year period (2004-2016), using routine primary healthcare data from the UK Clinical Practice Research Datalink. We compared ACEI/ARB initiation with calcium channel blocker (CCB) initiation, to minimise confounding by indication. We included all first ACEI/ARB or CCB prescriptions in adults with at least 1 haemoglobin result in the 12 months before and 6 months after drug initiation. Our primary outcome was a ≥1 g/dL haemoglobin reduction in the 6 months after drug initiation.

RESULTS

We examined 146 610 drug initiation events in 136 655 patients. Haemoglobin fell by ≥1 g/dL after drug initiation in 19.5% (16 936/86 652) of ACEI/ARB initiators and 15.9% (9521/59 958) of CCB initiators. The adjusted odds ratio of a ≥1 g/dL haemoglobin reduction in ACEI/ARB initiators vs CCB initiators was 1.15 (95% confidence interval 1.12-1.19).

CONCLUSION

ACEI/ARBs are associated with a modest increase in the risk of a haemoglobin reduction. For every 100 patients in our study that initiated a CCB, 16 experienced a ≥1 g/dL haemoglobin decline. If the effect is causal, 3 additional patients would have experienced this outcome if they had received an ACEI/ARB. This may have implications for drug choice and monitoring for many patients in primary care. Further research could identify patients at higher risk of this outcome, who may benefit from closer monitoring.

Adverse Drug Reactions to Guideline-Recommended Heart Failure Drugs in Women: A Systematic Review of the Literature

OBJECTIVES

This study sought to summarize all available evidence on sex differences in adverse drug reactions (ADRs) to heart failure (HF) medication.

BACKGROUND

Women are more likely to experience ADRs than men, and these reactions may negatively affect women's immediate and long-term health. HF in particular is associated with increased ADR risk because of the high number of comorbidities and older age. However, little is known about ADRs in women with HF who are treated with guideline-recommended drugs.

METHODS

A systematic search of PubMed and EMBASE was performed to collect all available information on ADRs to angiotensin-converting enzyme inhibitors, β-blockers, angiotensin II receptor blockers, mineralocorticoid receptor antagonists, ivabradine, and digoxin in both women and men with HF.

RESULTS

The search identified 155 eligible records, of which only 11 (7%) reported ADR data for women and men separately. Sex-stratified reporting of ADRs did not increase over the last decades. Six of the 11 studies did not report sex differences. Three studies reported a higher risk of angiotensin-converting enzyme inhibitor-related ADRs in women, 1 study showed higher digoxin-related mortality risk for women, and 1 study reported a higher risk of mineralocorticoid receptor antagonist-related ADRs in men. No sex differences in ADRs were reported for angiotensin II receptor blockers and β-blockers. Sex-stratified data were not available for ivabradine.

CONCLUSIONS

These results underline the scarcity of ADR data stratified by sex. The study investigators call for a change in standard scientific practice toward reporting of ADR data for women and men separately.

[Position Paper. The role of iron deficiency in patients with chronic heart failure and current corrective approaches]

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Cardiogenic Shock Due to End-Stage Heart Failure and Acute Myocardial Infarction: Characteristics and Outcome of Temporary Mechanical Circulatory Support

BACKGROUND

Mechanical circulatory support (MCS) is increasingly used in cardiogenic shock, but outcomes may differ between patients with acute myocardial infarction (AMI) or end-stage heart failure (ESHF). This study aimed to describe the characteristics of patients with cardiogenic shock due to AMI and ESHF.

METHODS

Single-center study of consecutive patients with cardiogenic shock due to AMI (n = 26) and ESHF (n = 42) who underwent MCS (extracorporeal life support, Impella or temporary ventricular assist devices). Arterial and venous O2 content and CO2 tension (PCO2), O2-hemoglobin affinity (P50) were measured. Veno-arterial difference in PCO2/arterio-venous difference in O2 content ratio was derived. Acid-base balance was characterized by the Gilfix method. MCS-related complications that required intervention or surgery were collected.

RESULTS

Patients with ESHF had lower ejection fraction, higher right and left-sided filling pressures, pulmonary artery pressure and vascular resistance, lower oxygen delivery (DO2) compared with AMI, which was not fully compensated by the increased hemoglobin P50. As a result, patients with ESHF had higher veno-arterial difference in PCO2 relative to arterio-venous difference in O2 content. Despite greater anerobic metabolism, patients with ESHF had less severe metabolic acidosis and base deficit compared with AMI, predominantly due to differences in strong ions.

CONCLUSION

The cardiogenic shock phenotype in ESHF was distinct from AMI, characterized by higher filling and pulmonary artery pressures, lower DO2, greater anaerobic metabolism but less severe metabolic acidosis.

Impact of Chronic Kidney Disease and Anemia on Outcomes After Percutaneous Coronary Revascularization

Few studies have evaluated outcomes after percutaneous coronary intervention (PCI) in patients with both anemia (hemoglobin < 12 g/dl in women; <13 in men) and chronic kidney disease (CKD, estimated glomerular filtration rate < 60 ml/min/1.73 m²). Patients with coronary artery disease who underwent PCI in our health system from 2010 to 2018 were included (n = 10,756), excluding those with ST-elevation myocardial infarction or shock. We evaluated the individual and combined effects of anemia and CKD on outcomes. Five-year mortality was highest in the cohort with both anemia and CKD and lowest in those with neither. After multivariate analysis, with the group with neither anemia nor CKD as a reference, the adjusted hazard ratio for mortality was 1.68 (95% confidence interval [CI] 1.45 to 1.95, p <0.001) for those with anemia alone, 1.33 (95% CI 1.15 to 1.53, p <0.001) for those with CKD alone, and 2.83 (95% CI 2.49 to 3.22, p <0.001) for those with both anemia and CKD. With respect to readmission and reintervention, similar tends were observed, with patients with both CKD and anemia having the highest risk for these outcomes. In conclusion, the combined effects of anemia and CKD on outcomes post-PCI appear to be worse than either of their effects individually.

Inhibition of the renin-angiotensin system in the cardiorenal syndrome with anaemia: a double-edged sword

: The term 'cardiorenal syndrome' (CRS) was introduced to describe problems related to the simultaneous existence of heart and renal insufficiency. The prevalence of anaemia in CRS is high and increases the risk of hospitalizations and death. Renin-angiotensin system (RAS) inhibition is the cornerstone therapy in cardiovascular and renal medicine. As angiotensin II regulates both glomerular filtration rate (GFR) and erythropoiesis, RAS inhibition can further deteriorate renal function and lower hematocrit or cause anaemia in patients with heart failure. The aim of this review is to explore the relationship among CRS, anemia and administration of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) and summarize the evidence suggesting that RAS inhibition may be considered an iatrogenic cause of deterioration of CRS with anemia. It should be emphasized however, that RAS inhibition reduces mortality in both groups with and without worsening of renal function, and therefore, no patient with CRS should be denied an ACEi or ARB trial without careful evaluation.

The Influence of Cardiovascular Medications on Iron Metabolism in Patients with Heart Failure

Background and objectives: The etiology of anemia associated with heart failure is not fully understood, but there are data suggesting the involvement of multiple mechanisms, including various drug therapies used in patients with heart failure. Our primary objective was to evaluate the impact of beta blockers, angiotensin-converting enzyme inhibitors, and calcium-channel blockers on iron metabolism in patients with heart failure. Materials and Methods: This was a prospective observational study that included patients diagnosed with heart failure and iron deficiency (defined by ferritin <100 μg/L, or 100-300 μg/L with transferrin saturation <20%). Patients with anemia secondary to a known cause were excluded. Results: We found a statistically significant correlation between beta-blocker treatment and ferritin values (p = 0.02). Iron, hemoglobin, and hematocrit levels were significantly lower in the patients using calcium-channel blockers than those who were not. We also found a statistically significant indirect correlation (p = 0.04) between the use of angiotensin-converting enzyme inhibitors and hematocrit levels. Conclusion: The contribution of our study arises from the additional data regarding the drug-induced etiology of iron deficiency. Practitioners should be aware of the potential impact of therapeutic recommendations and this should imply a close monitoring of the biochemical parameters of iron deficiency in this category of patients.

Anemia in heart failure - from guidelines to controversies and challenges

Anemia associated with heart failure is a frequent condition, which may lead to heart function deterioration by the activation of neuro-hormonal mechanisms. Therefore, a vicious circle is present in the relationship of heart failure and anemia. The consequence is reflected upon the patients’ survival, quality of life, and hospital readmissions. Anemia and iron deficiency should be correctly diagnosed and treated in patients with heart failure. The etiology is multifactorial but certainly not fully understood. There is data suggesting that the following factors can cause anemia alone or in combination: iron deficiency, inflammation, erythropoietin levels, prescribed medication, hemodilution, and medullar dysfunction. There is data suggesting the association among iron deficiency, inflammation, erythropoietin levels, prescribed medication, hemodilution, and medullar dysfunction. The main pathophysiologic mechanisms, with the strongest evidence-based medicine data, are iron deficiency and inflammation. In clinical practice, the etiology of anemia needs thorough evaluation for determining the best possible therapeutic course. In this context, we must correctly treat the patients’ diseases; according with the current guidelines we have now only one intravenous iron drug. This paper is focused on data about anemia in heart failure, from prevalence to optimal treatment, controversies, and challenges.

[Anaemia and iron deficiency in chronic heart failure patients]

Tis review focused on prevalence of anemia and iron defciency (ID) in CHF and their effect on the course and prognosis of this condition. Based on evaluation of numerous laboratory data defnitions of anemia and ID were suggested. Specifcally, a diagnostic value of measuring serum iron, serum ferritin, transferrin saturation, total iron-binding capacity, and concentration of soluble transferrin receptors was discussed. Te review highlighted the importance of measuring bone marrow iron, which is rarely used in everyday clinical practice even though this test is considered a «gold standard» of ID diagnosis. Te review provided an insight into pathogenetic mechanisms of ID in CHF including insufcient iron supply, role of inflammation, erythropoietin, RAS, and effects of some pharmacological therapies. Te authors described physiological consequences of ID and anemia, activation of hemodynamic and non-hemodynamic compensatory mechanisms, which develop in response to anemia and not infrequently aggravate CHF. Special atention was paid to current approaches to treatment of anemia and ID in CHF, including a discussion of efcacy and safety of oral and intravenous dosage forms of iron and hemopoiesis stimulators.

Anaemia in heart failure patients: the prevalence of haematinic deficiencies and the role of ACE inhibitors and aspirin doses as risk factors

Background:

Patients with heart failure often have comorbidities that alter the progression of heart failure and impact on prognosis. One such comorbidity is anaemia, and clinicians have started to appreciate the full gravity of its impact on heart failure patients. Yet, the extent of the problem is not fully understood, particularly the role of heart failure therapy itself as a risk factor for developing anaemia.

Objective:

This study aimed to investigate the prevalence of anaemia in a cohort of heart failure patients. The impact of using different ACEIs and different doses of aspirin was also explored, together with the prevalence of haematinic deficiencies.

Methods:

Medication lists and pathology results were examined to establish the prevalence of ACEIs use, and the use of aspirin at its most common doses of 100mg and 150mg, together with haematinic deficiencies. Multinomial logistic regression and the Student’s t-test were utilised for the analysis of data. Statistical significance was pre-set at p<0.05.

Results:

Ninety-six patients were eligible for analysis, with 26% having anaemia. The use of ACEIs had a RR of 17.4 for the presence of anaemia. Perindopril was associated with a RR of 20.8, while the use of ramipril was not significantly associated with such a high RR. Haematinic anaemia occurred only at a rate of 3.3%, but borderline deficiencies were found in more than a third of all patients. An aspirin dose of 150mg was associated with a higher risk for anaemia, compared to a dose of 100mg.

Conclusions:

ACEIs are associated with the presence of anaemia, with perindopril posing more risk than ramipril when used in heart failure patients. The dose of aspirin may also be a factor in the development of anaemia, with lower doses being safer. Despite the lack of high prevalence of haematinic anaemia among this cohort of patients, borderline haematinic deficiencies were common.

Anemia in Adolescents and Young Adult Patients With Congenital Heart Disease

INTRODUCTION

Despite anemia in acquired heart disease being a common problem, little is known in patients with congenital heart disease (CHD).

METHODS

In total, 544 consecutive stable noncyanotic CHD patients were studied to determine demographic, clinical, and analytic parameters. Anemia was defined as a condition in which hemoglobin concentration was <13 g/dL in male individuals and <12 g/dL in female individuals.

RESULTS

In total, 49 (9%) CHD patients had anemia. Patients with complex anatomy had the highest prevalence of anemia (33%). The median hemoglobin concentration was 14.4 (13.5 to 15.6) mg/dL. Of the total anemic CHD patients, 21 of 49 (43%) were microcytic (mean corpuscular volume <84 fL) and 46 of 49 (94%) had a mean corpuscular volume under 95 fL. Oral anticoagulation, oral antiaggregation, diuretic treatment, and having valve prostheses or cardiovascular risk factors, such as arterial hypertension or diabetes mellitus, did not reach statistical significance between anemic and nonanemic CHD patients. Multivariate analyses determined as risk factors for anemia a worse New York Heart Association functional class (patients in class >II/IV) (odds ratio [OR], 8.37; 95% confidence interval [CI], 1.69-41.35), N-terminal proB-type natriuretic peptide levels >125 pg/mL (OR, 7.90; 95% CI, 2.88-21.69), and apoferritn levels below 15 ng/mL (OR, 0.21; 95% CI, 0.09-0.50). The Kaplan-Meier survival analysis showed no significant differences in mortality between anemic and nonanemic CHD patients (P=0.143).

CONCLUSIONS

The incidence of anemia in CHD patients is similar to that of the normal population and iron deficiency anemia accounts for most of the cases. There were no significant differences in mortality between CHD patients with and without anemia.

Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair

Objectives

MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip.

Methods

Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE.

Results

During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20–17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03–11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66–8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ± 1.3 vs 2.1 ± 0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507–0.848]) in this subgroup.

Conclusions

BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients.

Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4

Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.

Early Postpartum Hemoglobin Less Than 10 g/dL Is Associated with Future Maternal Atherosclerotic Morbidity

OBJECTIVE

Anemia is associated with increased cardiovascular morbidity in the general population. Anemia is common during pregnancy. We examined the association between anemia at the very early postpartum period and long-term atherosclerotic-related morbidity.

PATIENTS AND METHODS

A retrospective study including women who gave birth between 1988 and 2013 was conducted. The women were divided into two groups according to hemoglobin (Hb) value on the first day after delivery: Hb <10 g/dL and Hb ≥10 g/dL. We examined the rates of hospitalization due to atherosclerotic-related morbidity, which were classified into minor and major events. The follow-up period was from the index birth until either hospitalization or the end of study period. Survival estimates were calculated by Kaplan-Meier survival analysis. Cox proportional hazards models were used to evaluate whether Hb <10 gr/dL is an independent risk factor for long-term atherosclerotic events.

RESULTS

The study population included 30,088 (37.40%) women with Hb <10 g/dL and 50,354 (63%) women with Hb ≥10 g/dL at the index birth. The hospitalization incidence density was higher in the Hb <10 g/dL group versus the Hb ≥10 g/dL group, for total atherosclerotic- related hospitalizations (4.35 vs. 3.76, p < 0.001), and hospitalization for major events (1.83 vs. 1.51, p < 0.001) and minor events (2.60 vs. 2.31, p < 0.001). In Cox proportional hazards models, it was demonstrated that Hb <10 g/dL was independently associated with total hospitalizations (HR 1.13; CI: 1.04-1.24 p = 0.004) and hospitalizations for major events (HR 1.16; CI: 1.01-1.34 p = 0.034) Conclusions: Hb <10 g/dL at the very early postpartum period might be a marker for long-term atherosclerotic-related morbidity.

Diabetes and Anemia: International Diabetes Federation (IDF) - Southeast Asian Region (SEAR) position statement

Anemia is often associated with diabetes mellitus and is known to intensify the risk of developing diabetes-related microvascular and macrovascular complications. There is paucity in understanding of co-existence of these conditions, especially in Southeast Asian countries. Iron and/or erythropoietin deficiencies are the major causes of anemia in diabetes, and diabetic kidney disease plays a key role. Patients with diabetes need to be screened for anemia along with other risk factors and anemia should be corrected appropriately to improve overall clinical outcomes. This position statement aims to provide a comprehensive overview and an algorithm for appropriate management of anemia in patients with diabetes.

Absolute and Functional Iron Deficiency Is a Common Finding in Patients With Heart Failure and After Heart Transplantation

BACKGROUND

Anemia is relatively common in patients with heart failure and heart transplant recipients. Both absolute and functional iron deficiency may contribute to the anemia in these populations. Functional iron deficiency (defined as ferritin greater than 200 ng/mL with TSAT (Transferrin saturation) less than 20%) is characterized by the presence of adequate iron stores as defined by conventional criteria, but with insufficient iron mobilization to adequately support. The aim of this study was to determine prevalence of absolute and functional iron deficiency in patients with heart failure (n = 269) and after heart transplantation (n = 130) and their relation to parameters of iron status and inflammation.

METHODS

Iron status, complete blood count, and creatinine levels were assessed using standard laboratory methods. C-reactive protein, hepcidin and hemojuvelin were measured using commercially available kits.

RESULTS

Absolute iron deficiency was present in 15% of patients with heart failure and 30% in heart transplant recipients, whereas functional iron deficiency was present in 18% of patients with heart failure and 17% in heart transplant recipients. Functional iron deficiency was associated with significantly higher C-reactive protein and hepcidin levels in heart failure patients, and higher hepcidin and lower estimate glomerular filtration rates in heart transplant recipients. Prevalence of anemia (according to the World Health Organization) was significantly higher in heart transplant recipients (40% vs 22%, P < .001), they were also younger, but with worse kidney function than patients with heart failure.

CONCLUSIONS

Both absolute and functional iron deficiency were present in a considerable group of patients. This population should be carefully screened for possible reversible causes of inflammation.

Renin-angiotensin system inhibitors linked to anemia: a systematic review and meta-analysis

BACKGROUND

The objective of this meta-analysis was to evaluate the risk of anemia in patients who received renin-angiotensin system (RAS) inhibitors.

METHODS

A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from inception through November, 2014. Studies that reported relative risks, odd ratios or hazard ratios comparing the anemia risk in patients who received angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) vs. those who did not were included. We performed the prespecified sensitivity analysis including only only studies with confounder adjusted analysis. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Seven studies (2 cohort and 5 cross-sectional studies) with 29,061 patients were included in the analysis to assess the risk of anemia and the RAS inhibitors use. The pooled RR of anemia in patients receiving ACEIs was 1.56 (95% CI, 1.40-1.73, I(2) = 17%). When meta-analysis was limited only to studies with confounder adjusted analysis, the pooled RR of anemia in patients using ACEIs was 1.57 (95% CI, 1.43-1.73, I(2) = 0%) The pooled RR of anemia in patients receiving ARBs was 1.60 (95% CI, 1.27-2.00, I(2) = 39%). The meta-analysis of studies with confounder adjusted analysis demonstrated the pooled RR of anemia in patients using ARBs of 1.59 (95% CI, 1.38-1.83, I(2) = 0%).

CONCLUSIONS

Our meta-analysis demonstrates an association between anemia and the use of RAS inhibitors. Hematological parameters should be monitored in patients treated with RAS inhibitors.

Erythropoiesis and Blood Pressure Are Regulated via AT1 Receptor by Distinctive Pathways

The renin–angiotensin system (RAS) plays a central role in blood pressure regulation. Although clinical and experimental studies have suggested that inhibition of RAS is associated with progression of anemia, little evidence is available to support this claim. Here we report that knockout mice that lack angiotensin II, including angiotensinogen and renin knockout mice, exhibit anemia. The anemia of angiotensinogen knockout mice was rescued by angiotensin II infusion, and rescue was completely blocked by simultaneous administration of AT1 receptor blocker. To genetically determine the responsible receptor subtype, we examined AT1a, AT1b, and AT2 knockout mice, but did not observe anemia in any of them. To investigate whether pharmacological AT1 receptor inhibition recapitulates the anemic phenotype, we administered AT1 receptor antagonist in hypotensive AT1a receptor knockout mice to inhibit the remaining AT1b receptor. In these animals, hematocrit levels barely decreased, but blood pressure further decreased to the level observed in angiotensinogen knockout mice. We then generated AT1a and AT1b double-knockout mice to completely ablate the AT1 receptors; the mice finally exhibited the anemic phenotype. These results provide clear evidence that although erythropoiesis and blood pressure are negatively controlled through the AT1 receptor inhibition in vivo, the pathways involved are complex and distinct, because erythropoiesis is more resistant to AT1 receptor inhibition than blood pressure control.

Is anemia a new cardiovascular risk factor?

Anemia is frequent in patients with cardiovascular disease and is often characterized as the fifth cardiovascular risk factor. It is considered to develop due to a complex interaction of iron deficiency, cytokine production and impaired renal function, although other factors, such as blood loss, may also contribute. Unfortunately, treatment of anemia in cardiovascular disease lacks clear targets and specific therapy is not defined. Treatment with erythropoietin-stimulating agents in combination with iron is the basic strategy but clear guidelines are not currently available. This review aims to clarify poorly investigated and defined issues concerning the relation of anemia and cardiovascular risk--in particular in patients with acute coronary syndromes and chronic heart failure--as well as the current therapeutic strategies in these clinical conditions.