Anemia in heart failure: still an unsolved enigma

Impact of anemia on clinical outcomes in patients with acute heart failure: A systematic review and meta-analysis

Anemia and acute heart failure (AHF) frequently coexist. Several published studies have investigated the association of anemia with all-cause mortality and all-cause heart failure events in AHF patients, but their findings remain controversial. This study is intended to evaluate the relationship between anemia and AHF. We systematically searched PubMed, Medline, the Cochrane Library, Embase, and Elsevier's ScienceDirect databases until July 30, 2023, and selected prospective or retrospective cohort studies to evaluate anemia for AHF. A total of nine trials involving 29 587 AHF patients were eventually included. Pooled analyses demonstrated anemia is associated with a higher risk of all-cause heart failure event rate (OR: 1.82, 95% CI: 1.58-2.10, p < .01) and all-cause mortality, both for short-term (30 days) all-cause mortality (OR: 1.91, 95% CI: 1.31-2.79, p < .01) and long-term (1 year) all-cause mortality (OR: 1.72, 95% CI: 1.27-2.32, p < .01). The evidence from this meta-analysis suggested that anemia may be an independent risk factor for all-cause mortality and all-cause heart failure events in patients with AHF and might emphasize the importance of anemia correction before discharge.

Predictors of mortality in heart failure patients with reduced or mildly reduced Ejection Fraction: The CASABLANCA HF Study

BACKGROUND

Heart failure (HF) poses a significant public health challenge throughout the world and Morocco. Our objective was to delineate the epidemiological characteristics of Moroccan patients living with chronic heart failure and to identify prognostic factors correlated with CHF mortality.

RESULTS

A total of 1344 patients participated in this study, with survival rates at 3, 6, and 10 years recorded at 75.2%, 60%, and 34%, respectively. During the follow-up, 886 patients succumbed, representing a mortality rate of 65.9%. A Cox regression model, utilizing baseline candidate variables, was developed to predict cardiovascular (CV) mortality. Predictors all of which had a P value less than 0.05 included age, left ventricular ejection fraction (EF) at commencement (< 35%), hypertension, male sex, anemia, creatinine levels, and the number of hospitalizations due to HF decompensation. Notably, the frequency of hospitalizations emerged as the most potent predictor of mortality, with an HR of 2.5 (95% CI [2-2.9]). Almost 90% of patients with three or more readmissions for HF decompensation experienced mortality by the follow-up's conclusion.

CONCLUSIONS

This study offers valuable insights into risk factors and clinical outcomes in HF patients in Morocco. Factors such as male gender, advanced age, a history of hypertension, lower systolic blood pressure, rehospitalizations for HF decompensation, low left ventricular ejection fraction, anemia, and elevated creatinine levels were associated with increased mortality. Medical and health services managers should be aware of the substantial burden and future challenges posed by HF in Morocco, prompting the adoption of multidisciplinary strategies for its management and care.

An Audit of Iron Deficiency in Hospitalised Heart Failure Patients: A Commonly Neglected Comorbidity

Introduction Iron deficiency (ID) is a common comorbidity in patients with heart failure (HF) and can significantly impact morbidity and mortality, regardless of the presence of anaemia. Aim This audit aimed to assess the current practice in diagnosing and assessing iron deficiency (ID) in hospitalised patients with heart failure and reduced ejection fraction (HFrEF). The primary goal was to determine the prevalence of ID in HF patients and the frequency of iron testing in those patients. Additionally, the secondary aims included evaluating the presence of anaemia, the length of hospital stay, and the adequacy of appropriate management for iron deficiency in this patient population. Methods A retrospective audit was conducted, reviewing data from patients admitted to St. Vincent University Hospital over a period of 4 months. Results Out of the 111 patients audited, only 74% (82) had their iron status checked, and among those tested, 63% (52) met the criteria for iron deficiency according to the European Society of Cardiology (ESC). Additionally, 54% (28) of iron-deficient patients were also anaemic. Iron replacement was administered to 34 out of the 52 patients diagnosed with iron deficiency, accounting for 65% of the identified cases. The average duration of hospital stay for patients with iron deficiency was 13.8 days, while those without iron deficiency had a shorter mean length of stay of 11.2 days. However, it is important to note that the presence of co-morbidities and other confounding factors might have influenced these results. Conclusion Despite guideline recommendations, iron deficiency remains under-recognised and undertreated in clinical practice among heart failure patients. There is a crucial need for increased awareness, education, and practical guidance to improve the screening, diagnosis, and management of iron deficiency in hospitalised heart failure patients.

Iron Deficiency in Heart Failure: What Do We Know So Far?

Iron is vital for multiple biological processes in the human body. Heart failure (HF) patients are at a high risk of becoming iron deficient. Iron deficiency is a marker of severe HF and an ominous sign of poor outcomes. Iron deficiency can be absolute (low iron stores) or functional (improper functioning in the metabolic processes). The European Society of Cardiology recommends routine screening of iron stores in HF patients using ferritin and transferrin saturation. It advises iron replacement in deficient patients irrespective of the presence of anemia. Iron replacement improved HF symptoms, exercise capacity, and quality of life in deficient patients. It alleviates their disordered breathing during sleep. Therefore, the treatment of iron deficiency is an important target in managing HF. Oral iron is not effective in repleting iron stores in HF patients. Intravenous iron is an effective way to replenish iron stores in this cohort.

A Case Report on an Underappreciated Cause of Heart Failure: Chronic Viral Myocarditis

A 64-year-old male with a history of congestive heart failure (CHF), coronary artery disease status post two stents in 2014, hypertension, and chronic kidney disease (CKD) stage III, was admitted for acute exacerbation of CHF. Treatment started with blood pressure control and high-dose diuretics. While the patient’s volume status improved, his clinical status declined, and he required a dobutamine infusion. Cardiac catheterization revealed nonischemic cardiomyopathy. He was ultimately found to have myocarditis secondary to chronic Coxsackie B infection. A comprehensive investigation ruled out other potential etiologies. This case highlights how viruses continue to be an underappreciated cause of heart failure. Infectious agents should not be underestimated as several types of viral infections carry substantial cardiovascular risks, potentially leading to significant deterioration in decompensated patients.

Heart Failure Treatments Such As Angiotensin Receptor/Neprilysin Inhibitor Improve Heart Failure Status and Glucose Metabolism

A recent study suggested that angiotensin receptor/neprilysin inhibitor (ARNI; sacubitril/valsartan) can improve functional capacity and cardiac reverse remodeling in patients with heart failure with reduced ejection fraction (HFrEF). Another study suggested that ARNI reduced glycated hemoglobin (HbA1c) in patients with diabetes and HFrEF; however, the details of its efficacy are unknown. We herein report a case of HFrEF with abnormal glucose metabolism in which ARNI was initiated. On the 7^th day of admission (before the initiation of ARNI), blood tests showed an abnormal glucose metabolism as follows: fasting blood glucose 134 mg/dL; and fasting blood insulin 11.4 µU/mL (homeostasis model assessment of insulin resistance (HOMA-IR) index 3.77; homeostasis model assessment of β-cell function (HOMA-β), 57.8%). On the 23^rd day after the initiation of ARNI, even though the patient was not using hypoglycemic drugs, his fasting blood glucose markedly decreased to 70 mg/dL without hypoglycemic symptoms, and his fasting blood insulin decreased to 5.4 µU/mL (HOMA-IR decreased to 0.93, HOMA-β increased to 277.7%). These results imply that ARNI has the potential to improve insulin resistance and the islet beta-cell function in patients with heart failure, in addition to the original effect of improving the hemodynamics, although the effect of improving the glucose metabolism is also considered to have been influenced by the improvement of the heart failure status and other drugs that the patient was taking.