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Nakao M, Nagai T, Anzai T. Iron supplementation is a residual piece of management in Asian patients with heart failure? Int J Cardiol 2024; 406:132014. [PMID: 38582240 DOI: 10.1016/j.ijcard.2024.132014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Santas E, Del Canto I, Cardells I, Miñana G, Llàcer P, Almenar L, Fácila L, Maceira AM, Sanchis J, Núñez J. Improvement in left atrial strain following ferric carboxymaltose in heart failure: an analysis of the Myocardial-IRON trial. ESC Heart Fail 2024; 11:1258-1262. [PMID: 38115745 DOI: 10.1002/ehf2.14630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS Iron deficiency (ID) is associated with an impaired cardiac function and remodelling in heart failure (HF). Treatment with ferric carboxymaltose (FCM) has been showed recently to improve biventricular systolic function and ventricular strain parameters in patients with HF with reduced ejection fraction and ID, but there is no evidence on the benefit of FCM on the left atrium (LA). In this study, we aimed to evaluate the effect of FCM on LA longitudinal strain (LA-LS). METHODS AND RESULTS This is a post hoc subanalysis of a double-blind, placebo-controlled, randomized clinical trial that enrolled 53 ambulatory patients with HF, left ventricular ejection fraction (LVEF) < 50%, and ID [Myocardial-IRON trial (NCT03398681)], treated with FCM or placebo. Cardiac magnetic resonance-featured tracking (CMR-FT) strain changes were evaluated before and 7 and 30 days after randomization using linear mixed regression analysis. The median age of the sample was 68 years (interquartile range: 64-76), and 20 (69%) were men. Mean ± standard deviation of LVEF was 39 ± 11%, and most (97%) were in stable New York Heart Association class II. At baseline, mean LA-LS was -8.9 ± 3.5%. At 30 days, and compared with placebo, LA-LS significantly improved in those allocated to FCM treatment arm (LA-LS = -12.0 ± 0.5 and -8.5 ± 0.6, respectively; - ∆ 3.55%, P < 0.001). CONCLUSIONS In patients with stable HF, LVEF < 50%, and ID, treatment with FCM was associated with short-term improvements in LA-LS assessed by CMR-FT. Future works should assess the potential benefit of iron repletion on LA function.
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Affiliation(s)
- Enrique Santas
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Irene Del Canto
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
| | - Ingrid Cardells
- Department of Cardiology, Hospital de Manises, Valencia, Spain
| | - Gema Miñana
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Valencia, Spain
| | - Pau Llàcer
- Department of Internal Medicine, Hospital Ramón y Cajal, Madrid, Spain
| | - Luis Almenar
- Department of Cardiology, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - Lorenzo Fácila
- Department of Cardiology, Hospital General Universitario de Valencia, Valencia, Spain
| | - Alicia M Maceira
- Cardiovascular Imaging Unit, Ascires Biomedical Group, Valencia, Spain
| | - Juan Sanchis
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Valencia, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia, Universitat de València, INCLIVA, Valencia, Spain
- CIBER Cardiovascular, Valencia, Spain
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Uskach TM, Tereschenko SN. [The Effects of Therapy for Iron Deficiency in Patients With Different Etiologies of Heart Failure and Concomitant Diseases]. Kardiologiia 2023; 63:87-95. [PMID: 38088117 DOI: 10.18087/cardio.2023.11.n2604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023]
Abstract
Iron deficiency (ID) in patients with heart failure (HF) is a factor for unfavorable course and prognosis of the disease. The significance of ID in the diagnosis and treatment of HF has previously been demonstrated by multiple studies and meta-analyses. Therapy for ID in patients with HF is one of the most relevant and discussed issues. The use of intravenous iron medicinal products for the treatment of ID is currently being actively studied in patients of various categories; attempts are being made to specify the indications for use to produce the greatest effect on the prognosis and quality of life of HF patients.
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Affiliation(s)
- T M Uskach
- Chazov National Medical Research Center, Moscow; Russian Medical Academy of Continuous Professional Education, Moscow
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Filippatos G, Ponikowski P, Farmakis D, Anker SD, Butler J, Fabien V, Kirwan BA, Macdougall IC, Metra M, Rosano G, Ruschitzka F, van der Meer P, Wächter S, Jankowska EA. Association Between Hemoglobin Levels and Efficacy of Intravenous Ferric Carboxymaltose in Patients With Acute Heart Failure and Iron Deficiency: An AFFIRM-AHF Subgroup Analysis. Circulation 2023; 147:1640-1653. [PMID: 37051919 PMCID: PMC10487376 DOI: 10.1161/circulationaha.122.060757] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/15/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Iron deficiency, with or without anemia, is an adverse prognostic factor in heart failure (HF). In AFFIRM-AHF (a randomized, double-blind placebo-controlled trial comparing the effect of intravenous ferric carboxymaltose on hospitalizations and mortality in iron-deficient subjects admitted for acute heart failure), intravenous ferric carboxymaltose (FCM), although having no significant effect on the primary end point, reduced the risk of HF hospitalization (hHF) and improved quality of life versus placebo in iron-deficient patients stabilized after an acute HF (AHF) episode. These prespecified AFFIRM-AHF subanalyses explored the association between hemoglobin levels and FCM treatment effects. METHODS AFFIRM-AHF was a multicenter, double-blind, randomized, placebo-controlled trial of FCM in hospitalized AHF patients with iron deficiency. Patients were stratified by baseline hemoglobin level (<12 versus ≥12 g/dL). In each subgroup, the primary composite (total hHF and cardiovascular death) and secondary (total hHF; total cardiovascular hospitalizations and cardiovascular death; time to cardiovascular death, and time to first/days lost due to hHF or cardiovascular death) outcomes were assessed with FCM versus placebo at week 52. Sensitivity analyses using the World Health Organization anemia definition (hemoglobin level <12 g/dL [women] or <13 g/dL [men]) were performed, among others. RESULTS Of 1108 AFFIRM-AHF patients, 1107 were included in these subanalyses: 464 (FCM group, 228; placebo group, 236) had a hemoglobin level <12 g/dL, and 643 (FCM, 329; placebo, 314) had a hemoglobin level ≥12 g/dL. Patients with a hemoglobin level <12 g/dL were older (mean, 73.7 versus 69.1 years), with more frequent previous HF (75.0% versus 68.7%), serum ferritin <100 μg/L (75.4% versus 68.1%), and transferrin saturation <20% (87.9% versus 81.4%). For the primary outcome, annualized event rates per 100 patient-years with FCM versus placebo were 71.1 and 73.6 (rate ratio, 0.97 [95% CI, 0.66-1.41]), respectively, and 48.5 versus 72.9 (RR, 0.67 [95% CI, 0.48-0.93]) in the hemoglobin levels <12 and ≥12 g/dL subgroups, respectively. No significant interactions between hemoglobin subgroup and treatment effect were observed for primary (Pinteraction=0.15) or secondary outcomes. Changes from baseline in hemoglobin, serum ferritin and transferrin saturation were significantly greater with FCM versus placebo in both subgroups between weeks 6 and 52. Findings were similar using the World Health Organization definition for anemia. CONCLUSIONS The effects of intravenous FCM on outcomes in iron-deficient patients stabilized after an AHF episode, including improvements in iron parameters over time, did not differ between patients with hemoglobin levels <12 and ≥12 g/dL. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02937454.
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Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, Athens, Greece (G.F., D.F.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University; and Institute of Heart Diseases, University Hospital, Wroclaw, Poland (P.P., E.A.J.)
| | - Dimitrios Farmakis
- National and Kapodistrian University of Athens Medical School, Athens University Hospital Attikon, Athens, Greece (G.F., D.F.)
| | - Stefan D. Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin Berlin, Germany (S.D.A.)
| | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | | | - Bridget-Anne Kirwan
- Department of Clinical Research, SOCAR Research SA, Nyon, Switzerland (B-A.K.)
- London School of Hygiene and Tropical Medicine, University College London, UK (B-A.K.)
| | - Iain C. Macdougall
- Department of Renal Medicine, King’s College Hospital, London, UK (I.C.M.)
| | - Marco Metra
- Department of Cardiology, University and Civil Hospital, Brescia, Italy (M.M.)
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy (G.R.)
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Switzerland (F.R.)
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, the Netherlands (P.v.d.M.)
| | | | - Ewa A. Jankowska
- Institute of Heart Diseases, Wroclaw Medical University; and Institute of Heart Diseases, University Hospital, Wroclaw, Poland (P.P., E.A.J.)
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Dhaliwal S, Kalogeropoulos AP. Markers of Iron Metabolism and Outcomes in Patients with Heart Failure: A Systematic Review. Int J Mol Sci 2023; 24:ijms24065645. [PMID: 36982717 PMCID: PMC10059277 DOI: 10.3390/ijms24065645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Iron deficiency (ID) in conjunction with heart failure (HF) poses a challenge for clinicians and is associated with worse HF outcomes. Treatment of ID with IV iron supplementation for patients with HF has demonstrated benefits in quality of life (QoL) and HF-related hospitalizations. The aim of this systematic review was to summarize the evidence linking iron metabolism biomarkers with outcomes in patients with HF to assist in the optimal use of these biomarkers for patient selection. A systematic review of observational studies in English from 2010 to 2022 was conducted using PubMed, with keywords of “Heart Failure” and respective iron metabolism biomarkers (“Ferritin”, “Hepcidin”, “TSAT”, “Serum Iron”, and “Soluble Transferrin Receptor”). Studies pertaining to HF patients, with available quantitative data on serum iron metabolism biomarkers, and report of specific outcomes (mortality, hospitalization rates, functional capacity, QoL, and cardiovascular events) were included, irrespective of left ventricular ejection fraction (LVEF) or other HF characteristics. Clinical trials of iron supplementation and anemia treatment were removed. This systematic review was conducive to formal assessment of risk of bias via Newcastle-Ottawa Scale. Results were synthesized based on their respective adverse outcomes and iron metabolism biomarker(s). Initial and updated searches identified 508 unique titles once duplicates were removed. The final analysis included 26 studies: 58% focused on reduced LVEF; age range was 53–79 years; males composed 41–100% of the reported population. Statistically significant associations of ID were observed with all-cause mortality, HF hospitalization rates, functional capacity, and QoL. Increased risk for cerebrovascular events and acute renal injury have also been reported, but these findings were not consistent. Varying definitions of ID were utilized among the studies; however, most studies employed the current European Society of Cardiology criteria: serum ferritin < 100 ng/mL or the combination of ferritin between 100–299 ng/mL and transferrin saturation (TSAT) < 20%. Despite several iron metabolism biomarkers demonstrating strong association with several outcomes, TSAT better predicted all-cause mortality, as well as long-term risk for HF hospitalizations. Low ferritin was associated with short-term risk for HF hospitalizations, worsening functional capacity, poor QoL, and development of acute renal injury in acute HF. Elevated soluble transferrin receptor (sTfR) levels were associated with worse functional capacity and QoL. Finally, low serum iron was significantly associated with increased risk for cardiovascular events. Considering the lack of consistency among the iron metabolism biomarkers for association with adverse outcomes, it is important to incorporate additional biomarker data, beyond ferritin and TSAT, when assessing for ID in HF patients. These inconsistent associations question how best to define ID to ensure proper treatment. Further research, potentially tailored to specific HF phenotypes, is required to optimize patient selection for iron supplementation therapy and appropriate targets for iron stores replenishment.
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Yasui Y, Nakamura K, Omote K, Ishizaka S, Takenaka S, Mizuguchi Y, Shimono Y, Kazui S, Takahashi Y, Saiin K, Naito S, Tada A, Kobayashi Y, Sato T, Kamiya K, Nagai T, Anzai T. Prognostic Significance of Peak Workload-to-Weight Ratio by Cardiopulmonary Exercise Testing in Chronic Heart Failure. Am J Cardiol 2023; 193:37-43. [PMID: 36867917 DOI: 10.1016/j.amjcard.2023.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
The prognostic impact of peak workload-to-weight ratio (PWR) during cardiopulmonary exercise testing (CPET) and its determinants in patients with chronic heart failure (CHF) are not well understood. Consecutive 514 patients with CHF referred for CPET at the Hokkaido University Hospital between 2013 and 2018 were identified. The primary outcome was a composite of hospitalization because of worsening heart failure and death. PWR was calculated as peak workload normalized to body weight (W/kg) by CPET. Patients with low PWR (cut-off median 1.38 [W/kg], n = 257) were older and more anemic than those with high PWR (n = 257). In CPET, patients with low PWR displayed reduced peak oxygen consumption and impaired ventilatory efficiency compared with those with high PWR, whereas the peak respiratory exchange ratio was not significantly different between the 2 groups. There were 89 patients with events over a median follow-up period of 3.3 (interquartile range 0.8 to 5.5) years. The incidence of composite events was significantly higher in patients with low PWR than in those with high PWR (log-rank p <0.0001). In the multivariable Cox regression, lower PWR was associated with adverse events (hazard ratio 0.31, 95% confidence interval 0.13 to 0.73, p = 0.008). Low hemoglobin concentration was strongly related to impaired PWR (β coefficient = 0.43, per 1 g/100 ml increased, p <0.0001). In conclusion, PWR was associated with worse clinical outcomes, where blood hemoglobin was strongly related to PWR. Further study is required to identify therapies targeting peak workload achievements in exercise stress tests to improve the outcome in patients with CHF.
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Affiliation(s)
- Yutaro Yasui
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kosuke Nakamura
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sakae Takenaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yui Shimono
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sho Kazui
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuki Takahashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kohei Saiin
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Seiichiro Naito
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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de Godoi Rezende Costa Molino C, Woll L, Wieczorek M, Abderhalden LA, Lanz P, Schaer DJ, Spahn DR, Orav EJ, Egli A, Bischoff-Ferrari HA. Association between iron deficiency and hospitalization rate in community-dwelling older adults: A 3-year prospective observational study of DO-HEALTH. Am J Clin Nutr 2023; 117:12-21. [PMID: 36789930 DOI: 10.1016/j.ajcnut.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Iron deficiency (ID) is associated with negative health outcomes in older adults. However, data on the impact of ID on the number of hospitalizations and length of hospital stay (LOS) is lacking. OBJECTIVE To explore the associations between baseline ID and the number of hospitalizations and between baseline ID and at least one LOS ≥5 days in community-dwelling older adults. METHODS This is a secondary observational analysis of a randomized controlled trial including 2157 community-dwelling adults aged ≥70 years without major diseases at baseline. The main exposure was defined as ID (soluble transferrin receptor [sTfR] concentrations >28.1 nmol/L) at baseline. The primary outcome was the number of hospitalizations over a 3-year follow-up. The secondary outcome was having at least one LOS ≥5 days over the study period among individuals with one or more hospitalizations. Interaction between ID and anemia (hemoglobin <130 g/L for men and <120 g/L for women) was also investigated. RESULTS Baseline sTfR concentration was determined in 2141 participants (median age 74.0 years). At 3 year, 1497 hospitalizations were reported with an incidence rate of hospitalization of 0.26 per person-year (95% CI: 0.24, 0.28). Overall, baseline ID was associated with a 24% increased incidence rate of hospitalization (incidence rate ratio: 1.24; 95% CI: 1.05, 1.45) over 3 years. This association was independent of anemia status at baseline since the interaction between ID and anemia at baseline was not significant. Moreover, ID was not significantly associated with having a LOS ≥5 days (OR: 1.40; 95% CI: 1.00, 1.97) among participants with at least one hospitalization over 3 years. CONCLUSIONS ID is associated with increased hospitalization rate and not associated with LOS ≥5 days among generally healthy older adults. Efforts to minimize ID in older adults may improve overall health and optimize healthcare costs.
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Affiliation(s)
- Caroline de Godoi Rezende Costa Molino
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Laurence Woll
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Maud Wieczorek
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lauren A Abderhalden
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patricia Lanz
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dominik J Schaer
- Clinic for Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - E John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Andreas Egli
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Center on Aging and Mobility, University Hospital Zurich, Zurich City Hospital-Waid and University of Zurich, Zurich, Switzerland; Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland; University Clinic for Aging Medicine, Zurich City Hospital-Waid, Zurich, Switzerland.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Docherty KF, Welsh P, Verma S, De Boer RA, O’Meara E, Bengtsson O, Køber L, Kosiborod MN, Hammarstedt A, Langkilde AM, Lindholm D, Little DJ, Sjöstrand M, Martinez FA, Ponikowski P, Sabatine MS, Morrow DA, Schou M, Solomon SD, Sattar N, Jhund PS, McMurray JJ. Iron Deficiency in Heart Failure and Effect of Dapagliflozin: Findings From DAPA-HF. Circulation 2022; 146:980-994. [PMID: 35971840 PMCID: PMC9508991 DOI: 10.1161/circulationaha.122.060511] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Iron deficiency is common in heart failure and associated with worse outcomes. We examined the prevalence and consequences of iron deficiency in the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure) and the effect of dapagliflozin on markers of iron metabolism. We also analyzed the effect of dapagliflozin on outcomes, according to iron status at baseline. METHODS Iron deficiency was defined as a ferritin level <100 ng/mL or a transferrin saturation <20% and a ferritin level 100 to 299 ng/mL. Additional biomarkers of iron metabolism, including soluble transferrin receptor, erythropoietin, and hepcidin were measured at baseline and 12 months after randomization. The primary outcome was a composite of worsening heart failure (hospitalization or urgent visit requiring intravenous therapy) or cardiovascular death. RESULTS Of the 4744 patients randomized in DAPA-HF, 3009 had ferritin and transferrin saturation measurements available at baseline, and 1314 of these participants (43.7%) were iron deficient. The rate of the primary outcome was higher in patients with iron deficiency (16.6 per 100 person-years) compared with those without (10.4 per 100 person-years; P<0.0001). The effect of dapagliflozin on the primary outcome was consistent in iron-deficient compared with iron-replete patients (hazard ratio, 0.74 [95% CI, 0.58-0.92] versus 0.81 [95% CI, 0.63-1.03]; P-interaction=0.59). Similar findings were observed for cardiovascular death, heart failure hospitalization, and all-cause mortality. Transferrin saturation, ferritin, and hepcidin were reduced and total iron-binding capacity and soluble transferrin receptor increased with dapagliflozin compared with placebo. CONCLUSIONS Iron deficiency was common in DAPA-HF and associated with worse outcomes. Dapagliflozin appeared to increase iron use but improved outcomes, irrespective of iron status at baseline. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Kieran F. Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - Paul Welsh
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Canada (S.V.)
| | - Rudolf A. De Boer
- Department of Cardiology, University Medical Center and University of Groningen, The Netherlands (R.A.D.B.)
| | - Eileen O’Meara
- Montreal Heart Institute, Université de Montréal, Canada (E.O.)
| | - Olof Bengtsson
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.).,George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Ann Hammarstedt
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Anna Maria Langkilde
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Daniel Lindholm
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Dustin J. Little
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Mikaela Sjöstrand
- AstraZeneca R&D, Gothenburg, Sweden (O.B., A.H., A.M.L., D.L., D.J.L., M. Sjöstrand)
| | - Felipe A. Martinez
- George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | | | - Marc S. Sabatine
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (M.S.S., D.A.M.)
| | - David A. Morrow
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (M.S.S., D.A.M.)
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark (M. Schou)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (S.D.S.)
| | - Naveed Sattar
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (K.F.D., P.W., N.S., P.S.J., J.J.V.M.)
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10
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Kalogeropoulos AP, Tam E. Intravenous iron in heart failure with reduced ejection fraction: just about right. Eur J Heart Fail 2022; 24:1114-1116. [PMID: 35481845 DOI: 10.1002/ejhf.2520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Edlira Tam
- Division of Cardiology, Department of Medicine, Stony Brook University, Stony Brook, NY, USA
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11
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Fitzsimons S, Poppe KK, Choi Y, Devlin G, Lund M, Lam CSP, Troughton R, Richards AM, Doughty RN. Relationship between soluble transferrin receptor and clinical outcomes in patients with Heart Failure According to Ejection Fraction Phenotype: The New Zealand PEOPLE Study. J Card Fail 2022; 28:1255-1263. [DOI: 10.1016/j.cardfail.2021.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 12/25/2022]
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12
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Fitzsimons S, Yeo TJ, Ling LH, Sim D, Leong KTG, Yeo PSD, Ong HY, Jaufeerally F, Ng TP, Poppe K, Lund M, Devlin G, Troughton R, Lam CSP, Richards AM, Doughty RN. Impact of change in iron status over time on clinical outcomes in heart failure according to ejection fraction phenotype. ESC Heart Fail 2021; 8:4572-4583. [PMID: 34592056 PMCID: PMC8712912 DOI: 10.1002/ehf2.13617] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/19/2021] [Accepted: 09/04/2021] [Indexed: 12/28/2022] Open
Abstract
Aims The importance of iron deficiency (ID) in heart failure with preserved ejection fraction (HFpEF) is unknown. In HF with reduced ejection fraction (HFrEF), ID is reported as an independent predictor of mortality in HF although not all published studies agree. Different definitions of ID have been assessed, and the natural history of untreated ID not established, which may explain the conflicting results. This study aimed to assess the relationship between ID and mortality in HFpEF, clarify which definition of ID correlates best with outcomes in HFrEF, and determine the prognostic importance of change in ID status over time. Methods and results Analyses were conducted on data from 1563 patients participating in a prospective international cohort study comparing HFpEF with HFrEF. Plasma samples from baseline and 6 month visits were analysed for the presence of ID. Two ID definitions were evaluated: IDFerritin = ‘ferritin < 100 mcg/L or ferritin 100–300 mcg/L + transferrin saturation < 20%’ and IDTsat = ‘transferrin saturation < 20%’. The risk of all‐cause mortality and death/HF hospitalization associated with baseline ID (IDFerritin or IDTsat) and change in ID status at 6 months (persistent, resolving, developing, or never present) was estimated in multivariable Cox proportional hazards models. Of 1563 patients, 1115 (71%) had HFrEF and 448 (29%) HFpEF. Prevalence of ID was similar in HFpEF and HFrEF (58%). Patients with ID were more likely to be female, diabetic, and have a higher co‐morbid burden than patients without ID. ID by either definition did not confer independent risk for either all‐cause mortality or death/HF hospitalization for patients with HFpEF [IDFerritin hazard ratio (HR) 0.65 (95% confidence interval 0.40–1.05), P = 0.08; IDTsat HR 1.16 (0.72–1.87), P = 0.55]. In the overall study cohort (HFrEF + HFpEF) and HFrEF subgroup, IDFerritin was inferior to IDTsat in prediction of all‐cause mortality [overall cohort: HR 1.21 (0.95–1.53), P = 0.12 vs. HR 1.95 (1.52–2.51), P < 0.01; HFrEF: HR 1.12 (0.85–1.48), P = 0.43 vs. HR 1.57 (1.15–2.14), P < 0.01]. Persistence of IDTsat at 6 months was strongly associated with poor outcomes compared with never having IDTsat [HR 2.22 (1.42–3.46), P < 0.01] or having IDTsat at baseline self‐resolve by 6 months [HR 1.40 (1.06–1.86), P = 0.02]. Conclusions Iron deficiency is equally prevalent in HFpEF and HFrEF but is negatively prognostic only in HFrEF. The natural history of ID is important; persistent ID is strongly associated with mortality whereas resolution is not. IDTsat is the superior definition of ID and should inform future trials investigating the efficacy of intravenous iron replacement in patients with HFrEF.
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Affiliation(s)
- Sarah Fitzsimons
- Heart Health Research Group, University of Auckland, Auckland, New Zealand
| | - Tee Joo Yeo
- Cardiovascular Research Institute, National University Health System, Singapore.,National University Heart Centre Singapore, Singapore
| | - Lieng H Ling
- Cardiovascular Research Institute, National University Health System, Singapore.,National University Heart Centre Singapore, Singapore
| | - David Sim
- National University Heart Centre Singapore, Singapore
| | | | | | | | | | - Tze P Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Katrina Poppe
- Heart Health Research Group, University of Auckland, Auckland, New Zealand
| | | | | | - Richard Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Carolyn S P Lam
- Cardiovascular Research Institute, National University Health System, Singapore.,National University Heart Centre Singapore, Singapore
| | - A Mark Richards
- Cardiovascular Research Institute, National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Robert N Doughty
- Heart Health Research Group, University of Auckland, Auckland, New Zealand
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13
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Abstract
Clinical risk stratification is a key strategy used to identify low- and high-risk subjects to optimize the management, ranging from pharmacological treatment to palliative care, of patients with heart failure (HF). Using statistical modeling techniques, many HF risk prediction models that combine predictors to assess the risk of specific endpoints, including death or worsening HF, have been developed. However, most risk prediction models have not been well-integrated into the clinical setting because of their inadequacy and diverse predictive performance. To improve the performance of such models, several factors, including optimal sampling and biomarkers, need to be considered when deriving the models; however, given the large heterogeneity of HF, the currently advocated one-size-fits-all approach is not appropriate for every patient. Recent advances in techniques to analyze biological "omics" information could allow for the development of a personalized medicine platform, and there is growing awareness that an integrated approach based on the concept of system biology may be an excessively naïve view of the multiple contributors and complexity of an individual's HF phenotype. This review article describes the progress in risk stratification strategies and perspectives of emerging precision medicine in the field of HF management.
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Affiliation(s)
- Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
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14
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Delgado JF, Oliva J, González-Franco Á, Cepeda JM, García-García JÁ, González-Domínguez A, Garcia-Casanovas A, Jiménez Merino S, Comín-Colet J. Budget impact of ferric carboxymaltose treatment in patients with chronic heart failure and iron deficiency in Spain. J Med Econ 2020; 23:1418-1424. [PMID: 33073660 DOI: 10.1080/13696998.2020.1838872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The treatment of iron deficiency (ID) with ferric carboxymaltose (FCM) improves the functional class and quality of life of chronic heart failure (CHF) patients with reduced left ventricular ejection fraction (LVEF), and reduces the rate of hospitalization due to worsening CHF. This study aims to evaluate the budget impact for the Spanish National Health System (SNHS) of treating ID in reduced LVEF CHF with FCM compared to non-iron treatment. METHODS We simulated a hypothetical cohort of 1000 CHF patients with ID and reduced LVEF based on the Spanish population characteristics. A decision-analytic model was also built using the data from the largest FCM clinical trial (CONFIRM-HF) that lasted for a year. We considered the use of healthcare resources from a national prospective study. A deterministic sensitivity analysis was carried out varying the corresponding baseline data by ±25%. RESULTS The cost of treating the simulated population with FCM was €2,570,914, while that of the non-iron treatment was €3,105,711, which corresponds to a cost saving of €534,797 per 1,000 patients in one year. Cost savings were mainly due to a decrease in the number of hospitalizations. All sensitivity analysis showed cost savings for the SNHS. CONCLUSIONS FCM results in an annual cost saving of €534.80 per patient, and would thus be expected to reduce the economic burden of CHF in Spain.
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Affiliation(s)
- Juan F Delgado
- Cardiology Service, Hospital Universitario 12 de Octubre, Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Faculty of Medicine, Complutense University, Madrid, Spain
| | - Juan Oliva
- Department of Economic Analysis, University of Castilla-La Mancha, Toledo, Spain
| | - Álvaro González-Franco
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Asturias, Spain
- Heart Failure and Atrial Fibrillation Group, Spanish Society of Internal Medicine (SEMI)
| | - Jose María Cepeda
- Department of Internal Medicine, Hospital Vega Baja de Orihuela, Alicante, Spain
| | | | | | | | | | - Josep Comín-Colet
- Community Heart Failure Program, Department of Cardiology, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
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15
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Abstract
Anemia is a frequent complication of kidney disease. When severe, it causes symptoms that can be debilitating. The course of anemia tends to track the decline in kidney function, with prevalence increasing in more advanced disease. Although the most common cause is relative erythropoietin deficiency, other factors such as reduced iron availability contribute to the pathobiology. In this review, we use cases to explore the surprising complexity of decision-making in management of renal anemia.
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16
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Yan J, Pan Y, He Y, Wang R, Shao W, Dong S. The effects of serum iron level without anemia on long-term prognosis of patients with coronary heart disease complicated with chronic heart failure: a retrospective cohort study. Heart Vessels 2020; 35:1419-28. [PMID: 32361848 DOI: 10.1007/s00380-020-01613-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/17/2020] [Indexed: 02/06/2023]
Abstract
The effects of serum iron level without anemia on long-term prognosis of patients with coronary heart disease (CHD) complicated with chronic heart failure (CHF) is still unclear. The objective of this study was to explore the effects of serum iron level without anemia on long-term prognosis of patients with CHD complicated with CHF. In this retrospective cohort study, 221 patients with CHD complicated with CHF were consecutively investigated. These patients were divided into three groups according to the tertiles of the serum iron level: low-iron group (n = 71), medium-iron group (n = 76) and high-iron group (n = 74). The overall serum iron without anemia was 13.0 ± 5.50 μmol/L and serum iron in each group was 7.58 ± 1.63 μmol/L, 11.94 ± 1.79 μmol/L, and 19.37 ± 3.81 μmol/L, respectively. Composite endpoint events were composed of major adverse cardiovascular and cerebrovascular events (MACCE), including recurrent heart failure, all-cause death, acute coronary syndrome (ACS) and ischemic stroke. The median follow-up duration was 239 days. After adjusting relevant confounding risk factors, we found that excessively low or high serum iron level is correlated to the MACCE in patients with CHD complicated with CHF and that the prognosis of patients with excessively high serum iron level is poorer than that of patients with excessively low serum iron level. We further revealed the effect of serum iron level on MACCE is U-shaped, but not linear relationship. Sensitivity analysis showed that the correlation between serum iron level and MACCE is stable. In addition, according to the test for interaction, the variables that modify the effect including CRP (P for interaction < 0.0001), diuretics (P for interaction = 0.0212) and antiplatelet drugs (P for interaction = 0.0167). This study showed that excessively low or high serum iron level without anemia is an independent risk factor of MACCE in patients with CHD complicating with CHF.
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17
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Lacour P, Dang PL, Morris DA, Parwani AS, Doehner W, Schuessler F, Hohendanner F, Heinzel FR, Stroux A, Tschoepe C, Haverkamp W, Boldt LH, Pieske B, Blaschke F. The effect of iron deficiency on cardiac resynchronization therapy: results from the RIDE-CRT Study. ESC Heart Fail 2020; 7:1072-1084. [PMID: 32189474 PMCID: PMC7261541 DOI: 10.1002/ehf2.12675] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/09/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
Aims Cardiac resynchronization therapy (CRT) improves functional status, induces reverse left ventricular remodelling, and reduces hospitalization and mortality in patients with symptomatic heart failure, left ventricular systolic dysfunction, and QRS prolongation. However, the impact of iron deficiency on CRT response remains largely unclear. The purpose of the study was to assess the effect of functional and absolute iron deficiency on reverse cardiac remodelling, clinical response, and outcome after CRT implantation. Methods and results The relation of iron deficiency and cardiac resynchronization therapy response (RIDE‐CRT) study is a prospective observational study. We enrolled 77 consecutive CRT recipients (mean age 71.3 ± 10.2 years) with short‐term follow‐up of 3.3 ± 1.9 months and long‐term follow‐up of 13.0 ± 3.2 months. Primary endpoints were reverse cardiac remodelling on echocardiography and clinical CRT response, assessed by change in New York Heart Association classification. Echocardiographic CRT response was defined as relative improvement of left ventricular ejection fraction ≥ 20% or left ventricular global longitudinal strain ≥ 20%. Secondary endpoints were hospitalization for heart failure and all‐cause mortality (mean follow‐up of 29.0 ± 8.4 months). At multivariate analysis, iron deficiency was identified as independent predictor of echocardiographic (hazard ratio 4.97; 95% confidence interval 1.15–21.51; P = 0.03) and clinical non‐response to CRT (hazard ratio 4.79; 95% confidence interval 1.30–17.72, P = 0.02). We found a significant linear‐by‐linear association between CRT response and type of iron deficiency (P = 0.004 for left ventricular ejection fraction improvement, P = 0.02 for left ventricular global longitudinal strain improvement, and P = 0.003 for New York Heart Association response). Iron deficiency was also significantly associated with an increase in all‐cause mortality (P = 0.045) but not with heart failure hospitalization. Conclusions Iron deficiency is a negative predictor of effective CRT therapy as assessed by reverse cardiac remodelling and clinical response. Assessment of iron substitution might be a relevant treatment target to increase CRT response and outcome in chronic heart failure patients.
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Affiliation(s)
- Philipp Lacour
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Phi Long Dang
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Daniel Armando Morris
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Abdul Shokor Parwani
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Wolfram Doehner
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,BCRT-Center for Regenerative Therapies.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Franziska Schuessler
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Felix Hohendanner
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Frank R Heinzel
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Andrea Stroux
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12203, Germany.,Berlin Institute of Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Carsten Tschoepe
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Wilhelm Haverkamp
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Leif-Hendrik Boldt
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Burkert Pieske
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Florian Blaschke
- Department of Cardiology, Charité-Universitaetsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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18
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Omote K, Nagai T, Iwano H, Tsujinaga S, Kamiya K, Aikawa T, Konishi T, Sato T, Kato Y, Komoriyama H, Kobayashi Y, Yamamoto K, Yoshikawa T, Saito Y, Anzai T. Left ventricular outflow tract velocity time integral in hospitalized heart failure with preserved ejection fraction. ESC Heart Fail 2019; 7:167-175. [PMID: 31851433 PMCID: PMC7083464 DOI: 10.1002/ehf2.12541] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/19/2019] [Accepted: 09/29/2019] [Indexed: 01/26/2023] Open
Abstract
Aims The prognostic implication of left ventricular outflow tract velocity time integral (LVOT‐VTI) on admission in hospitalized heart failure with preserved ejection fraction (HFpEF) patients has not been determined. We sought to investigate whether LVOT‐VTI on admission is associated with worse clinical outcomes in hospitalized patients with HFpEF. Methods and results We studied consecutive 214 hospitalized HFpEF patients who had accessible LVOT‐VTI data on admission, from a prospective HFpEF‐specific multicentre registry. The primary outcome of interest was the composite of all‐cause death and readmission due to heart failure. During a median follow‐up period of 688 (interquartile range 162–810) days, the primary outcome occurred in 83 patients (39%). The optimal cut‐off value of LVOT‐VTI for the primary outcome estimated by receiver operating characteristic analysis was 15.8 cm. Lower LVOT‐VTI was significantly associated with the primary outcome compared with higher LVOT‐VTI (P = 0.005). Multivariable Cox regression analyses revealed that lower LVOT‐VTI was an independent determinant of the primary outcome (hazard ratio 0.94, 95% confidence interval 0.91–0.98). In multivariable linear regression, haemoglobin level was the strongest independent determinant of LVOT‐VTI among clinical parameters (β coefficient = −0.61, P = 0.007). Furthermore, patients with lower LVOT‐VTI and anaemia had the worst clinical outcomes among the groups (P < 0.001). Conclusions Lower admission LVOT‐VTI was an independent determinant of worse clinical outcomes in hospitalized HFpEF patients, indicating that LVOT‐VTI on admission might be useful for categorizing a low‐flow HFpEF phenotype and risk stratification in hospitalized HFpEF patients.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Shingo Tsujinaga
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Tadao Aikawa
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takao Konishi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoshiya Kato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hirokazu Komoriyama
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kazuhiro Yamamoto
- Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University, Tottori, Japan
| | | | - Yoshihiko Saito
- First Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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19
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D'Amario D, Migliaro S, Borovac JA, Restivo A, Vergallo R, Galli M, Leone AM, Montone RA, Niccoli G, Aspromonte N, Crea F. Microvascular Dysfunction in Heart Failure With Preserved Ejection Fraction. Front Physiol 2019; 10:1347. [PMID: 31749710 PMCID: PMC6848263 DOI: 10.3389/fphys.2019.01347] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 10/10/2019] [Indexed: 12/19/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is an increasingly studied entity accounting for 50% of all diagnosed heart failure and that has claimed its own dignity being markedly different from heart failure with reduced EF in terms of etiology and natural history (Graziani et al., 2018). Recently, a growing body of evidence points the finger toward microvascular dysfunction as the major determinant of the pathological cascade that justifies clinical manifestations (Crea et al., 2017). The high burden of comorbidities such as metabolic syndrome, hypertension, atrial fibrillation, chronic kidney disease, obstructive sleep apnea, and similar, could lead to a systemic inflammatory state that impacts the physiology of the endothelium and the perivascular environment, engaging complex molecular pathways that ultimately converge to myocardial fibrosis, stiffening, and dysfunction (Paulus and Tschope, 2013). These changes could even self-perpetrate with a positive feedback where hypoxia and locally released inflammatory cytokines trigger interstitial fibrosis and hypertrophy (Ohanyan et al., 2018). Identifying microvascular dysfunction both as the cause and the maintenance mechanism of this condition has opened the field to explore specific pharmacological targets like nitric oxide (NO) pathway, sarcomeric titin, transforming growth factor beta (TGF-β) pathway, immunomodulators or adenosine receptors, trying to tackle the endothelial impairment that lies in the background of this syndrome (Graziani et al., 2018;Lam et al., 2018). Yet, many questions remain, and the new data collected still lack a translation to improved treatment strategies. To further elaborate on this tangled and exponentially growing topic, we will review the evidence favoring a microvasculature-driven etiology of this condition, its clinical correlations, the proposed diagnostic workup, and the available/hypothesized therapeutic options to address microvascular dysfunction in the failing heart.
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Affiliation(s)
- Domenico D'Amario
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Stefano Migliaro
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Josip A Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Attilio Restivo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mattia Galli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Nadia Aspromonte
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Rössler J, Schoenrath F, Seifert B, Kaserer A, Spahn GH, Falk V, Spahn DR. Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study. Br J Anaesth 2019; 124:25-34. [PMID: 31668348 DOI: 10.1016/j.bja.2019.09.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/13/2019] [Accepted: 09/04/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Iron deficiency is frequent in patients undergoing cardiac surgery. The relevance of iron deficiency, however, is ill defined. Therefore, our study aimed to investigate the impact of iron deficiency (ferritin <100 μg L-1) with or without concomitant anaemia on clinical outcome after cardiac surgery. METHODS In this prospective observational study, 730 patients undergoing elective cardiac surgery were assigned into four groups according to their iron status and anaemia. Mortality, serious adverse events (SAEs), major cardiac and cerebrovascular events (MACCEs), allogenic blood transfusion requirements, and length of hospital stay were assessed during a 90-day follow-up period. The effect of iron deficiency on these outcomes was first calculated in models adjusting for anaemia only, followed by two multivariate models adjusting for anaemia and either the EuroSCORE II or any possible confounders. RESULTS The presence of iron deficiency (ferritin <100 μg L-1) was associated with an increase in 90-day mortality from 2% to 5% in patients without anaemia, and from 4% to 14% in patients with anaemia. Logistic regression resulted in an odds ratio of 3.5 (95% confidence interval: 1.5-8.4); P=0.004. The effect persisted in both multivariate models. Moreover, iron deficiency was associated with an increased incidence of SAEs, MACCEs, transfusion, and prolonged hospital stay. CONCLUSIONS Preoperative iron deficiency (ferritin <100 μg L-1) was independently associated with increased mortality, more SAEs, and prolonged hospital stay after cardiac surgery. These findings underline the importance of preoperative iron deficiency screening in the context of a comprehensive patient blood management programme, and highlight its importance as a research topic in cardiac surgery. CLINICAL TRIAL REGISTRATION NCT02031289.
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Affiliation(s)
- Julian Rössler
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Burkhardt Seifert
- Department of Biostatistics at the Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Gabriela H Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.
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Nikolaou M, Chrysohoou C, Georgilas TA, Giamouzis G, Giannakoulas G, Karavidas A, Papadopoulos C, Patsilinakos S, Tziakas D, Parissis J. Management of iron deficiency in chronic heart failure: Practical considerations for clinical use and future directions. Eur J Intern Med 2019; 65:17-25. [PMID: 31109847 DOI: 10.1016/j.ejim.2019.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/24/2019] [Accepted: 05/13/2019] [Indexed: 01/01/2023]
Abstract
Heart Failure (HF) is a global pandemic with rapidly increasing prevalence. In an attempt to maintain patients well being, the therapeutic interest has expanded to the vicious cycles that confer to HF mortality and morbidity and a number of comorbidities have been targeted. Iron deficiency represents a common comorbid condition that affects outcomes in HF. The treatment of iron deficiency is strongly supported by the cardiologic societies all over the world. Intravenous iron, primarily ferric carboxymaltose, has shown clinical benefit in this setting, irrespective of the anemia status. Practical recommendations though are lacking. In this document, we have tried to cover the practical gap and provide useful details for intravenous iron use.
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Affiliation(s)
- Maria Nikolaou
- Cardiology Department, General Hospital "Sismanogleio-Amalia Fleming", Athens, Greece.
| | - Christina Chrysohoou
- Heart Failure Unit, 1st Cardiology Clinic, University of Athens, "Hippokratio" Hospital, Athens, Greece
| | | | | | - George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | | | | | | | - Dimitrios Tziakas
- Cardiology Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - John Parissis
- Heart Failure Unit, Second Cardiology Department, University of Athens, Attikon Hospital, Athens, Greece
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