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Diagnosis and Management of Anemia and Iron Deficiency in Heart Failure

Diagnosis and Management of Anemia and Iron Deficiency in Heart Failure

The American College of Cardiology/American Heart Association (ACC/AHA) heart failure (HF) guidelines recommend that routine baseline assessment for all patients with HF includes an evaluation for anemia. The anemia evaluation should include studies to screen for iron deficiency. Anemia is defined as hemoglobin (Hgb) <13 g/dL in men and <12 g/dL in women; in HF, iron deficiency anemia is additionally defined as ferritin <100 ng/mL, or ferritin 100 ng/mL to 300 ng/mL if transferrin saturation (TSAT) is <20%.

In patients with HF, an iron deficiency diagnosis based on TSAT ≤19.8% alone has a sensitivity of 94% and specificity of 84%. Serum iron levels by themselves should not be used for iron deficiency diagnosis, since serum iron levels can vary widely—even from hour to hour. Other serum markers, such as mean corpuscular volume (MCV), mean corpuscular Hgb (MCH), and mean corpuscular Hgb concentration (MCHC), are not reliable indicators of iron status, either.

Iron deficiency can be present with or without anemia, thus, Hgb levels alone should not be used to assess for iron deficiency. If there is anemia, it is prudent to look for other causes such as acute or subacute blood loss, GI malignancies, and hematologic disorders.

Intravenous iron repletion is now recommended for iron deficiency in patients with HF. It is worth mentioning that oral iron repletion has not been shown to be effective in this setting and thus is not recommended. The ACC/AHA HF guidelines set a class IIb recommendation to use IV iron to treat patients with NYHA class II and III HF with iron deficiency. There are several forms of IV iron, with iron sucrose being the most common. IV iron sucrose for repletion is usually given at 200 mg for 5 doses (or 300 mg for 3 doses) over a 14-day period. The total recommended treatment dose is 1000 mg. Reassessment of ferritin and/or TSAT should be performed 3 months after initiation of IV iron treatment. If iron deficiency is still present, another course of IV iron can be administered.

There are contraindications to administering IV iron, the most important of which is the presence of an active infection. Additionally, an allergic reaction can occur, so close monitoring during administration is vital. For more specific clinical considerations on the use of IV iron, consult the drug prescribing information and your pharmacy colleagues.

  • Anand IS, Gupta P. Anemia and iron deficiency in heart failure: Current concepts and emerging therapies. Circulation. 2018;138:80–98.
  • Nikolaou M, et al. Management of iron deficiency in chronic heart failure: Practical considerations for clinical use and future directions. Eur J Int Med. 2019;65:17–25.
  • Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137–e161.

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Filed under: Cardiometabolic

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