Screening, diagnosis and treatment of iron deficiency in chronic heart failure: putting the 2016 European Society of Cardiology heart failure guidelines into clinical practice

Abstract

Iron deficiency is common in patients with chronic heart failure (CHF) and is associated with reduced exercise performance, impaired health-related quality of life and an increased risk of mortality, irrespective of whether or not anaemia is present. Iron deficiency is a serious but treatable condition. Several randomized controlled clinical trials have demonstrated the ability of intravenous (IV) iron, primarily IV ferric carboxymaltose (FCM), to correct iron deficiency in patients with heart failure with reduced ejection fraction (HFrEF), resulting in improvements in exercise performance, CHF symptoms and health-related quality of life. The importance of addressing the issue of iron deficiency in patients with CHF is reflected in the 2016 European Society of Cardiology (ESC) heart failure guidelines, which recognize iron deficiency as an important co-morbidity, independent of anaemia. These guidelines recommend that all newly diagnosed heart failure patients are routinely tested for iron deficiency and that IV FCM should be considered as a treatment option in symptomatic patients with HFrEF and iron deficiency (serum ferritin < 100 µg/L, or ferritin 100-299 µg/L and transferrin saturation < 20%). Despite these specific recommendations, there is still a lack of practical, easy-to-follow advice on how to diagnose and treat iron deficiency in clinical practice. This article is intended to complement the current 2016 ESC heart failure guidelines by providing practical guidance to all health care professionals relating to the procedures for screening, diagnosis and treatment of iron deficiency in patients with CHF.

Keywords: Chronic heart failure; European Society of Cardiology; Ferric carboxymaltose; Guidelines; Iron deficiency.

Figure 1

Algorithm for screening/diagnosis and treatment/follow‐up of iron deficiency in patients with chronic heart failure. Hb, haemoglobin; HFrEF, heart failure with reduced ejection fraction; IV, intravenous; NYHA, New York Heart Association; TSAT, transferrin saturation^†. *Note: The use of ferric carboxymaltose has not been studied in children, and therefore is not recommended in children under 14 years. For full prescribing information, please refer to the Summary of Product Characteristics.39 ^†TSAT = (serum iron concentration/total iron‐binding capacity) x 100. Algorithm adapted from McDonagh and Macdougall.12