Iron deficiency in heart failure

Abstract

Iron deficiency is a major heart failure co-morbidity present in about 50% of patients with stable heart failure irrespective of the left ventricular function. Along with compromise of daily activities, it also increases patient morbidity and mortality, which is independent of anaemia. Several trials have established parenteral iron supplementation as an important complimentary therapy to improve patient well-being and physical performance. Intravenous iron preparations, in the first-line ferric carboxymaltose, demonstrated in previous clinical trials superior clinical effect in comparison with oral iron preparations, improving New York Heart Association functional class, 6 min walk test distance, peak oxygen consumption, and quality of life in patients with chronic heart failure. Beneficial effect of iron deficiency treatment on morbidity and mortality of heart failure patients is waiting for conformation in ongoing trials. Although the current guidelines for treatment of chronic and acute heart failure acknowledge importance of iron deficiency correction and recommend intravenous iron supplementation for its treatment, iron deficiency remains frequently undertreated and insufficiently diagnosed in setting of the chronic heart failure. This paper highlights the current state of the art in the pathophysiology of iron deficiency, associations with heart failure trajectory and outcome, and an overview of current guideline-suggested treatment options.

Keywords: Exercise capacity; Ferric carboxymaltose; Heart failure; Iron deficiency; Quality of life.

Figure 1

Basic physiological principles involved in iron absorption, transport and storage, as well aspathophysiological cascades responsible for absolute and functional iron deficiency. Fe, iron; Fr, ferroportin; GIT, gastrointestinal; RES, reticuloendothelial system; Tf, transferrin.

Figure 2

Proposed algorithm for the management of iron deficiency in heart failure. Algorithm adapted from McDonagh et al. Hb, haemoglobin; i.v., intravenous; NYHA, New York Heart Association Functional Classification; Pt, patient.

Figure 3

Overview of major publications and ongoing trials evaluating effects of treatment of iron deficiency in chronic heart failure. Ongoing trials are marked with an arrow. i.v., intravenous; p.o., per os.