Treating iron deficiency in patients with heart failure: what, why, when, how, where and who

Abstract

For patients with heart failure and reduced or mildly reduced left ventricular ejection fraction, iron deficiency is common and associated with more severe symptoms, worse quality of life and an increased risk of hospitalisations and death. Iron deficiency can be swiftly, effectively and safely treated by administering intravenous iron, either as ferric carboxymaltose or ferric derisomaltose, which improves patient well-being and reduces the risk of hospitalisations including those for heart failure. However, the current definition of iron deficiency in heart failure has serious flaws. A serum ferritin <100 µg/L does not identify patients more likely to respond to intravenous iron. In contrast, patients with transferrin saturations <20%, most of whom are also anaemic, are more likely to have a beneficial response to intravenous iron. In this review, we summarise the available evidence for use of intravenous iron in heart failure and provide recommendations for targeted future research and practical considerations for the general cardiologist.

Keywords: Biomarkers; Heart Failure, Systolic; Pharmacology, Clinical.

Figure 1. Stepwise guidance on how to assess, diagnose, manage and monitor patients with heart failure and iron deficiency. Abbreviations:- HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HFmrEF: heart failure with mildly reduced ejection; TSAT: transferrin saturation; IV: intravenous; Hb: haemoglobin; FCM: ferric carboxymaltose; FDI: ferric derisomaltose; GI: gastrointestinal; wks: weeks. *Single dose range for each preparation of intravenous iron. The iron need estimation can be performed using a Simplified Table (that uses patients weight and haemoglobin) for FCM or FDI from their respective Summary of Product Characteristics, or Ganzoni formula for FDI. For FCM the maximum single dose infusion is 1,000 mg and for FDI it is 20 mg/kg without upper limit. In practice, it is common to see 500 mg intervals used since this tracks with the respective Simplified Tables, and there are 500 mg and 1,000 mg vials.