What is the research on intravenous (IV) iron in anemic patients presenting with acute congestive heart failure (CHF) exacerbation?

From the Guidelines

Intravenous (IV) iron therapy is recommended for anemic patients presenting with active CHF exacerbation, as it improves functional capacity, quality of life, and reduces heart failure hospitalizations. For patients presenting with active CHF exacerbation and concurrent anemia, IV iron carboxymaltose is the most studied formulation, typically administered as a 1000 mg infusion, which can be repeated after 6 weeks if iron deficiency persists 1. Alternative formulations include iron sucrose (typically 200 mg per session over multiple sessions) or ferric derisomaltose (up to 1000 mg as a single dose). Treatment should target patients with ferritin levels <100 μg/L or ferritin between 100-299 μg/L with transferrin saturation <20% 1. Some key points to consider when administering IV iron therapy include:

• Improving functional capacity and quality of life in patients with heart failure and iron deficiency 1
• Reducing heart failure hospitalizations in iron-deficient patients with HFrEF 1
• Addressing both absolute iron deficiency and functional iron deficiency common in heart failure patients, improving oxygen transport, myocardial energetics, and reducing cardiac stress
• Initiating treatment during hospitalization after the patient is stabilized from the acute decompensation, with appropriate monitoring for hypersensitivity reactions during administration
• Periodically screening for anaemia and iron deficiency, as recommended by the ESC guidelines 1

From the FDA Drug Label

Trial 3: FER-CARS-05 (CONFIRM-HF) was a randomized, double-blind, placebo-controlled, study in patients with iron deficiency and chronic heart failure with left ventricular ejection fraction of < 45% and New York Heart Association (NYHA) class II/III to determine whether intravenous Injectafer improves exercise capacity measured as change from baseline to 24 weeks in 6-minute walk distance (6MWD). The mean change in 6MWD from Baseline to Week 24 in Injectafer-treated patients was 18 meters (95% CI 4,32), and placebo-treated patients was -7 meters (95% CI -21,7), with between group difference of 25 meters (7,43), p-value 0. 007, favoring Injectafer.

Intravenous Iron in Anemic Patients with Active CHF Exacerbation: The study shows that intravenous iron (ferric carboxymaltose) improves exercise capacity in patients with iron deficiency and chronic heart failure.

• The mean change in 6-minute walk distance (6MWD) from baseline to week 24 was significantly higher in Injectafer-treated patients compared to placebo-treated patients.
• The results suggest that intravenous iron therapy may be beneficial in patients with iron deficiency and chronic heart failure, including those presenting with active CHF exacerbation 2.

From the Research

Research on IV Iron in Anemic Patients with Active CHF Exacerbation

• Studies have shown that anemia and iron deficiency are common comorbidities in patients with heart failure, and are associated with poor clinical status and worse outcomes 3, 4, 5, 6.
• Iron deficiency can be absolute or functional, and can occur with or without anemia 3, 4, 5.
• Treatment of anemia in patients with heart failure with erythropoiesis-stimulating agents has been evaluated, but has not improved outcomes and has been associated with a higher risk of adverse events 3, 6.
• Intravenous iron supplementation has been shown to improve symptoms and exercise capacity in patients with heart failure and iron deficiency, with or without anemia 4, 5, 6, 7.
• Recent studies have demonstrated the benefit of intravenous iron repletion in patients with heart failure, including a reduction in future heart failure hospitalizations 4, 5.
• The European Society of Cardiology guidelines recommend testing all heart failure patients for iron deficiency and correcting it with intravenous iron supplementation if necessary 5.
• Ongoing trials are investigating the role of intravenous iron in improving mortality and outcomes in patients with heart failure, including those with acute heart failure and preserved ejection fraction 4, 5, 7.

Key Findings

• Iron deficiency is a common comorbidity in heart failure, affecting up to 80% of acute heart failure patients 7.
• Iron deficiency is associated with reduced quality of life, impaired exercise capacity, and higher hospitalization rates 4, 5, 7.
• Intravenous iron supplementation is a safe and effective treatment for iron deficiency in patients with heart failure 4, 5, 6, 7.
• Ferric carboxymaltose and ferric derisomaltose are two intravenous iron supplements that have been shown to be effective in treating iron deficiency in heart failure patients 7.