What are the implications of chronic systolic heart failure with anemia (low hemoglobin) and normal iron stores (ferritin 55 ng/mL)?

From the Guidelines

For a patient with chronic systolic heart failure, hemoglobin of 10.4 g/dL, and ferritin of 55 ng/mL, intravenous iron supplementation is recommended alongside heart failure management, as it has been shown to improve functional status and quality of life 1. The patient's low ferritin level confirms iron deficiency, which can impair oxygen delivery, worsen cardiac function, and compromise skeletal muscle metabolism. Key points to consider in the management of this patient include:

• Starting intravenous iron supplementation, preferably with ferric carboxymaltose, as it has been most extensively studied for the treatment of iron deficiency in patients with heart failure 1.
• A typical regimen would be ferric carboxymaltose 1000 mg administered as an IV infusion, potentially repeated after 4-12 weeks if iron deficiency persists.
• Oral iron supplements are less effective in heart failure patients due to poor absorption and gastrointestinal side effects.
• Continuing standard heart failure therapy, including ACE inhibitors/ARBs, beta-blockers, and diuretics, as appropriate.
• Regular monitoring of iron parameters and hemoglobin every 3-6 months is essential to assess treatment response and determine if additional iron infusions are needed 1. The use of intravenous iron has been supported by studies such as FAIR-HF and CONFIRM-HF, which demonstrated improvements in patient self-reported quality of life, New York Heart Association (NYHA) class, and exercise capacity 1. Additionally, guidelines from the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America suggest that intravenous iron replacement may be reasonable to improve functional status and quality of life in patients with heart failure and iron deficiency 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). Iron deficiency was defined as serum ferritin <100 ng/mL or 100 to 300 ng/mL with TSAT <20%. At baseline, mean (SD) Hb was 12 g/dl (1. 4), ferritin 57 ng/ml (45),

The patient has chronic systolic heart failure with a hemoglobin level of 10.4 g/dL and iron ferritin of 55 ng/mL. Based on the study, the patient's ferritin level is within the range of iron deficiency defined in the study (ferritin <100 ng/mL).

• The study suggests that intravenous ferric carboxymaltose (Injectafer) may be beneficial for patients with iron deficiency and chronic heart failure, as it improved exercise capacity measured by 6-minute walk distance (6MWD) at 24 weeks 2.
• However, the patient's hemoglobin level is lower than the mean hemoglobin level in the study (12 g/dL).
• It is essential to consider the patient's individual characteristics and medical history before making a clinical decision.
• Based on the available data, intravenous ferric carboxymaltose (Injectafer) may be considered as a treatment option for this patient, but it is crucial to weigh the potential benefits and risks and monitor the patient's response to treatment closely 2.

From the Research

Patient Characteristics

• The patient has chronic systolic heart failure with a hemoglobin level of 10.4 g/dL, which is below the normal range for adults, indicating anemia 3.
• The patient's iron ferritin level is 55 μg/L, which is below the threshold for iron deficiency (<100 μg/L) 3, 4.

Iron Deficiency and Anemia in Heart Failure

• Iron deficiency is a common comorbidity in patients with heart failure, with a prevalence ranging from 30% to 50% 3.
• Anemia is also a common comorbidity in patients with heart failure, with a prevalence ranging from 10% to 79% 5.
• Iron deficiency, with or without anemia, is associated with poor prognosis and increased risk of mortality and morbidity in patients with heart failure 6.

Treatment Options

• Intravenous iron supplementation has been shown to improve functional capacity and quality of life in patients with heart failure and iron deficiency 3, 4.
• Oral iron supplementation has been less effective in correcting iron deficiency in patients with heart failure 3.
• Erythropoietin-stimulating agents are no longer considered a treatment option for anemia in heart failure due to the lack of benefit on mortality or morbidity 6.

Clinical Implications

• The patient's iron deficiency and anemia may be contributing to their poor functional capacity and quality of life 4.
• Intravenous iron supplementation may be a viable treatment option to improve the patient's functional capacity and quality of life 3, 4.
• Further evaluation and management of the patient's iron deficiency and anemia are necessary to optimize their treatment and improve their outcomes 7.