From the Guidelines
Differentiating and managing symptoms of anemia versus heart failure requires careful assessment of distinct clinical presentations, although these conditions can sometimes coexist and share symptoms. Anemia typically presents with fatigue, weakness, pale skin, headaches, dizziness, and shortness of breath with exertion, while heart failure commonly manifests as dyspnea (especially when lying flat), peripheral edema, jugular venous distention, and fatigue. Laboratory testing is essential for diagnosis, with anemia showing low hemoglobin (typically <12 g/dL in women, <13 g/dL in men) and heart failure potentially showing elevated BNP/NT-proBNP levels.
Key Considerations
- Management of anemia focuses on treating the underlying cause, which may include iron supplementation (ferrous sulfate 325mg daily), vitamin B12 (1000mcg daily orally or monthly injections), folate (1mg daily), or erythropoietin-stimulating agents in certain cases, as noted in 1.
- Heart failure management includes ACE inhibitors (like lisinopril 10-40mg daily), beta-blockers (such as metoprolol succinate 25-200mg daily), diuretics (furosemide 20-80mg daily), and possibly SGLT2 inhibitors (empagliflozin 10mg daily).
- Physical examination findings can help distinguish the conditions, with anemia showing tachycardia and systolic flow murmurs, while heart failure may present with crackles on lung auscultation, S3 gallop, and peripheral edema.
- When both conditions coexist, treating anemia may improve heart failure symptoms by reducing cardiac workload and improving oxygen delivery to tissues, as suggested by 1 and 1.
Treatment Approach
- The use of erythropoiesis-stimulating agents is not recommended for patients with mild to moderate anemia and congestive heart failure or coronary heart disease, according to 1 and 1.
- Iron deficiency is a common cause of anemia in heart failure patients, and its correction can improve symptoms and outcomes, as discussed in 1.
- A restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7–8 g/dL) is recommended for hospitalized patients with coronary heart disease, as stated in 1.
From the Research
Differentiating Symptoms of Anemia and Heart Failure
- Anemia and heart failure often coexist and can have similar symptoms, making differentiation challenging 2, 3.
- Common symptoms of anemia include fatigue, shortness of breath, and pale skin, while heart failure symptoms include edema, fatigue, and shortness of breath 4, 5.
- A thorough medical history, physical examination, and laboratory tests are necessary to differentiate between the two conditions 6.
Managing Symptoms of Anemia vs Heart Failure
- Treatment of anemia in heart failure patients may involve erythropoiesis-stimulating agents (ESA) and iron therapy, particularly in patients with chronic kidney disease (CKD) 2, 5.
- Iron deficiency, whether absolute or functional, should be addressed in heart failure patients, as it can improve symptoms and exercise capacity 4, 5.
- Management of heart failure symptoms focuses on optimizing disease-modifying therapies, such as angiotensin-converting enzyme inhibitors, β-blockers, and aldosterone antagonists, as well as cardiac resynchronization therapy in selected cases 5.
- Intravenous iron therapy has shown promise in improving symptoms, quality of life, and exercise capacity in both anemic and non-anemic heart failure patients, although larger-scale and longer-term studies are needed to establish its safety and efficacy profile 5, 6.
Diagnostic Considerations
- Laboratory tests, including serum creatinine, estimated glomerular filtration rate (eGFR), serum iron, transferrin saturation, ferritin, vitamin B12, and folic acid, can help diagnose anemia and iron deficiency in heart failure patients 5.
- Assessment of the underlying cause of anemia is crucial in determining the best therapeutic course, and may involve further investigation, such as evaluation for occult gastrointestinal blood losses 5.
- Soluble transferrin receptor levels may be useful in assessing iron deficiency in heart failure patients, although its use in clinical practice is not yet established 5.