Goal Serum Ferritin Levels for HFrEF
For patients with Heart Failure with reduced Ejection Fraction (HFrEF), iron deficiency should be treated when serum ferritin is <100 ng/mL or when ferritin is between 100-300 ng/mL with transferrin saturation <20%. 1
Diagnosis of Iron Deficiency in HFrEF
Iron deficiency is common in heart failure, affecting approximately 50% of patients with HFrEF, and is associated with:
- Worse prognosis
- Reduced exercise capacity
- Impaired quality of life
- Higher hospitalization rates
Diagnostic Criteria:
- Serum ferritin <100 ng/mL, OR
- Serum ferritin 100-300 ng/mL with transferrin saturation <20%
Treatment Recommendations
Intravenous Iron Therapy:
- First-line treatment: Intravenous ferric carboxymaltose is recommended for patients with NYHA class II-III HF and iron deficiency 1
- Oral iron supplementation is NOT recommended due to poor absorption and inadequate repletion of iron stores in HFrEF patients 1, 2
Benefits of IV Iron Therapy:
- Improves functional capacity and exercise tolerance
- Enhances quality of life
- Improves NYHA functional class
- Reduces hospitalization for worsening HF
- Improves 6-minute walk test distance 1
Dosing Considerations for IV Ferric Carboxymaltose
For patients with iron deficiency and HFrEF:
Weight <70 kg:
- Hb <10 g/dL: 1000 mg initial dose
- Hb 10-14 g/dL: 1000 mg initial dose
- Hb >14 to <15 g/dL: 500 mg initial dose
Weight ≥70 kg:
- Hb <10 g/dL: 1000 mg initial dose
- Hb 10-14 g/dL: 1000 mg initial dose
- Hb >14 to <15 g/dL: 500 mg initial dose 3
Maintenance dosing may be required at weeks 6,12,24, and 36 based on ferritin and transferrin saturation levels.
Monitoring Recommendations
- Regular assessment of iron parameters (ferritin and transferrin saturation)
- Monitor for adverse effects of IV iron therapy
- Consider maintenance dosing if serum ferritin falls below 100 ng/mL or if ferritin is 100-300 ng/mL with transferrin saturation <20% 3
Clinical Pearls and Pitfalls
- Important: Always screen for potentially treatable causes of iron deficiency (e.g., gastrointestinal bleeding) 1
- The safety of IV iron is unknown in patients with HF and hemoglobin >15 g/dL 1
- Oral iron supplementation has been shown to be ineffective in HFrEF patients with iron deficiency 2
- Iron deficiency can occur with or without anemia and still impact outcomes in HFrEF
- Long-term safety data beyond 36 weeks is limited 3
Ongoing Research
The FAIR-HF 2 and HEART-FID trials are currently investigating the long-term effects of IV iron on morbidity and mortality in HFrEF patients with iron deficiency 1, 4, which may further refine treatment recommendations in the future.