Can a patient with cardiac amyloidosis receive iron supplements?

Iron Supplementation in Cardiac Amyloidosis

Patients with cardiac amyloidosis can receive intravenous iron supplementation if they have iron deficiency, as this approach has shown benefits in heart failure patients regardless of etiology, including those with cardiac amyloidosis. 1, 2

Prevalence and Impact of Iron Deficiency in Cardiac Amyloidosis

• Iron deficiency is common in cardiac amyloidosis, affecting approximately 49-56% of patients across all subtypes (AL, ATTRv, and ATTRwt) 2, 3
• Iron deficiency in cardiac amyloidosis is associated with worse functional status and more pronounced right ventricular dysfunction when defined by transferrin saturation <20% 3
• Similar to other heart failure etiologies, iron deficiency in cardiac amyloidosis can contribute to reduced exercise capacity and worsened symptoms 1, 4

Diagnostic Criteria for Iron Deficiency

• Iron deficiency in heart failure is defined as:
  • Ferritin <100 ng/mL regardless of transferrin saturation, OR
  • Ferritin 100-300 ng/mL with transferrin saturation <20% 1
• All patients with heart failure, including those with cardiac amyloidosis, should undergo routine evaluation for anemia and iron deficiency 1

Treatment Recommendations

Intravenous Iron Therapy

• Intravenous iron supplementation is preferred over oral iron in heart failure patients: 1
  • The 2022 AHA/ACC/HFSA guidelines recommend intravenous iron for patients with NYHA class II-III heart failure and iron deficiency 1
  • The 2025 European guidelines recommend intravenous iron supplementation in symptomatic heart failure patients with iron deficiency (Class I, Level A) 1
• Intravenous ferric carboxymaltose (FCM) has the strongest evidence base in heart failure patients 1
• Oral iron supplementation is not recommended as it has been shown ineffective in heart failure patients due to poor absorption and gastrointestinal side effects 1

Clinical Benefits of IV Iron in Heart Failure

• Intravenous iron therapy in heart failure patients has demonstrated:
  • Improved exercise capacity and 6-minute walk test distance 1
  • Enhanced quality of life and functional status 1
  • Reduced heart failure hospitalizations in some studies 1
  • Benefits independent of anemia status 1

Special Considerations for Cardiac Amyloidosis

• While specific large trials in cardiac amyloidosis are lacking, evidence suggests iron deficiency is common and associated with worse outcomes in this population 2, 3
• Iron deficiency in cardiac amyloidosis may be influenced by:
  • ATTR subtype (higher prevalence in ATTRv) 2
  • Presence of diabetes 2
  • Use of aspirin 2
  • Severity of cardiac dysfunction 3

Administration Guidelines

• For intravenous iron administration: 1
  • Ferric carboxymaltose is typically given as two individual doses of 750 mg each in the US 1
  • Patients should be monitored for at least 30 minutes after infusion for potential hypersensitivity reactions 1
  • Iron status should be re-evaluated approximately 3 months after supplementation 1

Cautions and Contraindications

• Contraindications to intravenous iron therapy include: 1

  • Hypersensitivity to the active substance or excipients
  • Known serious hypersensitivity to other parenteral iron products
  • Anemia not attributed to iron deficiency
  • Evidence of iron overload

• Use with caution in patients with: 1

  • Acute or chronic infection
  • Known drug allergies or history of severe asthma/atopic allergies
  • Immune or inflammatory conditions

Conclusion

Iron deficiency is prevalent in cardiac amyloidosis and associated with worse outcomes. Based on current heart failure guidelines and emerging evidence specific to cardiac amyloidosis, intravenous iron supplementation is appropriate for patients with cardiac amyloidosis who have documented iron deficiency, with potential benefits for functional capacity and quality of life.