With a borderline preserved left ventricular ejection fraction (down from normal 4.5 years ago) and new bilateral ankle edema and low forward flow, are intravenous iron infusions contraindicated, should I try oral iron (e.g., beef), and should I have C‑reactive protein measured now; what immediate management should I follow?

Urgent Evaluation and Management Plan for Declining LVEF with New Heart Failure Symptoms

You need immediate comprehensive heart failure evaluation—your new bilateral ankle edema combined with declining LVEF (from 65-70% to 55-60%) and subjective symptoms of low cardiac output represent decompensating heart failure that requires urgent workup and treatment optimization, not just iron supplementation. 1

Your LVEF Status and What It Means

Your current LVEF of 55-60% places you in the borderline preserved ejection fraction range, not the reduced ejection fraction category (≤40%) where most IV iron trial data exists. 1, 2

• The decline from 65-70% to 55-60% over 4.5 years is clinically significant and warrants investigation for underlying causes—ischemic disease, valvular disease, uncontrolled hypertension, or other cardiomyopathies. 1, 3
• Your new bilateral pitting edema indicates volume overload and elevated filling pressures, confirming symptomatic heart failure regardless of your preserved LVEF. 1, 3
• The subjective sensation of decreased contractility and low forward flow you describe aligns with early decompensation that can progress rapidly without intervention. 3

IV Iron Infusions: Are They Contraindicated at Your LVEF?

No, IV iron is not absolutely contraindicated at LVEF 55-60%, but the evidence supporting its use is limited to patients with LVEF ≤45%. 1, 2

Evidence-Based Criteria for IV Iron

The landmark trials (FAIR-HF, CONFIRM-HF, EFFECT-HF) that demonstrated benefit enrolled patients with:

• LVEF ≤40-45% 1, 2
• NYHA class II-III symptoms 1
• Iron deficiency defined as ferritin <100 μg/L OR ferritin 100-299 μg/L with transferrin saturation <20% 1, 2
• Hemoglobin <15 g/dL 1, 2

Your Specific Situation

• You do not meet the LVEF criterion (your 55-60% is above the ≤45% threshold studied). 1, 2
• Without documented iron studies (ferritin and TSAT), you cannot be diagnosed with iron deficiency by guideline criteria. 1
• The absolute contraindication is hemoglobin >15 g/dL, not your LVEF level. 1, 2, 4

Bottom line: IV iron is not FDA-approved or guideline-recommended for heart failure patients with LVEF >45%, regardless of iron status. 1, 2, 4

Should You Eat Beef to Raise Iron Stores?

No, oral iron (including dietary iron from beef) is ineffective for treating iron deficiency in heart failure patients. 1, 5

• The IRONOUT HF trial definitively showed that oral iron does not improve exercise capacity, symptoms, or adequately replenish iron stores in heart failure patients, even at high doses. 1
• Hepcidin upregulation in heart failure blocks intestinal iron absorption, making oral supplementation futile. 1
• Oral iron causes gastrointestinal side effects in up to 60% of patients, further limiting compliance. 1

If iron deficiency is confirmed by laboratory testing, only IV iron (specifically ferric carboxymaltose) has proven efficacy in heart failure. 1, 2

Should C-Reactive Protein Be Measured Now?

Yes, CRP should be measured as part of your comprehensive evaluation, but it is not the priority test. 1, 6

• Elevated CRP indicates systemic inflammation, which is common in heart failure and can affect interpretation of ferritin levels (ferritin rises with inflammation, potentially masking true iron deficiency). 1, 7
• CRP levels decrease with IV iron therapy in heart failure patients, suggesting iron repletion reduces inflammatory burden. 6

However, the critical tests you need immediately are:

1. Complete iron panel: serum ferritin, transferrin saturation (TSAT), serum iron 1, 7
2. Complete blood count with hemoglobin 1
3. BNP or NT-proBNP (to quantify heart failure severity) 1, 8
4. Comprehensive metabolic panel (renal function, electrolytes) 1, 3
5. Echocardiogram (to reassess LVEF, valvular function, filling pressures, and rule out new structural abnormalities) 1, 3, 8
6. ECG (to assess for arrhythmias, conduction abnormalities, or ischemic changes) 1, 3

Your Immediate Action Plan

Step 1: Emergency Department or Urgent Cardiology Evaluation (Within 24-48 Hours)

Your new bilateral pitting edema with declining LVEF and symptoms of low cardiac output constitute acute decompensated heart failure requiring urgent evaluation. 1, 3

• Do not wait for a routine outpatient appointment. Delay in starting appropriate therapy can be life-threatening in decompensating heart failure. 1, 3
• Present to an emergency department or contact your cardiologist immediately for same-day or next-day evaluation. 1

Step 2: Diagnostic Workup to Identify the Cause of LVEF Decline

Your declining LVEF from 65-70% to 55-60% requires investigation for reversible causes: 1, 3

1. Coronary angiography or stress testing to rule out ischemic heart disease (the most common cause of progressive LV dysfunction). 1, 3

   • If significant coronary disease is found, revascularization (PCI or CABG) may improve outcomes even with preserved LVEF if functionally significant stenoses are present. 1, 3

2. Comprehensive echocardiography to assess:

   • Valvular function (aortic stenosis, mitral regurgitation, aortic regurgitation can all cause progressive LV dysfunction) 3
   • Diastolic function and filling pressures (elevated filling pressures explain your edema) 3, 8
   • Regional wall motion abnormalities (suggest ischemic etiology) 3
   • Left ventricular dimensions (progressive dilatation indicates adverse remodeling) 3, 8

3. Laboratory evaluation for secondary causes:

   • Thyroid function tests (hyperthyroidism or hypothyroidism) 1
   • Hemoglobin A1c (uncontrolled diabetes) 1
   • Renal function (cardiorenal syndrome) 1, 3
   • Iron studies (ferritin, TSAT) 1

Step 3: Initiate Guideline-Directed Medical Therapy (GDMT)

Even with LVEF 55-60%, if you have symptomatic heart failure with volume overload, you need heart failure pharmacotherapy. 1, 3, 8

Immediate Diuretic Therapy for Volume Overload

• Loop diuretic (furosemide, torsemide, or bumetanide) to relieve your bilateral ankle edema and pulmonary congestion. 1, 3
• Minimum effective dose to achieve euvolemia without excessive preload reduction (important in preserved EF where preload is critical for cardiac output). 1, 3

Consider Neurohormonal Blockade

While the strongest evidence for ACE-inhibitors, beta-blockers, and mineralocorticoid receptor antagonists exists for LVEF ≤35-40%, these medications may still provide benefit in borderline preserved EF with symptoms: 1, 3, 8

• ACE-inhibitor or ARB (if blood pressure tolerates) to reduce afterload and prevent further adverse remodeling. 3, 8
• Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) to reduce heart rate, improve diastolic filling, and potentially prevent further LVEF decline. 3, 8
• SGLT2 inhibitor (dapagliflozin or empagliflozin) has shown benefit across the entire LVEF spectrum, including preserved EF, and reduces cardiovascular mortality and heart failure hospitalizations. 1, 3, 8

Step 4: Address Iron Deficiency IF Confirmed by Laboratory Testing

Only after obtaining iron studies can you determine if iron deficiency is present and whether treatment is indicated. 1, 7

If Iron Deficiency Is Confirmed (Ferritin <100 μg/L OR Ferritin 100-299 μg/L with TSAT <20%):

• IV ferric carboxymaltose is NOT guideline-recommended for LVEF >45%, but your cardiologist may consider off-label use if you develop symptomatic anemia or if your LVEF declines further to ≤45%. 1, 2
• Oral iron is ineffective and should not be used. 1, 5
• Investigate underlying causes of iron deficiency: occult gastrointestinal bleeding (colonoscopy, upper endoscopy), heavy menstrual bleeding (if applicable), malabsorption, or chronic inflammation. 1

If Hemoglobin >15 g/dL:

• IV iron is absolutely contraindicated. 1, 2, 4

Step 5: Monitor for Further LVEF Decline

If your LVEF continues to decline to ≤40%, you will meet criteria for HFrEF and require aggressive GDMT plus consideration for device therapy. 1, 3, 8

• Repeat echocardiography in 3-6 months (or sooner if symptoms worsen) to reassess LVEF and guide therapy escalation. 1, 3
• If LVEF falls to ≤35% with NYHA class II-III symptoms, you will meet criteria for:
  • Implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death. 1, 3
  • Cardiac resynchronization therapy (CRT) if you develop left bundle branch block with QRS ≥150 ms. 1, 3

Common Pitfalls to Avoid

1. Do not delay seeking urgent evaluation because your LVEF is "still preserved." Your new edema and declining LVEF trend indicate decompensation that requires immediate attention. 1, 3

2. Do not pursue IV iron without documented iron deficiency (ferritin and TSAT testing). IV iron has risks (hypersensitivity reactions, infection) and is not indicated without confirmed deficiency. 1, 2, 4

3. Do not rely on oral iron or dietary iron (beef) to treat iron deficiency in heart failure—it is ineffective. 1, 5

4. Do not ignore the possibility of ischemic heart disease as the cause of your declining LVEF. Coronary evaluation is critical. 1, 3

5. Do not assume your abdominal swelling is "normal" just because physicians have said so. Hepatic congestion from elevated right-sided pressures is a real complication of heart failure and warrants objective assessment (liver function tests, hepatic ultrasound). 3

Summary: Your Sense of Urgency Is Justified

Your clinical instinct is correct—you are experiencing early decompensated heart failure that requires urgent evaluation and treatment. 1, 3

• IV iron is not the solution at your current LVEF of 55-60%, and oral iron/beef is ineffective. 1, 2, 5
• The priority is identifying WHY your LVEF is declining (ischemia, valvular disease, hypertension, etc.) and initiating appropriate heart failure therapy (diuretics, GDMT, possible revascularization). 1, 3
• CRP can be measured, but iron studies, BNP, echocardiography, and coronary evaluation are more critical. 1, 7
• Seek urgent cardiology evaluation within 24-48 hours—do not wait for routine follow-up. 1, 3