What is the appropriate management for a woman in her late 80s with anemia (hemoglobin 8.4 g/dL) and a left ventricular ejection fraction of about 30%?

Management of Anemia in an Elderly Woman with Severe Heart Failure

In a woman in her late 80s with hemoglobin 8.4 g/dL and ejection fraction 30%, blood transfusion to achieve hemoglobin ≥10 g/dL is reasonable to reduce cardiovascular events, while avoiding erythropoiesis-stimulating agents which are contraindicated in this population. 1

Immediate Transfusion Strategy

Red blood cell transfusion should target hemoglobin ≥10 g/dL in this patient with acute coronary syndrome risk and severe heart failure (EF 30%). 1 The 2025 ACC/AHA guideline specifically recommends this threshold for patients with ACS and anemia, representing the most current evidence-based approach. 1

• Avoid restrictive transfusion strategies (<8 g/dL threshold) in this context. While restrictive strategies work well in hemodynamically stable ACS patients without severe heart failure, the combination of hemoglobin 8.4 g/dL and EF 30% creates dangerous myocardial oxygen supply-demand mismatch. 1

• Administer transfusions slowly (over 3-4 hours per unit) to minimize volume overload risk in a patient with severely reduced ejection fraction. 2

• Monitor closely for transfusion-related complications including volume overload, which is particularly hazardous given the EF of 30%. 2

Critical Contraindications

Do NOT use erythropoiesis-stimulating agents (ESAs) in this patient. 2, 3, 4 Multiple lines of evidence demonstrate:

• ESAs are ineffective for improving outcomes in heart failure with reduced ejection fraction, even when hemoglobin increases. 3, 4
• In older adults with heart failure and preserved EF, ESA therapy showed no benefit for left ventricular remodeling, exercise capacity, or quality of life despite raising hemoglobin. 3, 4
• Approximately 50% of elderly heart failure patients are non-responders to ESA therapy. 4
• ESAs increase thrombotic risk, which is particularly dangerous in elderly patients with cardiovascular disease. 2

Iron Management Approach

Determine iron status before supplementation:

• If ferritin <100 ng/mL or ferritin 100-300 ng/mL with transferrin saturation <20%, iron deficiency is present and requires treatment. 5, 6

• Intravenous iron is preferred over oral iron in heart failure patients with iron deficiency, as it improves exercise capacity (6-minute walk distance increased by 25 meters vs placebo at 24 weeks). 6

• Do NOT give iron if ferritin is elevated (>300 ng/mL), as this indicates iron overload risk and will not correct anemia due to chronic disease or bone marrow dysfunction. 5, 2, 7

Diagnostic Workup (Parallel to Treatment)

Identify the underlying cause of anemia:

• Obtain peripheral blood smear to evaluate for dysplastic cells, blasts, or abnormal morphology suggesting myelodysplastic syndrome. 2

• Check reticulocyte count to distinguish bone marrow failure (low reticulocyte count) from blood loss or hemolysis (elevated reticulocyte count). 2

• Screen for gastrointestinal bleeding given the high prevalence in elderly patients, though this patient's presentation suggests chronic anemia rather than acute blood loss. 5

• Measure inflammatory markers (CRP, ESR) if ferritin is borderline elevated, as inflammation can sequester iron and elevate ferritin despite functional iron deficiency. 7

Heart Failure Optimization

Maintain guideline-directed medical therapy for heart failure:

• Continue ACE inhibitors or ARBs as they reduce cardiovascular events and are particularly important in patients with reduced ejection fraction, even in the presence of anemia. 1

• Continue beta-blockers which provide mortality benefit in heart failure with reduced EF. 1

• Adjust diuretics carefully to manage volume status without causing excessive preload reduction, which could precipitate acute kidney injury in the setting of anemia. 1

Common Pitfalls to Avoid

• Do not delay transfusion while awaiting complete diagnostic workup when hemoglobin is 8.4 g/dL with EF 30%—the risk of cardiac decompensation is immediate. 2

• Do not use the restrictive transfusion threshold (<8 g/dL) from general medical populations in patients with severe heart failure, as anemia worsens cardiac output and increases left ventricular hypertrophy. 1

• Do not attribute all anemia to heart failure alone—elderly patients often have multiple contributing factors including chronic kidney disease, nutritional deficiencies, and bone marrow disorders. 1

• Do not over-diurese in an attempt to manage volume status, as anemia already reduces preload and excessive diuresis can precipitate cardiorenal syndrome. 1

Prognostic Considerations

Anemia independently worsens outcomes in heart failure with reduced EF:

• Each 1 g/dL decrease in hemoglobin below 11 g/dL increases cardiovascular death, MI, or recurrent ischemia with an odds ratio of 1.45. 1

• Anemia increases heart rate and cardiac output, leading to left ventricular hypertrophy and imbalance between myocardial oxygen demand and supply. 1

• In patients with cardiac disease, mortality decreased from approximately 40% per year at hematocrit 30% to 15% per year when normal hematocrit was achieved and maintained. 1