Iron Deficiency Common Related to - Poor quality of life - - - PowerPoint PPT Presentation

Iron Deficiency

• Common
• Related to
• Poor quality of life
• Heart failure symptoms
• Poor prognosis
• Consider screening patients
• Who are symptomatic
• Whose prognosis is declining

Iron deficiency is much more common than anemia.

Iron Deficiency: More Common Than Anemia

Klip IT, et al. Am Heart J. 2013;165(4):575‐582.

…screen for iron deficiency independently of hemoglobin level...

CONFIRM-HF: IV Iron Improves Exercise Capacity in HFrEF

Adapted from: Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al. Eur Heart J. 2015;36(11):657-668.

6‐Min Walk Test

FCM = ferric carboxymaltose 6MWT = 6‐minute walk test

FAIR-HF

• 50.3% of patients in the ferric carboxymaltose group reported

“much” or ”moderate” improvement on the patient global assessment vs. 27.5% of the placebo group.

• OR 2.51 (95% CI, 1.75-3.61; P <0.001)

Anker SD, et al. N Engl J Med. 2009;361(25)2436-2448.

IRONOUT

• Oral iron vs. placebo
• 225 patients with HFrEF (<40%)
• No significant effect on heart failure symptoms
• Oral iron is not well absorbed

Lewis GD, et al. JAMA. 2017;317(19):1958-1966.

ESC Guidelines

• Recommend only intravenous iron supplementation for iron

deficiency in patients with HFrEF

Ponikowski P, et al. Eur J Heart Fail. 2016;18(8):891-975.

Iron Deficiency

• Ferritin <100 g/L or
• Ferritin 100-299 g/L with TSAT <20%

Ponikowski P, et al. Eur J Heart Fail. 2016;18(8):891-975.

HFrEF = heart failure with reduced ejection fraction; McDonagh T, et al. Eur J Heart Fail. 2018;20(12):1664‐1672.

Consider ferric carboxymaltose as 500−1000 mg single doses of iron to correct iron deficiency Dosing calculations according to hemoglobin levels and body weight Hemoglobin Patient body weight g/dL mmol/L <35 kg 35 kg − <70 kg ≥70 kg <10 <6.2 500 mg 1500 mg 2000 mg 10−14 6.2–8.7 500 mg 1000 mg 1500 mg >14 >8.7 500 mg 500 mg 500 mg Check ferritin + TSAT at next scheduled visit (preferably at 3 months)

Check ferritin + TSAT 1−2 mes per year or if change in clinical picture or if hemoglobin decreases

Treatment of Iron Deficiency in HFrEF

Side Effects of Intravenous Iron

• Itching or rash at the injection site
• Anaphylactoid reaction
• Iron infusion staining

…[ferric carboxymaltose] is allowed to be administered both in inpatients but also in outpatients…

Effect of Ferric Carboxymaltose in HFrEF: Meta-analysis

HFrEF = heart failure with reduced ejection fraction; Anker SD, et al. Eur J Heart Fail. 2018;20(1):125-133.

Select Ongoing Large HFrEF Trials

HFrEF = heart failure with reduced ejection fraction; von Haehling S, et al. JACC Heart Fail. 2019;7(1):36-46.

Study Name AFFIRM‐AHF FAIR‐HF‐2 IRONMAN HEART‐FID # of Patients 1,100 1,200 1,300 3,014 Diagnosis Acute HF EF<50% Chronic HF EF≤45% Chronic HF <45% Chronic HF EF≤40% Blinding Double blind Double blind Open label Double blind Study Arm FCM FCM Iron (III) isomaltoside FCM Duration 52 weeks Event driven + at least 12 mos f/u 120 weeks Event driven + 12 mos last patient Primary Endpoint HF hosp + CVD HF hosp + CVD CVD or HF hosp All‐cause mortality + total HF hosp through 12 mos and 6‐month 6MWD

Iron Deficiency in HFpEF: Reduced Functional Capacity and QOL

6MWT = 6-minute walk test; HFrEF = heart failure with preserved ejection fraction ID = iron deficiency, MLHFQ = Minnesota Living with Heart Failure Questionnaire, QOL = quality of life; Alcaide-Aldeano A, Garay A, Alcoberro L, et al. J Clin Med. 2020;9(4):1199.

Take Home Message

• The most important clinical pearl is to screen for iron deficiency

and diagnose it in symptomatic patients.