Iron Deficiency in Heart Failure: A Rational Approach

Abstract

Heart failure (HF) is an epidemic syndrome of the 21st century, most often recognized in the elderly. The natural history
of chronic HF is characterized by its considerable symptomatic burden and recurrent acute decompensation leading
to repeated hospitalizations. Thus, HF is the main cause of
hospital admission and rehospitalizations, which translates
into markedly high costs. Accordingly, in order to improve
individual outcomes and maintain the sustainability of the
healthcare system, it is fundamental to adequately treat HF
and its common comorbidities. Recently, iron deficiency (ID)
has been recognized in over 30% of HF patients, indicating
a more severe symptomatic burden, morbidity and mortality
rates, constituting a novel therapeutic target. Given the relevance of ID in HF, we ought to:
1. Briefly discuss the main findings of trials comparing
iron to placebo or control, namely the inefficacy of oral iron
(IRONOUT HF) contrasting to the benefits of intravenous (IV)
iron, which led to significant symptomatic improvement and
potentially reduced hospitalizations due to worsening HF, as
demonstrated in the main ferric carboxymaltose trials (FAIR-
-HF, CONFIRM-HF, EFFECT-HF);
2. Propose a comprehensive rational algorithmic approach
to ID in adequately selected HF patients;
3. Emphasize the selection of candidates for IV iron based
on left ventricular ejection fraction, symptoms and haemoglobin concentration; and
4. Review the main adverse effects of IV iron and current
gaps in knowledge. An algorithmic approach to ID in HF as
an evidence-based intervention may result in optimal therapy
for selected patients, as well as decreased IV iron in inadequate scenarios