RECENT ADVANCES IN MANAGEMENT OF ANEMIA IN HEART FAILURE

Abstract

Though treatment and outcomes have significantly improved over the past 15years, morbidity and mortality of heart failure (HF) remains very high. In thesetting of heart failure comorbidities such as iron deficiency is present in nearly50% and anemia in 37%. Prevalence of anemia in heart failure depending on thedefinitions used, varies from 15% to 56%. In a retrospective study of outpatientswith CHF, the prevalence of anemia, using the World Health Organization (WHO)definition (hemoglobin<12 g/dL in women and<13 g/dL in men), ranged from9% to 19% in NYHA class I to II, to 79% in NYHA class IV.

Anemia has convincingly been shown to be a powerful predictor of re-hospitalization rates and survival in chronic heartfailure. Most studies have shown a linear relationship between hematocrit or haemoglobin and survival. SOLVD (Studies ofLeft Ventricular Dysfunction) trial reported 2.7% increase in the adjusted risk of death per 1% reduction in hematocrit andPRAISE (Prospective Randomized Amlodipine Survival Evaluation) trial described 3% increase in risk for each 1% decline inhematocrit. In a study on significance of anemia among patients hospitalized with acute decompensated heart failureOPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) documentedthat hemoglobin level independently predicted adverse events, even after adjustment for other covariates. For every 1 g/dldecrease in haemoglobin value, a 12% increase in the probability of death or re-hospitalization within 60 days of treatment wasobserved. In patients of heart failure with preserved systolic function, anemia was found to be independently associated withadverse outcomes (adjusted hazard ratio: 1.6 to 1).

To conclude, anemia in patients with HF is present in approximately one-third of patients with HF, and these patients have aworse prognosis and poor quality of life. The problem may be far more worse in our scenario. Anemia has multifactorial causesand may be due to nutritional deficiencies, renal disease, and volume overload. Although it is recommended thatunderlying disorders should be addressed, there is no evidence for the clinical benefit of increasing Hb levels as such.Intravenous iron treatment in HF appears promising for iron-deficiency and anemia. , The benefit is partly independent of Hblevels, and data on hard clinical endpoints are not yet available. As per to date, ESA therapy has shown neutral results on rates ofdeath and HF rehospitalization and causes more ischemic strokes, which outweigh their marginal effect on symptomimprovement.