IRON DEFICIENCY IN PATIENTS WITH HEART FAILURE: A MISSING LINK

Authors

  • Tariq Ashraf
  • Muhammad Ishaq Karachi Institute of Heart Diseases, Karachi, Pakistan
  • Asif Nadeem Armed Forces Institute of Cardiology, Rawalpindi, Pakistan

Abstract

Iron is present not only in hemoglobin but also actively involved in enzymatic action in cellular respiration, maintaining structure and functions of metabolically active cells. Iron deficiency may lead to impairment of metabolically active cells of different organs especially the heart.1

About 50% of patients with heart failure are iron deficient regardless of sex, race, anemia and left ventricular ejection fraction (LVEF). It can be due to decrease in total body iron or reduction in storage pool.2

There is controversy on the definition of iron deficiency (ID). First by World Heart Organization as serum ferritin <15ng/ml and ID as <30ng/ml and second by International guidelines on heart failure as Serum Ferritin <100ng/ml and serum ferritin 100-299ng/ml and transferrin saturation (TSAT) <20%.3

In a study conducted by Masini et al. in evaluating different ID definitions in prognosis of patients by using four definitions of ID. The study provided practicing physicians to evaluate ID with heart failure. Most reliable parameter would be TSAT<20% or serum iron ≤ 13 µmol/l.4,5

The great question arises that ID as marker of severity heart failure or causal factor for progression of heart failure. As heart failure progresses there is an increase in levels of inflammatory cytokines. This causes decrease absorption of iron into blood and retention in liver and reticuloendothelial cells. There is decrease in erythropoietin production and erythroblast proliferation.6

The study conducted by Masini et al showed highest rates of TSAT<20% and Serum Iron levels ≤ 13µmol/l with anemia and high levels of C-reactive protein (CRP) which indicates ID as marker of heart failure severity. Moreover reduced mitochondrial oxygen consumption favors glucose over fatty acid utilization. This may cause myocardial dysfunction and adverse remodeling.5

Survey of anemia in South Asian population showed 46% with congestive heart failure with mortality of 7% and rehospitalization of 81% in Pakistani population, 24% in Northwest Iran, and 58.8% in India.7-9

ID with different studies have found to be common in patients with heart failure irrespective of definitions accepted. TSAT<20% and serum iron ≤ 13 µmol/l were associated with high mortality. It’s important that we do a study in our population to find out prevalence of ID in different phenotypes of heart failure. This will help in selecting patients for Intravenous Iron Therapy (Ferric Carboxy maltose).

References

  1. Von Haehling S, Jankowska EA, Van Veldhuisen DJ, Ponikowski P, Anker SD. Iron deficiency and cardiovascular disease. Nat Rev Cardiol. 2015;12(11):659-69.
  2. Costanzo MR, Januzzi Jr JL. 21st Century CE: The New Iron Age?. J Am Coll Cardiol. 2022;79(4):352-4.
  3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2021;42(36):3599-726.
  4. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey Jr DE, Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776-803.
  5. Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016;387(10021):907-16.
  6. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey Jr DE, Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70(6):776-803.
  7. Iftekhar MF, Sami A, Khan I, Sher A. Frequency of anemia and clinical outcome in patients with congestive heart failure. Pak Heart J. 2018;51(1):77-81.
  8. Alizadehasl A, Golmohammadi Z, Panjavi L, Mahmoodmoradi S, Azarfarin R. The incideme of anacume in adult patients with cardiovascular disease in mouth wet Iron. J Pak Med Assoc. 2011;61:1091-5.
  9. Negi PC, Dev M, Paul P, Singh DP, Rathoure S, Kumar R, et al. Prevalence, risk factors, and significance of iron deficiency and anemia in nonischemic heart failure patients with reduced ejection fraction from a Himachal Pradesh heart failure registry. Indian Heart J. 2018;70:S182-8.

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Published

2022-12-31