Patients with heart failure have elevated levels of circulating inflammatory cytokines and commonly have iron deficiency anemia or anemia of chronic inflammation. Clinical trials in patients with congestive heart failure and iron deficiency have demonstrated that intravenous iron treatment appears to improve subjective and objective outcomes. Most patients in these trials were not anemic or only had mild anemia, and hemoglobin concentration rose only slightly after treatment with iron. Experimental evidence demonstrates that iron is a cofactor for muscle function, which could explain the improvement in clinical outcomes. Many questions remain to be answered to understand the role of iron therapy in patients with congestive heart failure.In a landmark randomized clinical trial, Anker and colleagues 1 found that intravenous iron improved symptoms and physical function in patients with chronic heart failure and anemia. This trial potentially has broad implications for the hematologist, cardiologist, and internist. In this paper, we review the essential background information on anemia and heart failure, including the frequency, causes, and consequences of anemia in heart failure. We summarize the results of this trial in detail and describe the strengths and weaknesses. We then describe potential pathophysiological explanation(s) for the results. We finish with a description of the many uncertainties and questions that this trial raises.
Prevalence and Consequences of Anemia in Heart FailureThe prevalence of anemia varies by age and gender. In an analysis of a representative population of community-dwelling persons from the US (NHANES-III [Third National Health and Nutrition Examination Survey]), the prevalence of anemia in patients 65 years and older was 10.6% and rises to over 20% in 85-year-old individuals. 2 However, in patients with congestive heart failure, the prevalence may be much higher. In a large cohort of patients with congestive heart failure, 37.2% were anemic. 3 In contrast, the prevalence of anemia was 17% in a population-based cohort of patients with new-onset congestive heart failure (mean age 78) from Canada. 4 The patient with heart failure who has anemia has an increased risk of death. In a systematic review of 153,180 patients with heart failure, 48% of anemic patients died within 6 months, compared with 29.5% of nonanemic patients (adjusted hazard ratio 1.46; 95% CI 1.26 -1.69). 3 This experience is similar to the Canadian cohort in which the risk of death was 1.34 times higher in anemic than in nonanemic patients with heart failure. 4 It is unknown if the increased risk of death is from anemia or is just a marker for underlying severity of disease.