Iron deficiency (ID) has been increasingly recognized
as an important co-morbidity associated with heart failure (HF). Irrespective
of anemic status, ID significantly impairs exercise tolerance and is an
independent predictor of poor outcomes in patients with HF. Routine screening
of ID is necessary in HF patients, and intravenous iron repletion has been
recommended by the American Heart Association HF treatment guidelines to
improve patient symptoms. Patients treated with intravenous iron show
improvement in quality of life, N-terminal pro-B-type natriuretic peptide levels,
6-minute walk test and New York Heart Association functional class. The effect
of iron therapy on HF re-hospitalization and mortality rate remains unclear. Large
dose oral iron treatment is found to be ineffective in improving HF patient
symptoms. This review summarizes the current knowledge on prevalence, clinical relevance,
and molecular mechanism of ID in patients with chronic HF and available
evidence for parenteral iron therapy.



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Heart failure

Iron deficiency



Iron therapy




Heart failure (HF) is a global epidemic with approximately 6
million adults being affected in United States alone (at a cost of about $20
billion per year). Despite the availability of new treatment strategies, the
incidence, hospitalizations and mortality associated with HF remains a big
health burden.1 In addition to increasing age,
the factors that contribute to poor prognosis in HF are the co-morbidities
associated with the disease. Iron deficiency (ID) has been increasingly
recognized as the important co-morbidity that contributes to increased
incidence, re-hospitalization and poor survival in patients with HF.2 Anemia is the ultimate
consequence of ID, but both these diseases represent distinct clinical
scenarios. Identification of ID in chronic diseases such as HF is of importance
as iron repletion has shown to improve patient symptoms irrespective of anemic



Iron is an essential micronutrient in all types of
cells, more importantly, in energy demanding cells such as cardiomyocytes.3
Iron acts as a co-factor for several enzymes involved in oxidative
phosphorylation and plays a key role in oxygen transport through
erythropoiesis. The etiology of ID in HF is not clearly understood – it could
possibly be due to multiple factors including poor iron absorption due to
edematous gastrointestinal tract, low bioavailability of iron, and chronic
inflammatory state present in HF.4  At the molecular level, one possible
mechanism of ID is related to hepcidin, an iron regulatory hormone, whose
synthesis is stimulated when iron stores or the cytokine, interlukin-6 (IL-6) levels
are elevated. In chronic inflammatory conditions, hepcidin levels are increased
owing to increased IL-6 and/or fluctuating iron levels. Elevated hepcidin results
in removal of ferroportin from the duodenal surfaces, a protein that increases iron
efflux into the bloodstream.5
However, in HF, a reverse mechanism exists: initially hepcidin level increases,
however, as HF progresses, hepcidin is downregulated maintaining ferroportin
levels thereby increasing iron efflux.6
The reason for this is still not clearly understood. Importantly, lower
hepcidin was associated with poor outcomes in HF patients. Another mechanism of
ID in HF is thought to be due to liver congestion7
that leads to increased hemosiderin laden macrophages. This results in
inappropriate stimulation of hepcidin which then increases iron stores
systematically. Importantly, cardiomyocytes have a high-energy demand and hence
are susceptible to ID. In patients referred to cardiac transplantation,
myocardial iron stores were lower compared to non-HF heart.8
HF patients also showed reduced myocardial oxygen respiration and reduction in
mitochondrial respiratory enzymes.9
In experimental models, the left ventricular cardiomyocytes with IRP (iron-regulatory
protein that maintains intracellular iron availability) depletion showed
reduced mitochondrial complex I activity and the mice were unable to increase ventricular
systolic function in response to dobutamine stress.10
Despite different possibilities for the mechanism underlying ID in HF disease,
it is quite not clear what is the exact underlying pathophysiology.



The prevalence of ID has been widely studied in
patients with chronic HF with reduced ejection fraction (HFrEF) and ranges
between 36 to 69% among different races.18
There were no differences between the percentages of anemic and non-anemic
subjects highlighting the fact that ID is prevalent independent of anemic
status. In patients presenting with acute decompensated HF (ADHF), the
prevalence of ID was much higher than chronic HF.15
A gender difference in the prevalence of ID in ADHF was shown by a study in
about 66% of men and 75% of women had ID. Independent correlates of ID in HF
include increased age, higher New York Heart Association (NYHA) functional
class, female gender, elevated N-terminal pro-B-type natriuretic peptide
(NT-proBNP), and high sensitivity C-reactive protein.2
The prevalence of ID in HFpEF is still unknown.



Heart failure with reduced ejection
fraction (HFrEF)

In patients with HFrEF, ID greatly decreases the
quality of life irrespective of the presence of anemia. Patients with
concurrent ID and HFrEF had lower peak oxygen consumption (peak VO2)
and increased ventilator response to exercise (VE-VCO2 slope) compared
to those without concurrent ID, both reflecting poor exercise capacity.11
Quality of life was significantly affected in HF patients irrespective of
diagnostic criteria: European Quality of Life-5D, Kansas City Cardiomyopathy or
the Minnesota Living with Heart Failure questionnaires.12
Short-term 6-month follow-up showed higher odds of death in patients with HF
and ID compared to patients with HF and no ID (8.7 vs 3.6% respectively, P<0.001).13 Similarly, in long-term follow-up of about 2.5 years, HF patients with ID had higher hazards of dying than without ID.13 The association to mortality was independent of anemic status. Also, HF patients with non-anemic ID had twice the risk of death than anemic patients on iron therapy.14 In a study that used serum-soluble transferrin receptor (sTfR) and hepcidin levels to define ID in ADHF patients, there was a 5% in-hospital mortality and a strikingly higher hazard of 6.59 (95% confidence interval CI, 2.97-14.62, P<0.001) for death within 12 months of discharge.15 Heart failure with preserved ejection fraction (HFpEF) The definitive role of ID in patients with HFpEF is poorly understood. In a small study16 involving 26 HFpEF subjects, neither cardiac function (both systolic and diastolic) nor reduced exercise capacity was dependent on ID. Another recent study17 involving 40 HFpEF patients, ID was a predictor of decreased exercise tolerance independent of ventricular diastolic function, renal function, hemoglobin and NT-proBNP. There was a significant correlation of both transferrin and ferritin levels with peak VO2 in these subjects. The difference in results between the two studies might be because the latter study involved subjects with more advanced disease (higher NT-proBNP, higher NYHA class, previous history of ADHF and relatively lower peak VO2). More studies are required to identify the significance of ID in HFpEF patients.   DIAGNOSIS OF IRON DEFICIENCY IN HEART FAILURE Diagnosis of ID in HF is complicated by the fact that the symptom of fatigue and exercise intolerance associated with ID highly overlap with the symptoms of HF. ID is characterized as absolute and functional depending on the serum ferritin concentration (marker of iron stores) and transferrin (iron transport protein) saturation level. In general population, a serum ferritin cut-off value of 30µg/L is used for the diagnosis of ID. Ferritin is an acute phase reactant, hence, in chronic inflammatory state such as HF, a higher cut-off serum level is used for diagnosis of ID.  Absolute ID is defined as reduced iron stores despite normal iron homeostasis diagnosed as serum ferritin level of <100µg/L. (Table 1) Functional ID is defined as an inability to meet bodies iron demand despite having normal iron stores and measured as combination of serum ferritin (100-300µg/L) and transferrin saturation (<20%) levels.3 The gold standard assay to diagnose ID is the bone marrow Prussian blue stain to identify absence of iron granules. It is an invasive procedure and is not routinely performed.   IRON THERAPY IN HEART FAILURE PARENTERAL IRON Having proven the significant correlation of ID in HF patients, several clinical trials of iron therapy have been conducted. The current treatment guidelines for HF with ID is displayed in Table 2 and is based on two large trails: FAIR-HF20 and CONFIRM-HF.21 Both trials tested intravenous ferric carboxymaltose (FCM) in ambulatory chronic systolic HF patients with ID in NYHA classes II and III. In FAIR-HF trial including 459 HFrEF patients (EF<45%), self-reported Patient Global Assessment was used which improved in 50% of patients in the FCM group (compared to 28% of the placebo group), along with improvement in NYHA functional class, 6-minute walk test and quality-of-life assessments. The positive changes were present in patients with ID both with and without anemia. CONFIRM-HF included 304 HFrEF patients and after 6 months of iron treatment, the primary end-point of 6-minute walk test significantly improved in FCM group compared to placebo group. All secondary end-points including NYHA class, quality-of-life, fatigue score and time for first re-hospitalization improved significantly in the FCM group. Both trials did not show any adverse side effects with intravenous iron therapy. Although individual clinical trials were not tested for major clinical events, a meta-analysis22 including FAIR-HF, CONFIRM-HF, EFFICACY-HF and FER-CARS-01 assessed the effect of iron therapy in cardiovascular hospitalization, and mortality in patients with HF and ID. Treatment with intravenous FCM had lower rates of combined HF hospitalizations and cardiovascular mortality (rate ratio 0.53, 95% CI 0.33-0.86, P=0.011). These findings from the meta-analysis has to be validated in randomized clinical trials. ORAL  IRON IRONOUT HF23 is a recent large-scale randomized clinical trial that tested the role of high dose oral iron therapy in 225 patients with HFrEF and ID. The primary end-point was change in peak VO2 at 16 weeks and secondary end points included change in NT-proBNP, 6-minute walk test and quality-of-life. In contrast to results from trials that used intravenous iron, IRONOUT HF trial failed to show improvements in both primary and secondary end-points.   CONCLUSION ID is more common in patients with HF and is often overlooked by physicians because of overlapping clinical symptoms. ID is associated with reduced exercise tolerance, poor quality-of-life and increased re-hospitalizations and mortality in HF. Routine screening for ID in patients with HF and treatment with iron is recommended by the HF treatment guidelines. Parenteral iron improves patient symptoms, quality-of-life and exercise capacity as early as four weeks after iron therapy. Despite improvements in HF symptoms, major clinical outcomes were not tested in clinical trials. Further, all trials included only patients with HFrEF and the role of ID in patients with HFpEF is not clearly understood. More randomized clinical trials are currently underway that might answer the open questions on the effect of iron repletion on long term symptom improvement, effects on re-hospitalization and survival in patients with concurrent ID and HF