FPIN's Clinical Inquiries
Iron Deficiency in Heart Failure
Am Fam Physician. 2017 Apr 15;95(8):514-516.
Is intravenous iron more effective than oral iron for the treatment of iron deficiency in patients with heart failure?
Treatment of iron deficiency in patients with heart failure using intravenous iron improves function, fatigue, and quality of life, and decreases risk of hospitalizations compared with placebo. (Strength of Recommendation [SOR]: B, based on a randomized controlled trial [RCT].) A small RCT suggests that treatment with intravenous and oral iron is equivalent in patients with heart failure. (SOR: C, based on a small RCT with disease-oriented outcomes.) Oral iron can be used to increase hemoglobin and iron levels in patients with heart failure. (SOR: C, based on a retrospective cohort study.)
A multicenter RCT of 304 ambulatory patients with symptomatic heart failure (ejection fraction less than 45%; New York Heart Association [NYHA] class II or III) examined the effects of treatment with intravenous iron compared with placebo.1 All patients had iron deficiency, defined as a ferritin level less than 100 ng per mL (225 pmol per L); if the ferritin level was 100 to 300 ng per mL (225 to 674 pmol per L), a transferrin saturation (Tsat) less than 20% and hemoglobin level less than 15 g per dL (150 g per L) were required. The average hemoglobin level was 12.4 g per dL (124 g per L) in each group. Patients in the treatment group received a 500- to 2,000-mg (based on body weight) bolus of ferric carboxymaltose at baseline and week 6, then 500 mg at weeks 12, 24, and 36. Placebo consisted of a normal saline bolus. Overall, 53 patients did not complete the trial (29 in the treatment group; 24 in the placebo group); 26 died (12 in the treatment group; 14 in the placebo group). Compared with the placebo group, the treatment group had greater improvement in the six-minute walk test from baseline at 24 weeks (+18 m vs. −16 m; mean difference = 33 m; 95% confidence interval [CI], 13 to 53). There was also significant
1. Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al.; CONFIRM-HF Investigators. Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency. Eur Heart J. 2015;36(11):657–668.
2. Beck-da-Silva L, Piardi D, Soder S, et al. IRON-HF study: a randomized trial to assess the effects of iron in heart failure patients with anemia. Int J Cardiol. 2013;168(4):3439–3442.
3. Niehaus ED, Malhotra R, Cocca-Spofford D, Semigran M, Lewis GD. Repletion of iron stores with the use of oral iron supplementation in patients with systolic heart failure. J Card Fail. 2015;21(8):694–697.
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