FPIN's Clinical Inquiries

Iron Deficiency in Heart Failure


Am Fam Physician. 2017 Apr 15;95(8):514-516.

Clinical Question

Is intravenous iron more effective than oral iron for the treatment of iron deficiency in patients with heart failure?

Evidence-Based Answer

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.)

Evidence Summary

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

Address correspondence to Corey Lyon, DO, at corey.lyon@ucdenver.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.

Copyright Family Physicians Inquiries Network. Used with permission.



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Apr 15, 2018

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