IV Iron for Heart Failure?

Iron deficiency (ID) is common in heart failure (HF), affecting around 40-50% of patients with chronic stable HF and up to 80% of patients with acute HF. In patients with HF, ID results in worse functional status and worse clinical outcomes: 

Source: Klip et al. Am Heart J. 2013

As a result, 2021 guidelines recommend the use of IV iron to improve functional status in patients with ID and LVEF <45% or to reduce HF hospitalizations in patients recently admitted for acute HF with LVEF <50%. Following this guideline recommendation, a 2023 meta-analysis published in JACC found that, for patients with HF and ID, IV iron reduces the risk of cardiovascular death or hospitalization for HF. 

The systematic review included 14 randomized controlled trials assessing the effect of IV iron in patients with ID and HF between 2000 and 2023 with aggregate-level data on 6,624 patients, 3,407 of whom were randomized to IV iron and 3,217 to placebo.

Patients who received IV iron had a significantly lower risk for cardiovascular death (odds ratio [OR], 0.867 [95% CI, 0.755-0.955]; P=0.04), a first HF admission (OR, 0.855 [95% CI, 0.744-0.983]; P=0.03), and the two outcomes combined (OR, 0.838 [95% CI, 0.751-0.936]; P=0.002), as well as a decrease in total HF admissions (rate ratio, 0.739 [95% CI, 0.661-0.827]; P<0.0001). There was significant heterogeneity among trials on the outcome HF admission, which appeared to relate to patients’ baseline transferrin saturation; lower transferrin levels were associated with a large effect.

“This meta-analysis provides important novel information about the cumulative benefit of IV iron on hard clinical endpoints in patients with HF, allowing practicing physicians and other entities (drug approval agencies, guideline committees, and governments) to get an appropriate treatment effect estimation of the benefit of IV iron based on the totality of all data generated in HF (trials predominantly with LVEF <45%),” said the study authors.

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