Iron deficiency is a common in pts with HF & is important even in the absence of anaemia – correcting it improves exercise tolerance, HF symptoms, and QoL.
Do you know when to give IV iron in HF?
Do you know the evidence behind it?
A thread on IV iron in heart failure 1/n
Do you know when to give IV iron in HF?
Do you know the evidence behind it?
A thread on IV iron in heart failure 1/n
ESC guidelines recommend IV iron in patients with HFrEF (EF<40%), Hb <15g/dL and iron deficiency, which is defined as:
🔸Ferritin <100mcg/l or
🔸Ferritin 100 to 299mcg/l and transferrin saturation <20%
academic.oup.com/eurheartj/arti…
2/n
🔸Ferritin <100mcg/l or
🔸Ferritin 100 to 299mcg/l and transferrin saturation <20%
academic.oup.com/eurheartj/arti…
2/n
So why does it recommend this?
The key trials proving the evidence for IV iron efficacy in HF are FAIR HF and CONFIRM HF
Both used ferric carboxymaltose (FCM) as their IV iron preparation
3/n
The key trials proving the evidence for IV iron efficacy in HF are FAIR HF and CONFIRM HF
Both used ferric carboxymaltose (FCM) as their IV iron preparation
3/n
FAIR HF (2009):
🔸RCT 459pts, 200mg IV FCM or placebo
🔸Primary EP: self reported pt global assessment & NYHA class
🔸Secondary EP included 6MWT distance
🔸At 24 weeks FCM pts felt better than placebo pts, had better NYHA class & could walk further
nejm.org/doi/full/10.10…
4/n
🔸RCT 459pts, 200mg IV FCM or placebo
🔸Primary EP: self reported pt global assessment & NYHA class
🔸Secondary EP included 6MWT distance
🔸At 24 weeks FCM pts felt better than placebo pts, had better NYHA class & could walk further
nejm.org/doi/full/10.10…
4/n
FAIR HF also showed benefit in giving IV iron to pts with HFrEF and iron deficiency even if they did not have anaemia
nejm.org/doi/full/10.10…
5/n
nejm.org/doi/full/10.10…
5/n
The other key trial is
CONFIRM HF(2015):
🔸RCT 304pts, IV FCM or placebo
🔸Primary EP:change in 6MWT distance
🔸At 52wks FCM significantly⬆️6MWT distance
academic.oup.com/eurheartj/arti…
6/n
CONFIRM HF(2015):
🔸RCT 304pts, IV FCM or placebo
🔸Primary EP:change in 6MWT distance
🔸At 52wks FCM significantly⬆️6MWT distance
academic.oup.com/eurheartj/arti…
6/n
Post hoc analysis of CONFIRM HF also showed combined risk of 1st HF hospitalisation or all-cause death to be significantly ⬇️ in FCM pts
This association was also supported by subsequent metanalysis of 4 RCTs (which included CONFIRM HF & FAIR HF)
onlinelibrary.wiley.com/doi/full/10.10…
7/n
This association was also supported by subsequent metanalysis of 4 RCTs (which included CONFIRM HF & FAIR HF)
onlinelibrary.wiley.com/doi/full/10.10…
7/n
But could you not just give oral iron?
NO!
IRONOUT (2017)
🔸RCT 225pts, oral iron or placebo
🔸No improvement in exercise capacity
Not really a surprise given it also showed iron stores minimally repleted
jamanetwork.com/journals/jama/…
8/n
NO!
IRONOUT (2017)
🔸RCT 225pts, oral iron or placebo
🔸No improvement in exercise capacity
Not really a surprise given it also showed iron stores minimally repleted
jamanetwork.com/journals/jama/…
8/n
So how should we put this evidence and these recommendations on IV iron in HFrEF into practice?
Great practical algorithm and tips in this paper
ncbi.nlm.nih.gov/pmc/articles/P…
9/n
Great practical algorithm and tips in this paper
ncbi.nlm.nih.gov/pmc/articles/P…
9/n
If you want further information on implementing the guidelines I’d recommend Ponikowski’s ESC 365 video:
esc365.escardio.org/Congress/Heart…
Or for information on trials that are ongoing, Stefan Anker’s ESC 365 video:
esc365.escardio.org/Congress/Heart…
Both free until July 2020
10/10
esc365.escardio.org/Congress/Heart…
Or for information on trials that are ongoing, Stefan Anker’s ESC 365 video:
esc365.escardio.org/Congress/Heart…
Both free until July 2020
10/10
