Heart failure module 5: special cases in heart failure

Released1 November 2017     Expires: 01 November 2019      Programme:

The future of iron therapy for patients with heart failure

IV iron is currently recommended by the European Society of Cardiology (ESC) guidelines to alleviate symptoms and improve QoL for patients with heart failure and iron deficiency (ferritin <100 μg/L or <300 μg/L and transferrin saturations <20%).21

Table 4. summarises the recent and ongoing trials of iron in outpatients with heart failure.

Heart failure learning module - Table 4. Recent and ongoing trials of iron in outpatients with heart failure
Table 4. Recent and ongoing trials of iron in outpatients with heart failure

However, caution is required as the primary end points of both FAIR-HF and CONFIRM-HF may have been subject to bias. For example, in FAIR-HF, the proportion of patients in the placebo group who reported any improvement in symptoms (either ‘a little improved’, ‘moderately improved’ or ‘much improved’) was 53% compared to 74% in the IV iron group. This improvement was despite significant differences in ferritin (312 μg/L vs. 74 μg/L, P<0.001) and transferrin saturations (29% vs. 19%, P<0.001) between the groups after 24 weeks of treatment. The possibility of a placebo effect cannot be ignored.

Similarly, the absolute improvement in 6MWT distance for patients treated with IV iron in CONFIRM-HF after 24 weeks was 18 metres. The 6MWT is prone to a ‘learning effect’ and such a small change in distance may not be purely due to treatment.

Peak VO2 is the ‘gold-standard’ measure of exercise capacity in patients with heart failure but was unchanged after 16 weeks of treatment with oral iron in the IRONOUT study. It was not studied in FAIR-HF or CONFIRM-HF and is not defined as a primary or secondary outcome for the IRONMAN study. Whether or not IV iron improves exercise capacity in patients with heart failure as measured by peak VO2 will remain unsettled. Meanwhile, IV iron is given for symptomatic relief and the results of the IRONMAN trial are eagerly awaited.

Summary statement

Electrolyte abnormalities, anaemia and iron deficiency are common complications of heart failure and its treatment. All have negative effects on prognosis and are potential therapeutic targets. However, whether or not correction of the abnormality translates into improved outcomes is unproven.

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