In this collection of articles we have attempted to crystallise the issues surrounding what we now recognise as a highly prevalent, and clinically relevant issue, iron deficiency in heart failure. As Eltayeb and colleagues have described,1 iron deficiency is highly prevalent in patients with heart failure and is associated with adverse outcomes, in terms of both quality and quantity of life. We have also seen that the body of evidence to date supports intravenous (IV) supplementation of iron in heart failure, in iron-deficient patients, irrespective of the presence or absence of anaemia.
However, identification of patients with iron deficiency is challenging and awareness of the importance of iron deficiency varies widely among clinicians caring for patients with heart failure; consequently, implementation of guideline-recommended IV iron supplementation is inconsistent, resulting in a large proportion of potentially eligible patients missing out on this therapy. Kwok and colleagues2 have described their early experience in integrating IV iron supplementation into their heart failure service, a model for others looking to follow-suit.
As described in each of the articles, the data supporting IV iron supplementation comes from the results of several randomised-controlled trials (RCTs) in which a number of IV iron preparations have been used, summarised by Foley in this edition.3 To date, the results from RCTs have shown IV iron supplementation in patients with heart failure to improve quality of life, with no clear survival benefit. Indeed, while we have been preparing the current supplement, the AFFIRM-AHF (ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial) has reported IV ferrous carboxymaltose to be associated with a reduction in the risk of heart failure hospitalisations, in patients stabilised after being admitted for an episode of acute heart failure.4
Over thirty or more years, since the first evidence for a survival benefit for angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction, the heart failure clinician has been guided primarily by interventions designed to improve survival. However, reduced quality of life is associated with adverse prognosis in heart failure, and for the patient with heart failure, improvements in quality, may be more valued than extended, quantity, of life, as described by Hooper et al. in this supplement.5
In this context, the results of AFFIRM-AHF, and earlier studies of IV iron supplementation in patients with heart failure, showing improved quality of life and reduced hospitalisation risk, should be seen as interventions of real value to the patient. With regard to possible impact on survival in patients with heart failure, we await the outcomes of ongoing studies.1 In the meantime, we should actively seek iron deficiency in our patients with heart failure, and treat according to national and international guidelines when we find it.
Conflicts of interest
IS has received remuneration for participation in advisory boards and educational events from Boehringer Ingelheim, Novartis and Vifor; his research institution has received financial support from Boehringer Ingelheim, Merck, Novartis and Vifor.
Professor of Cardiovascular Medicine and Honorary Consultant Physician
Department of Cardiovascular Sciences, University of Leicester and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP
Articles in this supplement
1. Eltayeb M, Ashok V, Squire I. Prevalence, causes, diagnosis and guidelines for treatment. Br J Cardiol 2021;28(suppl 1):S3–S6. https://doi.org/10.5837/bjc.2021.s01
2. Kwok CS, McDermott S, Bennett S, Duckett S. United Kingdom treatment of iron deficiency in heart failure: are we missing opportunities? Br J Cardiol 2021;28(suppl 1):S7–S9. https://doi.org/10.5837/bjc.2021.s02
3. Foley P. Intravenous iron therapies and their differences. Br J Cardiol 2021;28(suppl 1):S10–S14. https://doi.org/10.5837/bjc.2021.s03
4. Ponikowski, P, Kirwan B-A, Anker SD et al. Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: a multicentre, double-blind, randomised, controlled trial. Lancet 2020;[online first]. https://doi.org/10.1016/S0140-6736(20)32339-4
5. Hooper J, Hartshorne-Evans N, Cunnington C, Ahmed FZ. Iron deficiency – the invisible comorbidity in HF: prioritising QoL as a target for treatment. Br J Cardiol 2021;28(suppl 1):S15–S18. https://doi.org/10.5837/bjc.2021.s04