2011, Volume 18, Supplement 2: Anaemia in chronic heart failure: what constitutes optimal investigation and treatment?

Whilst the prognosis for patients with chronic heart failure (CHF) has improved over the last two decades, many patients suffer with severe limitation from symptoms and adverse prognosis. Heart failure is the most common cause of admission to hospital in people over 65 years in the developed world, and accounts for around 2% of the UK healthcare budget. Low haemoglobin is a common finding in patients with CHF. Although this observation was made several decades ago, the potential of an important pathophysiological link only recently became widely appreciated. While the cause of anaemia is not always easily identified, it is associated with the severity of heart failure, impairment of renal function, and other co-morbidities. Multifactorial aetiology of such anaemia is likely, and although few patients have a deficiency of vitamin B12 or folate this should always be excluded. Anaemia is an independent predictor of mortality and of acute hospital admission, and is also associated with exercise limitation....

Chronic heart failure (CHF) is one of the major health challenges in the 21st century. As might be expected from a chronic condition, which increases in prevalence with age, CHF is often accompanied by one or more co-morbid conditions. Many of these add to the patient’s symptom burden and to the complexity of managing the CHF. In addition, a few common co-morbid conditions are related intimately to the CHF disease process itself and may be, at least in part, the consequence of the heart failure syndrome. They may also contribute to its progression. Renal impairment and anaemia are the best-recognised conditions in this context and are frequently found together in the presence of CHF. There are multiple mechanisms by which anaemia may arise in the CHF population. Iron deficiency anaemia is relatively common in CHF and, given the potential for its correction, this type of anaemia has been the focus of a great deal of clinical and research interest. The aim of this article is to consider the prevalence of anaemia – iron deficiency or otherwise – in CHF, and its impact on morbidity and mortality....

We have already seen how anaemia is common in patients with chronic heart failure (CHF) and how it impacts on symptoms and prognosis. Increasingly, anaemia is being thought of as a possible target for treatment, and so an understanding of the possible causes of anaemia in CHF is vital for developing appropriate therapy (figure 1). Unfortunately, apart from unusual patients with specific pathologies underlying their anaemia, the origin of anaemia is multifactorial in most patients (table 1)....

The treatment of anaemia in chronic heart failure (CHF) has many parallels with the treatment of anaemia in chronic kidney disease. Two major therapies are available, namely erythropoietin replacement therapy and intravenous iron supplementation, and both have been widely used in nephrology for the last 20 years. Indeed, both have become standards of care for treating anaemia in chronic dialysis patients, the majority of whom have inappropriately low circulating erythropoietin levels and negative iron balance. Erythropoiesis-stimulating agents (ESAs) are required to boost the production of red cells in the bone marrow, whilst intravenous iron will correct any iron deficiency and also lower the dosage requirements of ESA therapy....

Anaemia is extremely common in patients with chronic kidney disease (CKD). Causes are multifactorial but erythropoietin deficiency, iron deficiency or diminished availability and chronic inflammation are pre-eminent. For over two decades it has been possible to correct the anaemia of patients with CKD with combinations of iron therapy and erythropoiesis-stimulating agents (ESA) with relative ease. Results of recent studies, however, have indicated that haemoglobin targets need to be revised and that more consideration should be directed to individualised treatment dependent upon the patient’s haemoglobin response, ESA dosage and level of co-morbidity....