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Treatment of anemia in patients with heart disease: a systematic review
Devan Kansagara1, Edward Dyer1, Honora Englander1
1From Portland Veterans Affairs Medical Center and Oregon Health & Science University, Portland, Oregon.
Insights
Treating anemia in heart disease patients with blood transfusions does not consistently improve mortality. Intravenous iron may help heart failure symptoms, while erythropoiesis-stimulating agents show no benefit and potential harm.
Area of Science:
- Cardiology
- Hematology
Background:
- Anemia treatment benefits in heart disease patients remain uncertain.
- U.S. Department of Veterans Affairs funded this research.
Purpose of the Study:
- To evaluate the benefits and harms of anemia treatments in adults with heart disease.
- Assessed blood transfusions, iron, and erythropoiesis-stimulating agents.
Main Methods:
- Searched MEDLINE, EMBASE, Cochrane databases, and clinical trial registries.
- Included English-language trials and observational studies on anemia in heart failure or coronary heart disease.
- Extracted data on study design, population, hemoglobin, and outcomes; assessed trial quality.
Main Results:
- Liberal blood transfusion protocols did not improve short-term mortality compared to less aggressive ones (RR, 0.94; 95% CI, 0.61 to 1.42).
- Intravenous iron improved short-term exercise tolerance and quality of life in heart failure patients.
- Erythropoiesis-stimulating agents showed no consistent benefits and may increase risks like venous thromboembolism.
Conclusions:
- Higher transfusion thresholds do not consistently improve mortality; large trials are needed.
- Intravenous iron may alleviate symptoms in heart failure patients with iron deficiency, warranting further study.
- Erythropoiesis-stimulating agents appear ineffective for mild to moderate anemia in heart disease and carry risks.
Background:
The benefits of anemia treatment in patients with heart disease are uncertain.
Purpose:
To evaluate the benefits and harms of treatments for anemia in adults with heart disease.
Data Sources:
MEDLINE, EMBASE, and Cochrane databases; clinical trial registries; reference lists; and technical advisors.
Study Selection:
English-language trials of blood transfusions, iron, or erythropoiesis-stimulating agents in adults with anemia and congestive heart failure or coronary heart disease and observational studies of transfusion.
Data Extraction:
Data on study design, population characteristics, hemoglobin levels, and health outcomes were extracted. Trials were assessed for quality.
Data Synthesis:
Low-strength evidence from 6 trials and 26 observational studies suggests that liberal transfusion protocols do not improve short-term mortality rates compared with less aggressive protocols (combined relative risk among trials, 0.94 [95% CI, 0.61 to 1.42]; I2 = 16.8%), although decreased mortality rates occurred in a small trial of patients with the acute coronary syndrome (1.8% vs. 13.0%; P = 0.032). Moderate-strength evidence from 3 trials of intravenous iron found improved short-term exercise tolerance and quality of life in patients with heart failure. Moderate- to high-strength evidence from 17 trials of erythropoiesis-stimulating agent therapy found they offered no consistent benefits, but their use may be associated with harms, such as venous thromboembolism.
Limitations:
Few trials have examined transfusions in patients with heart disease, and observational studies are potentially confounded by indication. Data supporting iron use come mainly from 1 large trial, and long-term effects are unknown.
Conclusion:
Higher transfusion thresholds do not consistently improve mortality rates, but large trials are needed. Intravenous iron may help to alleviate symptoms in patients with heart failure and iron deficiency and also warrants further study. Erythropoiesis-stimulating agents do not seem to benefit patients with mild to moderate anemia and heart disease and may be associated with serious harms.
Primary Funding Source:
U.S. Department of Veterans Affairs.
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