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Redefining Iron Deficiency in Patients With Chronic Heart Failure.
Milton Packer1,2, Stefan D Anker3, Javed Butler4,1,5
1Baylor University Medical Center (M.P.), Dallas, TX.
Circulation
|May 11, 2024
Summary
The current ferritin-based definition for iron deficiency in heart failure is unreliable. A more accurate approach uses transferrin saturation (TSAT) <20% to identify patients who benefit from iron therapy.
Area of Science:
- Cardiology
- Hematology
- Internal Medicine
Background:
- Traditional serum ferritin thresholds for identifying iron deficiency are inaccurate in patients with chronic kidney disease and heart failure due to inflammatory states.
- Current guidelines for iron deficiency in heart failure, based on elevated ferritin levels, misidentify patients and do not reliably predict response to iron therapy.
- Medications like neprilysin and sodium-glucose cotransporter 2 inhibitors can further distort serum ferritin levels.
Purpose of the Study:
- To evaluate the effectiveness of the current ferritin-driven definition of iron deficiency in heart failure.
- To propose an alternative, evidence-based definition for iron deficiency in heart failure patients.
- To determine if hypoferremia, indicated by transferrin saturation (TSAT) <20%, is a more reliable marker for iron deficiency and response to iron therapy.
Main Methods:
- Review of existing literature and clinical trial data regarding iron deficiency definitions and treatment outcomes in heart failure.
- Analysis of the diagnostic accuracy of serum ferritin versus TSAT in identifying iron-deficient states confirmed by bone marrow examination.
- Assessment of the impact of iron therapy on functional capacity and cardiovascular outcomes based on different iron deficiency definitions.
Main Results:
- The current ferritin-based definition inaccurately includes non-iron-deficient patients and excludes those who would benefit from iron.
- A TSAT <20% (hypoferremia) reliably identifies patients with iron deficiency, confirmed by bone marrow examination.
- Intravenous iron therapy in hypoferremic patients improves exercise tolerance and reduces cardiovascular death or heart failure hospitalizations by 20%-30%.
Conclusions:
- The ferritin-driven definition of iron deficiency in heart failure should be abandoned.
- A definition based on hypoferremia (TSAT <20%) is more evidence-based and clinically relevant for identifying heart failure patients who benefit from iron therapy.
- Adopting a TSAT <20% threshold can optimize iron supplementation strategies and improve patient outcomes in heart failure.
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