Management of Iron Deficiency in Heart Failure: Practical Considerations and Implementation of Evidence-Based Iron Supplementation (JACC Heart Failure December 2024)-Article: Management of Iron Deficiency in Heart Failure: Practical Considerations and Implementation of Evidence-Based Iron Supplementation

Article: Management of Iron Deficiency in Heart Failure: Practical Considerations and Implementation of Evidence-Based Iron Supplementation

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The review discusses the management and treatment of iron deficiency (ID) in heart failure (HF) patients, highlighting its prevalence, implications, and the current barriers to implementing intravenous (IV) iron supplementation. Approximately 50% of HF patients are estimated to have ID, with prevalence as high as 80% in those with symptomatic HF. Guidelines recommend IV iron for HF patients with reduced or mildly reduced ejection fractions due to its quality-of-life improvements and reduction in HF hospitalizations. However, implementation faces challenges due to clinician knowledge gaps and limited resources.<br /><br />Clinical evidence from trials like AFFIRM-AHF and IRONMAN indicates that IV iron, particularly ferric carboxymaltose, improves patient outcomes such as exercise capacity and hospitalization rates. Despite this, diagnosis and treatment of ID with IV iron remain underutilized. Specific inclusion criteria for IV iron treatment are ferritin levels below 100 ng/mL or 100-300 ng/mL with transferrin saturation below 20%.<br /><br />The authors suggest practical implementation strategies that include institutional protocols, educational initiatives, and standardized documentation to improve the uptake of evidence-based treatments. They recommend creating an "iron map" to improve patient access to necessary infusion centers.<br /><br />Additionally, the review addresses potential clinical controversies surrounding the risks of IV iron supplementation, including hypophosphatemia risks and infections. Specific groups, such as pregnant women, patients with active infections, and those with recent strokes, should use IV iron with caution.<br /><br />Future research is encouraged to clarify the optimal use, responders, and maintenance strategies for IV iron supplementation in HF patients. The authors hope such strategies will enhance the therapeutic management of HF patients with ID, improving outcomes and regional health equity in treatment access.

Keywords

iron deficiency

heart failure

intravenous iron

ferric carboxymaltose

AFFIRM-AHF

IRONMAN trial

ejection fraction

hypophosphatemia

transferrin saturation

treatment access