Iron deficiency in heart failure is not only common but represents a serious risk of poorer outcomes.

It may sound unlikely, but heart failure is increasingly being considered as a chronic inflammatory condition.

Moreover, it is not widely recognised that iron deficiency can often play a crucial negative role in exacerbations of cardiac failure and correction of that deficiency can be a game changer in resolving exacerbation.

“We know this because there are elevated levels of cytokines, interleukin 6 and interleukin 1 and tumour necrosis factor alpha,” says Associate Professor Ingrid Hopper, a heart failure physician and clinical pharmacologist with Melbourne’s Alfred Hospital and Monash University.

Professor Hopper adds that iron deficiency drives the inflammatory state and is the “commonest comorbidity we see in heart failure patients”. It is more frequent than renal failure, sleep apnea, chronic obstructive pulmonary disease, and diabetes.

Although the cause of the deficiency is “incompletely understood”, it is clear that it is “multifactorial,” Professor Hopper says.

“The first [factor] is reduced iron intake, and this comes from poor appetite and poor iron intake related to the heart failure. There’s also poor gastrointestinal absorption.”

As well, some concurrent medications, including omeprazole, interfere with iron uptake. Aspirin and other blood thinners can also be problematic.

“A really important take-home message here is that the GP has a central role in optimising comorbidities and heart failure. And in particular the commonest one, iron deficiency,” says Professor Hopper.

Step One for GPs is to assess patients for iron deficiency. But who should be tested? Professor Hopper recommends following the 2021 European Society of Cardiology heart failure guidelines, available online.

The core ESC recommendation is that every patient with heart failure should be periodically assessed for iron deficiency and also anaemia. Professor Hopper adds:

“If you’re undertaking routine blood tests to assess comorbidities in patients with heart failure, then add on iron studies, and also assess prior to hospital discharge or after an admission with acute heart failure.”

According to Professor Hopper, patients with heart failure have a high risk of hospitalisation despite being treated with multiple heart failure medications such as dapagliflozin, empagliflozin, vericiguat and omecamtiv mecarbil.

That is why she emphasises the 2020 AFFIRM-AHF trial of intravenous ferric carboxymaltose. “What this trial showed was that there was a trend towards reductions in the primary outcome of heart failure hospitalisations and cardiovascular deaths.”

To assist GPs unravel the complexities of managing heart failure patients Professor Hopper will present a talk at the 25 October webcast. Register here for free.