Clinical Implications of ESC/HFA Guideline Updates for Iron Deficiency in Heart Failure

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Dr. Butler:
Welcome to the Clinic Minutes program addressing updates to managing iron deficiency in patients with heart failure. Clinic Minutes are designed to focus on timely and important disease state information, forthcoming trial data, and key guideline updates, which is the focus of today’s program. The 2021 updates to the ESC/HFA Guidelines are the first since 2016. Since then, substantial research has been conducted in the care of patients with heart failure, including the impact and management of iron deficiency in these patients.  

This is ReachMD, and I am Dr. Javed Butler.

Dr. Ponikowski:
And I am Dr. Piotr Ponikowski. 

Dr. Butler:
So, Piotr, let’s now discuss some of the key highlights from the 2021 European Society of Cardiology/Heart Failure Association Guidelines for the management of patients with heart failure, with the perspective of iron deficiency. What stood out for you in terms of iron deficiency in heart failure patients and what the guidelines are now saying?

Dr. Ponikowski:
So let me make a very brief summary. In 2021 ESC Heart Failure Association Guidelines, iron deficiency is defined as a serum ferritin level below 100. If between 100-300, then we need to use transferrin saturation, which needs to be below 20%. So important comment, please remember that using only 2 simple blood biomarkers, ferritin and transferrin saturation, we can diagnose iron deficiency. 

Number 2, there is a screening recommendation that all patients with heart failure should be periodically screened for iron deficiency and anemia using these simple blood biomarkers. And please remember that if we have iron deficiency and anemia, we need to screen, also, the underlying causes of anemia.

And number 3, there are very clear treatment recommendations. In the previous 2016 guidelines, we recommended ferric carboxymaltose for patients with HFrEF [heart failure with reduced ejection fraction] to improve quality of life, to improve exercise capacity. Now, we have another trial, CONFIRM-HF trial, in which we treated patients with acute heart failure and iron deficiency with ferric carboxymaltose, and we were able not only to improve quality of life, but most importantly, also reduce heart failure hospitalizations.  

Please consider IV iron with ferric carboxymaltose in HFrEF patients in a stable setting to improve quality of life, to improve exercise capacity. But also consider IV iron with ferric carboxymaltose for patients admitted with decompensated heart failure with iron deficiency to improve the outcomes in the context of reduction in heart failure hospitalization. 

Dr. Butler:
That was just absolutely phenomenal, how much information you gave us in the past 3 or 4 minutes. Many of our colleagues don’t realize that iron deficiency anemia causes oxygen-carrying capacity issues, but that iron is also needed for ATP generation, irrespective of anemia. So whether or not you have anemia, iron deficiency is associated with poor outcomes in heart failure, that oral iron replacement does not work because you don’t get adequate replacement, and that with IV iron replacement in these patients, you can improve outcomes. 

So this is great. Thank you so much. This has been a great, short, fascinating conversation with a lot of information, but before we wrap up, Dr. Ponikowski, any take-home message?

Dr. Ponikowski:
Well, one quick take-home message. Please remember to screen all patients with heart failure for iron deficiency. You can do it very easily, only with 2 simple blood biomarkers: ferritin and transferrin saturation.  And if you have patients with iron deficiency, please remember that we have ferric carboxymaltose, and we are able to correct iron deficiency with ferric carboxymaltose, improve patients’ quality of life, exercise capacity, functional capacity, but also, in those who are admitted with decompensation, we are able to change to positive however we change the outcome and reduce heart failure hospitalization.

Dr. Butler:
Well, thank you so much for those thoughts. Unfortunately, that’s all the time we have today, so I want to thank our audience for listening in to this program, and thank you, Piotr, for your thoughts, your experience, and your insights on this very important matter. Great speaking with you today.

Dr. Ponikowski:
Thank you very much, Javed.

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