Iron deficiency in heart failure
Posted by dkwinter

The prevalence of iron deficiency in heart failure is 40-50%

  • It presents with AND WITHOUT anemia
  • In heart failure, iron deficiency (independent of baseline Hgb/Hct) is associated with higher rates of CV morbidity and mortality, higher rate of hospitalization, impaired functional status, and associated with worse QOL


Diagnosis of Iron Deficiency

  • in patients with HF, iron deficiency is defined as either:
    • a serum ferritin concentration of <100 ng/mL 
    • OR
    • a serum ferritin concentration of 100-299 ng/mL with transferrin saturation (TSAT) <20%
    • Source: McDonagh TA, et al. Eur Heart J. 2021;42(36): 3599-3726.



  • In studies, patients with HFrEF and twice daily oral iron polysaccharide failed to improve exercise capacity, inflammatory markers and QOL compared to placebo
  • Use IV iron instead!
    • ​2021 ESC/HFA guidelines: IV iron supplementation with ferric carboxymaltose should be considered in symptomatic patients with LVEF <45% and iron deficiency, defined as serum ferritin <100 ng/mL or serum ferritin 100-299 ng/mL with TSAT <20%, to alleviate HF symptoms and improve exercise capacity and QOL
    • 2022 AHA/ACC/HFSA guidelines: In patients with HFrEF and iron deficiency with or without anemia, intravenous iron replacement is reasonable to improve functional status and QOL
  • ​Give:
    • ​If admitted for CHF exac: give 1st dose IV iron prior to discharge
    • Then 2nd dose 6 weeks after the first dose irrespective of iron levels



  • Avoid measuring ferritin and transferrin saturation too early after IV iron administration
  • Recheck no sooner than 12 weeks after the second infusion