Skill Checkup: A 69‐Year‐Old Woman With Acutely Worsening Heart Failure

Marco Guazzi, MD, PhD


March 21, 2022

In patients with HF and anemia, agents such as darbepoetin alfa should not be used to improve morbidity and mortality, based on new evidence showing lack of therapeutic benefit.

According to the ESC and AHA/ACC/HRS, IV iron supplementation should be considered in symptomatic patients recently hospitalized with HFrEF and iron deficiency.

Oral iron therapy tends to be poorly tolerated, with gastrointestinal side effects occurring in more than half of patients. Iron injections may be given intramuscularly, usually into the buttocks. While iron injections may be faster than iron infusions, they can be painful.

Treatment of iron deficiency should be considered regardless of whether the patient has anemia. Iron deficiency in patients with HF, when severe, can worsen HF and have a negative impact on symptoms, quality of life, exercise capacity, and clinical outcomes. A 2021 study of patients with stable HFrEF found that iron deficiency with and without anemia was an independent predictor of death or heart transplant.

To date, no clinical trial has proven the efficacy of oral iron in patients with HFrEF. Further, severe side effects can limit use of oral iron.


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