Melissa Walton-Shirley

Disclosures

August 31, 2014

On the Cleveland Clinic site "Diseases and Conditions," there is a paragraph describing who is more likely to develop iron deficiency:

  • Women: Blood loss during monthly periods and childbirth can lead to anemia.

  • People over 65, who are more likely to have iron-poor diets.

  • People who are on blood thinners such as aspirin, clopidogrel, warfarin, or heparin.

  • People who have kidney failure (especially if they are on dialysis), because they have trouble making red blood cells.

  • People who have trouble absorbing iron.

All of the above are valid, but after the CONFIRM-HF press presentation looking at NYHA class 2-3 patients with an LVEF of <45% with a brain natriuretic peptide (BNP) of >100, a serum ferritin of <100, or an iron saturation and a hemoglobin of less than 15, at the top of the leader board we should add, "Patients with congestive heart failure." Astoundingly, 50% of all heart-failure patients have iron deficiency.

From now on, instead of just acknowledging an "iron level <35" in my heart-failure patients and then instituting an appropriate anemia workup, I won't stop there. I'll remember the slide shown by Dr Piotr Ponikowski (Wrocław Medical University, Poland) that combined the findings of JL Beard, LL Dunn, GJ Anderson, and CD Vulpe describing the consequences of iron deficiency, and they are dire for our heart-failure patients. They include:

  • Mitochondrial dysfunction.

  • Deranged activity of enzymes.

  • Abnormal transport and structural proteins.

  • Cell death/apoptosis.

  • Abnormal tissue remodeling.

  • Impaired organ efficiency.

  • Impaired exercise capacity.

  • Reduced work efficacy.

  • Impaired cognitive performance and behavior.

  • Increased morbidity and mortality.

So much for, "It's just a little iron deficiency."

My relationship with IV iron changed five years ago as I descended with my mom around 100 steps into the historic Horse Cave in Horse Cave, KY. It had been 70 years since she had visited a favorite childhood play area at the mouth of the cave. She smiled as the vegetation changed from towering oaks and locusts to lush green shade-loving plants. The temperature became noticeably cooler as the voices above vanished into much less humid air. Our guide began his explanation of how the intricate systems of sink holes and caves were connected to one of the seven natural wonders of the world, the Mammoth Cave, just a few miles away. Mom reminisced for a while before we began our climb back up into the real world, but her smile faded quickly as she became alarmingly short of breath after just a few steps. Her pulse revealed moderate tachycardia, but she had no chest pain or nausea. Oddly, she wasn't diaphoretic. It had taken us only 15 minutes to descend, but 90 minutes after starting our climb up, mom was still hanging onto the rails every 10 steps or so, panting. Within two hours of getting back to the top, I found her hemoglobin was only 7.2. Over the course of six hours, following two units of packed cells, her hemoglobin was 10. A few months later her count was back down to 8.

At that point in my 18-year career, I'd never ordered an iron infusion in my life.

Long story short: After trying po iron several times, resulting in her having severe stomach cramps and nausea, I gave up and referred her to a hematologist for an iron infusion. I was petrified she'd have an anaphylactic reaction; after all, that's the standard tag line for any discussion of IV iron during med school. (Heme-onc folks are probably chuckling right about now.) It was four years before she required another one. She's now had a total of three. So much for my iron-infusion phobia.

Iron might not be gold, but it's been worth its weight to my family.

Fast-forward to how quickly I requested a serum iron infusion for my dad, who has class 4 heart failure. Despite a normal lower scope and now minor upper pathology, he still couldn't keep his hemoglobin level above 9.0, and his serum iron level was 27. He was winded and pale. He had no appetite, and his personality was as dull as dishwater. Three weeks post–iron infusion and with two brand-new Mitra clips, we had the best of both the cardiology and hematology worlds—a tolerable hemoglobin and a new lease on life. (Thank you, Dr Andy Morse, of St Thomas Hospital in Nashville, TN!)

According to the CONFIRM-HF data, after a treatment plan of IV ferric carboxymaltose infusions, our heart-failure patients can expect an improved six-minute-walk test at week 24, improvements in self-reported patient global assessment scores, and a better NYHA functional class. There was even an impact on hospitalization for worsening heart failure (p=0.009) that should get third-party payers' attention! We still lack mortality data, but who knows? Maybe someday . . .

The Cleveland Clinic site continues its very excellent information sharing on the topic of who might require IV iron:

  • Patients who are bleeding in the gastrointestinal tract and need to replace iron quickly.

  • Patients who have inflammatory bowel disease and cannot take oral iron because it upsets their GI tract.

  • Patients who are on kidney dialysis, who often lose blood during dialysis. In addition, these patients are usually taking an erythropoiesis-stimulating agent (ESA) and may need extra iron.

  • Cancer patients who have anemia and are taking an ESA.

And of course, the most common indication of all after today's CONFIRM-HF study presentation may become:

  • The patient with congestive heart failure, the future's most likely "Who's Who of IV Iron Therapy."

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