Ileana L. Piña, MD, MPH


February 22, 2022

This transcript has been edited for clarity.

Hi, everyone. This is Ileana Piña. I'm filming today from Jefferson University at the Kimmel School of Medicine, where I will be in a part-time job as quality chief for the cardiovascular line.

We've chosen today to talk to you about a topic that we see a lot in heart failure patients, and that's iron deficiency. There's been a lot written by the Europeans about iron deficiency, telling us, don't only look at the hemoglobin to make this diagnosis of iron deficiency, but take a look at the ferritin and take a look at the transferrin. And if the ferritin is below 100 ng/mL or if it's a little bit higher, then look at the saturation of transferrin (TSAT). That's how you're going to make the diagnosis.

Now, why is that important? Because anemia and low iron really do affect patients. There's more fatigue, there's less ability to exercise, and there’s just this loss of well-being. We have now turned to using IV iron quite commonly because we know that the oral iron that we're so accustomed to giving — iron sulfate — doesn't really get absorbed very well. I've had patients on iron sulfate for years, and nothing much has changed.

IV iron seems to be delivering what the patients need with some excellent results. There have been at least three large trials — a couple of them still ongoing — that have been looking at iron supplementation with IV iron. Some of them show that quality of life and activity get better, but not mortality. Mortality really hasn't improved. This very interesting paper in the Journal of the American College of Cardiology comes from a group in Hull, UK, which is the former home of John Cleland, another heart failure expert. They looked at charts across time at this one institution where they had measured the iron ferritin and the transferrin. Let's remember: The ferritin is an acute protein reactor, so in moments of high inflammation, ferritin does tend to go up.

They're telling us to take a look at this standard way of predicting how the patients will do, and the standard way to define iron deficiency, and think about it a little bit differently. They found that women tended to have more iron deficiency than men, which we've seen before. And it didn't matter what the ejection fraction (EF) was, so this was independent of whether it was an HFpEF patient with higher EF or a low-EF patient.

They found that if they only looked at iron levels, and they looked at transferrin and the saturation, then that was more important than the serum ferritin because serum ferritin seemed to be associated with inflammation. However, the patients who may have had the lower iron and the lower TSAT, and had a low ferritin, actually had a lower mortality. So, lack of that inflammatory response seems to be connected to a better outcome.

Well, along with this paper comes a very well-written editorial — knowing the author very well, as I do. She is Maria Rosa Costanzo, who has had a long interest in iron and anemia, both in heart failure and in transplant patients. I think her points are very well taken — that we've just taken this as the right definition. We need to maybe go back and look at all these other trials that we've done, maybe the ones that appear to be negative, and redefine iron deficiency. We still need some work because iron is a very important substance, not just in hemoglobin. A lot of other enzyme functions, which she details very nicely in her editorial, have iron as one of its cations.

So, maybe we need to go back and take a look at those trials and continue to think about this. What I want to leave you, the clinicians, with today is: Don't just take the hemoglobin. Go after that iron and measure it. And measure the TSAT, and — if your patients truly are in deficiency — consider the IV iron.

We don't know what the American Heart Association and the American College of Cardiology guidelines will tell us, but certainly I have used the IV iron myself and have found remarkable changes in how patients feel. So, before you just say, "This is the heart failure getting worse," investigate the iron. I think we're going to find some very interesting relationships.

With that, I leave you. I hope this helps you in your practice. This is Ileana Piña, signing off. Have a great day.

Ileana L. Piña, MD, MPH, is a heart failure and cardiac transplantation expert. She serves as an advisor/consultant to the FDA's Center for Devices and Radiological Health and has been a volunteer for the American Heart Association since 1982. Originally from Havana, Cuba, she is passionate about enrolling more women and minorities in clinical trials. She also enjoys cooking and taking spin classes.

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