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Anemia and iron deficiency are two important comorbidities that contribute to poorer clinical statuses in patients with heart failure. The prevalence of anemia in patients with heart failure is around approximately 30% of stable patients, and 50% of hospitalized patients, compared to 10% of the general population (Anand & Gupta, 2018). Furthermore, nearly 50% of patients with heart failure have low levels of iron, with or without anemia (Anand & Gupta, 2018). Anemic patients with heart failure are also more likely to be female, have diabetes, chronic kidney disease, worse functional status, lower exercise capacity, worse health-related quality of life, greater edema, lower blood pressure, greater need for diuretics, and a higher prevalence of neurohormonal and proinflammatory cytokine activation (Anand & Gupta, 2018).This risk status aligns with the patient in this case study, as she is a 50 year old female patient with congestive heart failure and renal impairment.

Iron deficiency anemia and anemia of chronic disease differ from each other in many ways. Serum ferritin is the one test that can be used to distinguish between anemia of chronic disease and iron deficiency anemia (Rocha et al., 2018). In the general population, iron deficiency is defined as plasma ferritin <15 μg/l. However, there is a higher cutoff for plasma ferritin in chronic inflammatory conditions, such as ferritin <100 μg/l in congestive heart failure (Rocha et al., 2018). Apart from oxygen transportation and storage, iron has an important role in the activation of key enzymes to perform normal activities (Rocha et al., 2018). Packed red blood cells can be used as a short-term therapy, however they are associated with many risks and provide only temporary benefit (Anand & Gupta, 2018). A study showed that untreated anemia had roughly a 10% increase of mortality in patients with congestive heart failure, while the adjusted risk of mortality was approximately 70% higher in anemic patients with heart failure who received transfusions (Anand & Gupta). That being said, I would suggest that the provider hold off on transfusions at this time, as the potential risks outweigh the benefits. Clinical practices vary among different settings and patient presentations, however a suggestion from Anand & Gupta (2018) states that red blood cell transfusions should be limited to hemoglobin less than 7.5 g/dL.Identification and correction of deficiencies such as iron and other vitamins or hypothyroidism should be the first step in addressing iron deficiency anemia in heart failure patients (Anand & Gupta, 2018).

Iron deficiency anemia can be treated in both the inpatient and outpatient setting. In the hospital or an infusion clinic, patients can receive a variety of different intravenous infusions of iron, depending on their exact need and clinical status. In the outpatient setting, patients can increase their iron levels by taking oral iron supplements and adjusting their diet accordingly. This patient may benefit from an intravenous infusion of iron, depending on her current ferritin level and severity of her symptoms. Furthermore, patients should be started on an oral iron supplement along with other vitamin supplementation, and educated on eating a nutrient diet rich in iron (Rocha et al., 2018). If erythropoietic agents are used for patients with anemia of chronic disease, the provider should take special consideration into assessment and prevention of thromboembolic events, as these agents assist in producing more red blood cells, and therefore could result in hypercoagulability and a higher risk of thrombus formation (Anand & Gupta, 2018). The provider should weigh the risks and benefits with the patient, however, as resolution of anemia and assistance in oxygen delivery may very well outweigh the risks of the agents (Anand & Gupta, 2018). Iron studies should be obtained from the patient and the provider should follow up within two weeks with the patient on the status of these labs.Meanwhile, the patient should be started on oral iron supplementation, started on a nutrient-dense diet high in iron, and seek emergency care for concerning symptoms such as increased shortness of breath, elevated heart rate, decrease in blood pressure, extreme fatigue, or signs of bleeding.

References

Anand, I. S., & Gupta, P. (2018). Anemia and iron deficiency in heart failure: current concepts and emerging therapies. Circulation, 138(1), 80-98.

Rocha, B. M., Cunha, G. J., & Menezes Falcao, L. F. (2018). The burden of iron deficiency in heart failure: therapeutic approach. Journal of the American College of Cardiology, 71(7), 782-793.