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IV iron in heart failure

The final lecture of the day, given by Professor Philip Kalra (University of Manchester), helped to elaborate on one of the hot topics in heart failure – the ongoing IRONMAN study.

This has stemmed from work done approximately 15 years ago demonstrating that the use of intravenous (IV) iron (and subcutaneous erythropoietin) resulted in both an improvement in cardiac function (left ventricular ejection fraction)1 and a decrease in hospitalisation associated with heart failure symptoms.2 Although IV iron fell out of fashion, this area is being studied again via the large multi-centre trial. IRONMAN is looking at both long-term cardiovascular mortality and frequency of hospital admissions for heart failure in those with sufficiently low serum iron and transferrin saturations.

The adverse effects from IV iron have been widely debated and patients should have the correct education prior to being recruited to the study. At present, short-term adverse effects include reactions to the infusion – either hypersensitivity or labile reactions. The IV iron in use is iron isomaltoside (Monofer™) and whilst, in the past, ‘test doses’ to IV iron were needed, they are currently not indicated due to the relative safety of this particular preparation. In the longer term, there has been discussion about IV iron increasing the risk of infection if used in chronic disease. Recent studies have now suggested that this is not correlated but it is important to remember that IV iron should not be given during active infection.

Furthermore, the intended benefits from IRONMAN may be enhanced further following the increasing use of sacubitril/valsartan. This was approved for use in April 2016 by NICE (TA388),3 following the overwhelming evidence that it showed improved outcomes in severe symptomatic heart failure when compared with enalapril (PARADIGM-HF trial4). The crossover between the two treatments is unlikely to have a significant bearing on the outcomes of IRONMAN but certainly this is an exciting time for therapeutics associated with heart failure.

References

1. Silverberg DS, Wexler D, Sheps D et al. The effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study. J Am Coll Cardiol 2001;37:1775–80.

2. Silverberg DS, Wexler D, Blum M et al. The use of subcutaneous erythropoietin and intravenous iron for the treatment of the anemia of severe, resistant congestive heart failure improves cardiac and renal function and functional cardiac class, and markedly reduces hospitalizations. J Am Coll Cardiol 2000;35:1737–44.

3. McMurray JJV, Packer M, Desai AS et al. Angiotensin–neprilysin inhibition versus Enalapril in heart failure (PARADIGM-HF). N Engl J Med 2014;371: 993–1004. http://dx.doi.org/10.1056/NEJMoa1409077

4. National Institute for Health and Care Excellence. Technology Appraisal Guidance (TA388):Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction. NICE: April 2016.  https://www.nice.org.uk/search?q=TA39

Published on: February 21, 2017

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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