Title: Ironing Out the Risk: Bleeding Outcomes with Intravenous Iron in Anticoagulated Patients with Heart Failure and Reduced Ejection Fraction (HFrEF)
Authors: Haoxin Liu, PharmD; Kristen Goodrich, PharmD, BCCP; Tania Ahuja, PharmD, FACC, BCCP, BCPS, CACP; Morris Jrada, MD
Objective: Participants will be able to describe the impact of Intravenous (IV) iron on bleeding events in patients with heart failure with reduced ejection fraction (HFrEF) and concomitant anticoagulation usage.
Self Assessment Question: IV iron administration in HFrEF patient with AC use is associated with
- Increased bleeding events
- Higher mortality
- Increased hospital length of stay
- Decreased bleeding events
- None of the above.
Background: HFrEF patients often have comorbidities requiring anticoagulation. While IV iron improves functional status, its impact on mitigating bleeding risk remains unknown. We hypothesize that IV iron reduces bleeding risk in anticoagulated HFrEF patients.
Methods: This was a multi-site retrospective cohort study of hospitalized adults (≥18 years) with HFrEF on anticoagulation and iron deficiency anemia (hemoglobin (Hgb) <13.5 g/dL; ferritin <100 mg/dL or 100–299 mg/dL with transferrin saturation (TSAT) <20%). Patients receiving IV iron were compared to those who did not. Exclusion criteria were receipt of <500 mg IV iron, infective endocarditis or sepsis, active bleeding, iron allergy, pregnancy, dialysis, use of erythropoiesis-stimulating agents or blood transfusions, and loss to follow-up. The primary outcome was a composite of international society of thrombosis and haemostasis (ISTH) major, clinically relevant non-major, and minor bleeding within 6 months. Secondary outcomes included 30- and 90-day readmission, and ferritin, TSAT, and hemoglobin at 1, 3, and 6 months. Electronic health records were reviewed for patient characteristics. Research Electronic Data Capture was used for data collection and SPSS software was used for data analysis.
Results: A total of 223 patients were included (IV iron n=111; no iron n=112). The cohort was 73 [62-82] years, 65% male, 52% white. Median EF was 25 [20-35]% and baseline Hgb was 11.2 [9.7-12.8] g/dL. Apixaban was the most used anticoagulant (n =165,74%), primarily for atrial fibrillation (n =180, 83%). At 6 months, ferritin and TSAT increased by 52.9 ng/dL and 10.5% with IV iron vs. -0.3 ng/dL and 7.5% without. The primary outcome of bleeding occurred in 34.2% in the IV iron group vs. 54.5% in the no iron group (p=0.002). Major bleeding occurred in 1 (0.9%) patient in the IV iron group vs. 6 (5.6%) patients in the no IV iron group. No differences were observed in 30- or 90-day readmissions or mortality rates, or in adverse events between groups.
Conclusion: We found a decreased risk of bleeding events in patients with HFrEF and anticoagulation with the receipt of IV iron compared to those that did not receive IV iron, without an increase in adverse outcomes over a 6-month follow-up period. Further studies are warranted to determine whether these findings are generalizable to HFpEF or general patients without heart failure, and to assess the durability of this effect over longer follow-up durations.
