Approach to anemia in adults with heart failure
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
- Section Editors
- Stephen S Gottlieb, MD
Stephen S Gottlieb, MD
- Section Editor — Heart Failure
- Professor of Medicine
- University of Maryland School of Medicine
- Stanley L Schrier, MD
Stanley L Schrier, MD
- Editor-in-Chief — Hematology
- Section Editor — Myeloproliferative Disorders; Red Cell Disorders
- Professor of Medicine
- Stanford University School of Medicine
Anemia is a frequent finding in adults with heart failure (HF), with prevalence varying depending upon the population studied . As an example, in an analysis from the SOLVD trial, 22 percent of patients had a hematocrit ≤39 percent and 4 percent had values below 35 percent . A similar rate of anemia (17 percent) was noted in a population-based cohort of 12,065 patients with newly diagnosed HF . The incidence of anemia appears to increase with worsening functional class (from 9 percent for New York Heart Association class I to 79 percent for class IV in one report) (table 1) .
Evaluation, prognosis and treatment of anemia in patients with HF will be reviewed here . General approaches to anemia in adults and older adults are presented separately. (See "Approach to the adult patient with anemia" and "Anemia in the older adult".)
General considerations — Symptoms related to anemia can result from decreased oxygen delivery to tissues, and, in patients with acute, severe bleeding, the added insult of hypovolemia. Symptoms of anemia such as dyspnea and fatigue may be difficult to distinguish from symptoms of heart failure (HF). (See "Approach to the adult patient with anemia", section on 'Symptoms'.)
Symptoms from reduced oxygen delivery due to anemia generally occur only with severe anemia, but may occur at less severely reduced hemoglobin levels in patients with HF. Since the extraction of oxygen by tissues can increase from 25 to about 60 percent with anemia or hypoperfusion, in individuals with normal hemodynamics, normal oxygen delivery is preserved by extraction alone down to a hemoglobin concentration of about 8 g/dL. The hemodynamic effects of chronic anemia were evaluated in a right heart catheterization study . Normal cardiac hemodynamics were maintained in patients with hemoglobin values as low as 7 g/dL; the cardiac output increased at lower hemoglobin concentrations.
In healthy individuals, acute, isovolemic reduction in the hemoglobin concentration induces a variety of compensatory changes including increases in heart rate, stroke volume, and cardiac index along with enhanced tissue oxygen extraction . The net effect is that oxygen delivery can be maintained at rest at a hemoglobin concentration below 5 g/dL (equivalent to a hematocrit of 15 percent) if intravascular volume is maintained.
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- Clinical presentation
- - General considerations
- - Development of high-output HF
- Initial evaluation
- Potential causes of anemia related to heart failure
- - Increased circulating cytokines and the anemia of inflammation
- - Dilutional anemia
- - Iron deficiency
- - Use of angiotensin converting enzyme inhibitors
- - Renal dysfunction and other contributing factors
- Endogenous erythropoietin
- Changes in hemoglobin
- Low transferrin saturation
- Erythropoiesis stimulating agents
- - Intravenous iron
- - Oral iron
- Society guidelines
- SUMMARY AND RECOMMENDATIONS