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Approach to anemia in adults with heart failure

Wilson S Colucci, MD
Section Editors
Stephen S Gottlieb, MD
Stanley L Schrier, MD
Deputy Editors
Susan B Yeon, MD, JD, FACC
Jennifer S Tirnauer, MD


Anemia is a frequent finding in adults with heart failure (HF), with prevalence varying depending upon the population studied [1]. 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 [2]. A similar rate of anemia (17 percent) was noted in a population-based cohort of 12,065 patients with newly diagnosed HF [3]. 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) [4].

Evaluation, prognosis, and treatment of anemia in patients with HF will be reviewed here [5]. 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".)


Clinical presentation

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 'Signs and symptoms of anemia'.)

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 approximately 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 approximately 8 g/dL. The hemodynamic effects of chronic anemia were evaluated in a right heart catheterization study [6]. 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 [7]. 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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Literature review current through: Nov 2017. | This topic last updated: Jun 23, 2017.
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