Iron deficiency screening at Heart Failure Clinic Abela Mark, Karl Sapiano Cardiology Conference 2014

Outline Introduction Clinical Audit Screening for Iron Deficiency Iron store status and re-admission rates Iron store status and NT-proBNP Anaemia – the end of the line Limitations Conclusion

Introduction

Iron deficiency in Heart Failure Highly prevalent – present in up to 39% of non- anaemic and anaemic Heart Failure patients 1 Iron deficiency (ID) independently from Haemoglobin (Hb) is a strong prognostic marker for future mortality – x2 risk of death in anaemic vs non-anaemic ID patients 2 – x4 risk of death when compared to iron replete patients 2 1 Jankowska E.A, Rozentryt P, Witkowska A, et al. Iron deficiency: an ominous sign in patients with systolic chronic heart failure. Eur Heart J, 2010, 30, Okonko OD, Mandal KA, Missouris GC, Poole-Wilson AP. Disordered iron homeostasis in chronic heart failure. JACC, 2011, 58(12),

ID independent of anaemia is also predictive of – Higher New York Heart Association (NYHA) functional class – Decreased aerobic performance – Poorer exercise tolerance – Lower quality of life – Increased risk of heart transplantation

Types of Iron Deficiency Relative Deficiency – Normal total body iron stores – Defective iron mobilisation from reticuloendothelial system to the bone marrow – Thought to occur secondary to up-regulation of inflammatory cytokines (TNF-a, IL-1) Absolute Deficiency – Consequence of relative deficiency – Worsening heart failure decreases iron absorption High Hepcidin Increased bowel oedema – Other reasons: Anti-platelets, Malnutrition, Chronic Kidney Disease

Anaemia The end of the line Mixture of – Ineffective erythropoiesis (poor Iron mobilisation) – Haemodilution – Renal impairment with decreased erythropoietin – Other factors (example Drugs, Malnutrition)

Clinical Audit

Aim The aim of this audit was to compare local iron deficiency screening at heart failure clinic and if it coincides with ESC recommendations. Methodology Retrospective Database (excluding discharged patients) was obtained from the Heart Failure Clinic Blood results obtained from Isoft Re-admission data from the electronic case summary

Screening for Iron Deficiency

Peraira-Moral J. Roberto, Núñez-Gil Ivan J. Anaemia in heart failure: intravenous iron therapy. E-journal of the ESC Council for Cardiology Practice 2012; 10:1619.

Blood TestsFrequency% Haemoglobin MCV RCDW Ferritin+B12+Folate+Fe+TSAT+TIBC Fe/TSAT/TIBC Fe/TSAT/TIBC/B12/Folate 51.8 Fe/TSAT/TIBC/Folate/Ferritin 10.4 Fe/TSAT/TIBC/B Ferritin/B12/Folate 20.7 Fe/TSAT/TIBC/B12/Ferritin 10.4 Fe/TSAT/TIBC/Ferritin 31.1 No B12/Folate/Ferritin/TIBC/Fe/TSAT

Iron store status and re-admission rates

AdmissionsNumber of Patients Re-admission rate in Heart Failure Clinic Patients Total of 228 admissions over 12 months

Admissions in patients with Ferritin <100(μg/L) Admissions Sample: N=34 NumberFrequency%Non-cardiac Heart Failure Cardiac (non-Heart Failure)

Admissions in patients with TSAT <20% and Ferritin (μg/L) Admissions Sample: N=13 NumberFrequency% Non- cardiac Heart Failure Cardiac (non-Heart Failure)

Iron status and NT-proBNP

Anaemia - The end of the line

Limitations The majority of patients not having a full haematenemic screen might be explained by the fact that the iron profile in Isoft is separate from the rest (B12/Folate/Ferritin) All available NT-proBNP s were included, irrespective of clinical scenario Not using Ejection Fraction as a marker of cardiac function Failing to identify those patients who are on iron supplementation already

Conclusions Screening for iron deficiency in heart failure patients at heart failure clinic is very low Iron deficient patients seem to have a higher propensity for re-admission to hospital Routine screening for iron deficiency should be implemented on all patients attending heart failure clinic

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