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

2. 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

3. Introduction

4. 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, 1872-1880 2 Okonko OD, Mandal KA, Missouris GC, Poole-Wilson AP. Disordered iron homeostasis in chronic heart failure. JACC, 2011, 58(12), 1241-1251

5. 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

6. 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

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

8. Clinical Audit

9. 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

13. Screening for Iron Deficiency

14. 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.

15. Blood TestsFrequency% Haemoglobin 275100 MCV 275100 RCDW 275100 Ferritin+B12+Folate+Fe+TSAT+TIBC 7627.6 Fe/TSAT/TIBC 114.0 Fe/TSAT/TIBC/B12/Folate 51.8 Fe/TSAT/TIBC/Folate/Ferritin 10.4 Fe/TSAT/TIBC/B12 72.5 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 16058.2

21. Iron store status and re-admission rates

22. AdmissionsNumber of Patients 0155 165 229 310 48 53 62 71 80 91 Re-admission rate in Heart Failure Clinic Patients Total of 228 admissions over 12 months

23. Admissions in patients with Ferritin <100(μg/L) Admissions Sample: N=34 NumberFrequency%Non-cardiac Heart Failure Cardiac (non-Heart Failure) 01544.1000 11029.4820 2411.8331 325.9150 42 521 512.5500 600000 700000 800000

24. Admissions in patients with TSAT <20% and Ferritin 100-299(μg/L) Admissions Sample: N=13 NumberFrequency% Non- cardiac Heart Failure Cardiac (non-Heart Failure) 0430.8000 1215.4110 2538.5352 317.7120 400000 500000 61 150 700000 800000

25. Iron status and NT-proBNP

29. Anaemia - The end of the line

35. 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

36. 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

37. Thank You