Iron deficiency in Heart failure
Step 1: HFrEF/HFmrEF
HF admission or Clinic visit with symptom
Step 2: Check iron status
Iron deficiency criteria: Serum ferritin < 100 or TSAT < 20% with serum ferritin levels between 100-299 ng/ml.
Please note that clinical trials enrolled patients with hemoglobin levels not exceeding 15 g/dl.
If a male's hemoglobin (Hb) level is below 13 g/dL or a female's Hb level is below 12 g/dL, the following steps should be taken to exclude other potential causes of anemia based on clinical status:
- Check for occult bleeding (e.g., gastrointestinal issues or malignancies).
- Evaluate for renal insufficiency, which can affect erythropoietin production.
- Assess for other deficiencies, such as vitamin B12 or folic acid.
- Consider other hemoglobinopathies, including thalassemia or sickle cell anemia.
Step 3: Dose of IV iron based on body weight and Hemoglobin
Ferric carboxymaltose (FCM) dose based on Hb and body weight (upper limit 1000 mg/week) + 0.9% NaCl (should not be diluted to concentrations less than 2 mg iron/ml) i.v. drip at least 6-15 minutes.
Hemoglobin
Body weight
g/dL | mmol/L | Less than 35 kg | 35 - 70 kg | Greater or equal to 70 kg |
|---|---|---|---|---|
<10 | < 6.2 | 500 | 1500 | 2000 |
10 to < 14 | 6.2 to < 8.7 | 500 | 1000 | 1500 |
≥ 14 to < 15 | ≥ 8.7 to < 9.3 | 500 | 500 | 500 |
Step 4: Recheck, Monitoring, Redose
Recheck: every 1 - 4 months after first dose
Monitor: 1 - 2 times per year
Redose: if TSAT < 20%
References
1) von Haehling S, Ebner N, Evertz R, Ponikowski P, Anker SD. Iron Deficiency in Heart Failure: An Overview. JACC: Heart Failure [Internet]. 2019 Jan 1;7(1):36–46. Available from: https://www.sciencedirect.com/science/article/pii/S2213177918306279
2) Graham FJ, Guha K, Cleland JG, et al Treating iron deficiency in patients with heart failure: what, why, when, how, where and who Heart 2024;110:1201-1207.
3) Mountfort K, Comin-Colet J, Lam CS, Ponikowski P, Anker S. Iron Deficiency in Heart Failure - the Relevance for the Patient: Proceedings of a Satellite Symposium Held at the ESC Congress 2014, 1 September 2014, Barcelona, Spain. Card Fail Rev. 2015 Apr;1(Suppl 1):1-8. doi: 10.15420/cfr.2015.1.1.S1. PMID: 40271389; PMCID: PMC12012853.
4) McDonagh T, Damy T, Doehner W, Lam C, Sindone A, Meer P, et al. Screening, diagnosis and treatment of iron deficiency in chronic heart failure: putting the 2016 European Society of Cardiology heart failure guidelines into clinical practice. European Journal of Heart Failure. 2018 Oct 1;20.
5) Vifor Pharma Canada Inc. FERINJECT® (ferric carboxymaltose) Product Monograph [Internet]. Montreal (QC): Vifor Pharma Canada Inc.; 2023 [cited 2025 Jun 3]. Available from: https://pdf.hres.ca/dpd_pm/00074900.PDF
6) Pfizer Canada ULC. (2025). MONOFERRIC® (Ferric Derisomaltose for Injection) Product Monograph [Product monograph]. Retrieved June 3, 2025, from https://webfiles.pfizer.com/file/645d5e9f-8730-4715-9c74-fdb0e759cb96