Prognostic value of three iron deficiency definitions in patients with advanced heart failure

Charikleia Papadopoulou, Johannes Reinhold, Nicolai Grüner-Hegge, Anna Kydd, Sai Bhagra, K. Jayan Parameshwar, Clive Lewis, Luis Martinez, Stephen J. Pettit

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Aims: There is uncertainty about the definition of iron deficiency (ID) and the association between ID and prognosis in patients with advanced heart failure. We evaluated three definitions of ID in patients referred for heart transplantation.

Methods and results: Consecutive patients assessed for heart transplantation at a single UK centre between January 2010 and May 2022 were included. ID was defined as (1) serum ferritin concentration of <100 ng/ml, or 100–299 ng/ml with transferrin saturation <20% (guideline definition), (2) serum iron concentration ≤13 μmol/L, or (3) transferrin saturation <20%. The primary outcome measure was a composite of all-cause mortality, urgent heart transplantation or need for mechanical circulatory support. Overall, 801 patients were included, and the prevalence of ID was 39–55% depending on the definition used. ID, defined by either serum iron or transferrin saturation, was an independent predictor of the primary outcome measure (hazard ratio [HR] 1.532, 95% confidence interval [CI] 1.264–1.944, and HR 1.595, 95% CI 1.323–2.033, respectively), but the same association was not seen with the guideline definition of ID (HR 1.085, 95% CI 0.8827–1.333). These findings were robust in multivariable Cox regression analysis. ID, by all definitions, was associated with lower 6-min walk distance, lower peak oxygen consumption, higher intra-cardiac filling pressures and lower cardiac output.

Conclusions: Iron deficiency, when defined by serum iron concentration or transferrin saturation, was associated with increased frequency of adverse clinical outcomes in patients with advanced heart failure. The same association was not seen with guideline definition of ID.
Original languageEnglish
Pages (from-to)2067-2074
Number of pages8
JournalEuropean Journal of Heart Failure
Issue number11
Early online date27 Aug 2023
Publication statusPublished - Nov 2023


  • Advanced heart failure
  • Heart transplant
  • Iron deficiency

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