Treatment of anemia in heart failure patients

The prevalence of anemia in patients with advanced heart failure is significant and is present in more than 50 % of this patient population. The exact pathophysiologic mechanism of anemia in heart failure is still not known - it could be a direct consequence of the heart failure or it could be caused by some other disease in this population of polymorbid patients. There are several mechanisms through which heart failure could contribute to the development of anemia. The most plausible among them are hemodilution, renal insufficiency, increased proinflammatory cytokines, malnutrition, decreased erhythropoiesis in bone marrow and heart-failure medications (predominantly ACEI). Anemia is an independant risk factor for recurrent hospitalizations and increased mortality. Several small-scale studies demonstrated that the treatment of anemia in heart-failure patients decreased heart failure signs and symptoms in this patient population. Anemia in heart-failure patients can be treated with: blood transfusion, iron replacement therapy, or with synthetic analogues of erhythropoietin. Before the treatment with synthetic analogues of erhythropoietin. is started, other causes of anemia (gastrointestinal bleeding, malnutrition, renal insufficiency, hematological diseases and malignancies) have to be excluded. Iron blood levels, ferritin, transferrin and TIBC also have to be determined. If body iron stores are depleted, iron has to be replaced intravenously, the target levels of ferritin being around 250 ng/mL. If anemia persists after 2 weeks of iron replacement therapy, treatment with erhythropoietin is indicated. Currently 4 erhythropoietin analogues are available: epoetin alpha (Eprex (R)), epoetin beta (NeoRecormon (R)), darbepoetin alpha (Aranesp (R)) and metoksipolietilenglikol epoetin beta, (Mircere (R)). Anemia needs to be treated in all NYHA III and IV heart failure patients and hemoglobin levels below 110 g/dL. The treatment of anemia with erhythropoietin and the adjustment of its doses should be done by heart-failure specialist. Patient follow up and regular CBC screening can be done by general practitioners. The Hb target values are between 120 and 130 g/dL.