Left ventricular ejection fraction recovery in patients with heart failure treated with intravenous iron: a pilot study

Abstract

AimsIn patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency, treatment with intravenous iron has shown a clinical improvement regardless of anaemic status. Cardiac magnetic resonance (CMR) T2* sequence has shown a potential utility for evaluating myocardial iron deficiency. We aimed to evaluate whether T2* sequence significantly changes after ferric carboximaltose (FCM) administration, and if such changes correlate with changes in left ventricle ejection fraction (LVEF).Methods and resultsIn this pilot study, we included eight patients with chronic symptomatic (New York Heart Association II–III) HFrEF and iron deficiency. A CMR, including T2* analysis, was performed before and at a median of 43 days (interquartile range = 35–48) after intravenous FCM administration. Pearson or Spearman correlation coefficient (r) was used for bivariate contrast as appropriate. A partial correlation analysis was performed between ΔLVEF and ΔT2* while controlling for anaemia status at baseline. Anaemia was present in half of patients. After FCM administration, T2* decreased from a median of 39.5 (35.9–48) to 32 ms (32–34.5), P = 0.012. Simultaneously, a borderline increase in median of LVEF [40% (36–44.5) to 48.5% (38.5–53), P = 0.091] was registered. In a bivariate correlational analysis, ΔT2* was highly correlated with ΔLVEF (r = −0.747, P = 0.033). After controlling for anaemia at baseline, the association between ΔT2* and ΔLVEF persisted [r(partial): −0.865, R 2(partial): 0.748, P = 0.012]. A median regression analysis backed‐up these findings.ConclusionsIn a small sample of patients with HFrEF and iron deficiency, myocardial iron repletion assessed by CMR was associated to left ventricular remodelling. Further studies are warranted.

Co‐morbidities in heart failure beginning to sprout—and no end in sight?

“…This result also persisted after adjusting for anaemia at baseline, and the authors concluded that myocardial iron repletion was associated with positive effects on left ventricular remodelling. 8 Very recent data have shown that patients with HF who are iron deficient are unlikely to benefit from oral iron administration, because data from the IRONOUT HF study have shown that oral iron is poorly absorbed in the duodenum and its prescription not associated with an increase in the patients' peak VO 2 value. 9 However, further studies are well under way to strengthen our views and positive evaluations of treating iron deficiency in patients with HF, for example, the PRACTICE-ASIA-HF study, 10 the FAIR-HF 2 trial, or the FAIR-HFpEF trial.…”

“…Using cardiac magnetic resonance T2* sequence analysis performed before and after a median of 43 days after administration of intravenous ferric carboxymaltose, a pilot study recently found that a borderline increase in median left ventricular ejection fraction was registered [40% (interquartile range 36–45%) to 49% (39–53%), P =0.09]. This result also persisted after adjusting for anaemia at baseline, and the authors concluded that myocardial iron repletion was associated with positive effects on left ventricular remodelling . Very recent data have shown that patients with HF who are iron deficient are unlikely to benefit from oral iron administration, because data from the IRONOUT HF study have shown that oral iron is poorly absorbed in the duodenum and its prescription not associated with an increase in the patients' peak VO 2 value .…”

Changes in myocardial iron content following administration of intravenous iron (Myocardial‐IRON): Study design

“…Later, these authors also reported that T2* CMR was related to an increased risk of adverse outcomes . In a pilot study of 8 patients with HFrEF, our group found that treatment with FCM was associated with significant 30‐day changes in T2* CMR, and they were associated with marked improvement in LVEF . Some new CMR techniques, such as T1 mapping, have emerged as potential alternatives for myocardial iron quantification .…”

“…We used repeated‐measures ANOVA using the Lawley‐Hotelling test to evaluate the effect of treatment. Based on studies from our group, we predict a mean difference of 9.25 ±8.69 in T2* at 30 days after treatment, and a correlation of 0.38 between T2* measurements at baseline and 1 month later. The correlation of T2* at baseline and 7 days would be 0.40, because we expect the correlation to decrease with time.…”

“…In a recent pilot study, our group reported an association between IV FCM administration and myocardial iron repletion assessed by T2* CMR. Interestingly, myocardial iron changes were strongly related to an improvement in left ventricular ejection fraction (LVEF) …”