Iron Deficiency: An Underappreciated Cause Of Readmissions In Heart Failure With Reduced Ejection Fraction
Author: Phoo Pwint Nandar, MD, Additional Authors**
Background
Iron deficiency is a common comorbidity in patients with heart failure with reduced ejection fraction (HFrEF) and is associated with reduced quality of life and exercise capacity. A retrospective analysis from the EVEREST trial showed that anemia is prevalent in patients hospitalized for worsening HFrEF and is associated with a worse outcome. Data from AFFIRM-AHF show that treatment with IV iron after a hospitalization for acute HFrEF reduced the risk of readmission in patients with HFrEF and iron deficiency with or without manifested anemia. Although our admission order sets for acute HFrEF include ordering iron studies for a hemoglobin less than 11 g/dL, it was unclear whether these order sets were being appropriately utilized.
Objective
We hypothesized that iron deficiency is an under-recognized and undertreated possible contributor to HFrEF readmissions.
Methods
To identify the factors contributing to 30 days readmissions for HFrEF, the Clinical Performance Improvement (CPI) committee reviewed potential clinical contributors with the help of tools and methodologies from the Summa Health Quality Department. We reviewed the primary diagnosis for a 30-day readmission in 141 patients with a prior index admission for acute HFrEF, between Jan 2019 and April 2020. Of those 141 patients, 47% (67/141) were readmitted with a primary diagnosis of HFrEF. The cardiology team was involved in 85% of the index admissions and patients were medically optimized and scheduled for follow up within a week.
Results
The HF team and CPI committee observed that 93% (131/141) patients had Hb <15 g/dl and 44% (62/141) had Hb <11 g/dl. Of those 131 patients, 97 patients (74%) did not have complete iron study (Ferritin and TSAT level). The other 34 patients (26%) had iron studies done during the index admission or within the prior 3 months. Among these 34 patients, 27 patients met criteria (ferritin <100ng/ml or ferritin 100-300ng/ml with TSAT <20%/<25% for CKD/ESRD) for IV iron therapy. Remarkably, only 26% (7/27) of them received IV iron therapy.
Conclusions
Our findings show that iron deficiency with and without anemia is an under-recognized and under-treated condition and a possible cause of hospital readmissions in patients with HFrEF.To improve compliance with screening for iron deficiency regardless of anemia, we have raised awareness of the importance of checking for iron deficiency. In addition, to increase the appropriate treatment in patients admitted with acute HFrEF, we have launched an algorithm for IV iron replacement in HFrEF patients who meet above mentioned iron deficiency criteria.
**Additional Authors:
Phoo Pwint Nandar, MD, Summa Health System, Akron, OH
Ottorino Costantini, MD, Summa Health System, Akron, OH
Bridget Hilker, RN, Summa Health System, Akron, OH
Renee Brinker, Director, Quality Analytics, Summa Health System, Akron, OH
Gabriela Orasanu, MD, Summa Health System, Akron, OH
