Unmet needs of heart failure and iron deficiency patients in Canada

Brought to you by CSL ViforImpacting over 750,000 Canadians, heart failure (HF) is a leading cause of hospitalization and requires ongoing management.1 Further, HF’s burden can frequently be compounded by iron deficiency (ID), which commonly affects HF patients. “Prevalence is often thought to be about one third of patients with heart failure, and it may be as high as half or even more,” explains Dr. Justin Ezekowitz, Professor of Medicine, Cardiologist, Mazankowski Alberta Heart Institute, President, Canadian Heart Failure Society. “For those in hospital, prevalence could be as high as 70%, which is quite striking.”“It's far more prevalent than most clinicians and patients are aware,” adds Dr. Shelley Zieroth, Professor, University of Manitoba, Director, St. Boniface Hospital Heart Function Clinics, Head, Medical Heart Failure Program, Cardiac Sciences Manitoba. HF impacts numerous processes in the body that can contribute to risk of developing ID, including blocking iron utilization. Dr. Ezekowitz explains, “Typically, heart failure is causing or is associated with iron deficiency, rather than the other way around.”The upshot? ID can increase a patient’s risk of numerous pathophysiologic consequences, including impacting mitochondrial function, immune response, myoglobin content and oxygen storage. ID also reduces exercise capacity, increases risk of hospitalizations, and has been associated with reduced survival in patients with HF. Dr. Zieroth shares, “I think many clinicians would be surprised that iron deficiency is a stronger prognostic factor for mortality than anemia.” Need for increased screeningUnfortunately, low screening rates result in many HF patients remaining undiagnosed for ID, despite its prevalence. Dr. Ezekowitz recommends HF patients be screened annually for ID with both a transferrin saturation and a ferritin, regardless of their hemoglobin or Complete Blood Count (CBC), given ID can progress over time. Dr. Ezekowitz, also an investigator on recent studies of ferric carboxymaltose in HF with ID, says when reading lab results, randomized trial inclusion criteria are a good rule of thumb for whether patients should be on iron therapy. “For any patient with transferrin saturation of 20% or less we would generally think IV iron is indicated and may get the most benefit,” he explains. “Similarly, patients with ferritin under 100 would get the most benefit. But the inclusion criteria allow for a broader range of both those variables.”Dr. Ezekowitz says screening for ID is common in heart function clinics, but less common beyond those settings. He says increasing awareness about the importance of screening for ferritin and transferrin saturation could help bridge this gap. Fortunately, testing is available and inexpensive across Canada. A case for evidence-based treatments after diagnosisEven for those diagnosed with ID, undertreatment remains an issue. Dr. Zieroth notes, “There's been some inpatient studies showing only 20% of eligible patients are receiving the therapy in hospital. Hospital touchpoints are important for minimizing risk of future events and improving symptom burden.”Misconceptions about treatment options are also prevalent. Dr. Ezekowitz notes, “Oral iron is not well absorbed, not supported by clinical trials versus IV iron. We have IV iron preparations that are delivered quickly and have a safety profile that exceeds many other medications. It’s a misconception that we don't have available safe treatments.”Dr. Zieroth adds, “We have randomized controlled trials showing a clear benefit of using IV iron and ferric carboxymaltose to improve outcomes in patients living with heart failure.” She adds, “The CDA recently made a formal recommendation for the treatment of iron deficiency in patients with heart failure.”2Treatment uptake among patientsIn addition to being well-tolerated and safe, Dr. Ezekowitz notes IV iron tends to be readily accepted into patient routines because of high symptomatic benefit, helping patients feel and function better, and reducing pill burden. Dr. Ezekowitz notes general awareness around the need for iron in the body may be one reason patients are highly willing to incorporate IV iron into their routine. Dr. Zieroth has seen a similar response. “A lot of patients aren't aware they have iron deficiency. When I tell them they would be eligible for IV iron replacement, they are very welcoming of the concept.” She also says innovation can enhance patients’ treatment experience. “Our heart function clinic has developed a process by which we can admit patients for a couple of hours to an IV infusion ward to administer therapy.” She adds, “I think as the heart failure community becomes increasingly aware of the benefit of IV iron and ferric carboxymaltose in patients with heart failure, it will develop ways for patients to get access to this therapy.”Updating guidelines for screening and treatmentDr. Zieroth sees room for evolution in screening guidelines, and is hopeful change is ahead. “Within in-hospital care, screening for iron deficiency needs to be updated on our heart failure care maps and pathways. It's important for us to stay on top of contemporary evidence and update protocols so we can continue to do the best for patients.”Meanwhile, Dr. Ezekowitz notes evidence is available to help guide physicians in treating patients with HF and ID. “We have clinical trials that show outcomes change when we treat patients with the right doses and the right therapy.”Dr. Ezekowitz also confirms recent clinical trial data indicates ferric carboxymaltose therapy reduces symptoms and improves quality of life in patients who have heart failure with a reduced ejection fraction and iron deficiency.3,4Dr. Zieroth highlights international guidelines are already evolving. “US and European Society of Cardiology guidelines have been recently updated to reflect the most recent clinical trial evidence in support of IV iron and ferric carboxymaltose use in patients with heart failure with reduced ejection fraction and mildly reduced ejection fraction. The Canadian guidelines also recommend IV iron, but have not been updated recently. I anticipate that will evolve over time.”5,6,7She adds, “Heart failure care involves physicians, nurses, team members, pharmacists, and the patient themselves. As we increase awareness amongst these key individuals, I think we're going to see more appropriate use of IV iron in the setting of iron deficiency.”

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