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J Am Coll Cardiol, 2001; 37:1775-1780
© 2001 by the American College of Cardiology Foundation
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CLINICAL STUDY: HEART FAILURE

The effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study

Donald S. Silverberg, MDa, Dov Wexler, MDa, David Sheps, MDa, Miriam Blum, MDa, Gad Keren, MDa, Ron Baruch, MDa, Doron Schwartz, MDa, Tatyana Yachnin, MDa, Shoshana Steinbruch, RNa, Itzhak Shapira, MDa, Shlomo Laniado, MDa and Adrian Iaina, MDa

a Department of Nephrology and Cardiology and Congestive Heart Failure Program, Tel Aviv Medical Center, Weizman 6, Tel Aviv, Israel

Manuscript received October 13, 2000; revised manuscript received February 12, 2001, accepted February 19, 2001.

Reprint requests and correspondence: Dr. D. S. Silverberg, Department of Nephrology, Tel Aviv Medical Center, Weizman 6, Tel Aviv, 64239, Israel

OBJECTIVES

This is a randomized controlled study of anemic patients with severe congestive heart failure (CHF) to assess the effect of correction of the anemia on cardiac and renal function and hospitalization.

BACKGROUND

Although mild anemia occurs frequently in patients with CHF, there is very little information about the effect of correcting it with erythropoietin (EPO) and intravenous iron.

METHODS

Thirty-two patients with moderate to severe CHF (New York Heart Association [NYHA] class III to IV) who had a left ventricular ejection fraction (LVEF) of ≤40% despite maximally tolerated doses of CHF medications and whose hemoglobin (Hb) levels were persistently between 10.0 and 11.5 g% were randomized into two groups. Group A (16 patients) received subcutaneous EPO and IV iron to increase the level of Hb to at least 12.5 g%. In Group B (16 patients) the anemia was not treated. The doses of all the CHF medications were maintained at the maximally tolerated levels except for oral and intravenous (IV) furosemide, whose doses were increased or decreased according to the clinical need.

RESULTS

Over a mean of 8.2 ± 2.6 months, four patients in Group B and none in Group A died of CHF-related illnesses. The mean NYHA class improved by 42.1% in A and worsened by 11.4% in B. The LVEF increased by 5.5% in A and decreased by 5.4% in B. The serum creatinine did not change in A and increased by 28.6% in B. The need for oral and IV furosemide decreased by 51.3% and 91.3% respectively in A and increased by 28.5% and 28.0% respectively in B. The number of days spent in hospital compared with the same period of time before entering the study decreased by 79.0% in A and increased by 57.6% in B.

CONCLUSIONS

When anemia in CHF is treated with EPO and IV iron, a marked improvement in cardiac and patient function is seen, associated with less hospitalization and renal impairment and less need for diuretics.

Abbreviations and Acronyms
  CABG = coronary artery bypass graft
  CHF = congestive heart failure
  CRF = chronic renal failure
  EPO = erythropoietin
  %Fe Sat = percent iron saturation
  GFR = glomerular filtration rate
  Hb = hemoglobin
  Hct = hematocrit
  IU = international units
  IV = intravenous
  LVEF = left ventricular ejection fraction
  NYHA = New York Heart Association
  PA = pulmonary artery
  sc = subcutaneous
  SOLVD = Studies Of Left Ventricular Dysfunction




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J Am Coll CardiolHome page
S. Namiuchi, Y. Kagaya, J. Ohta, N. Shiba, M. Sugi, M. Oikawa, H. Kunii, H. Yamao, N. Komatsu, M. Yui, et al.
High Serum Erythropoietin Level Is Associated With Smaller Infarct Size in Patients With Acute Myocardial Infarction Who Undergo Successful Primary Percutaneous Coronary Intervention
J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1406 - 1412.
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J Am Coll CardiolHome page
G. M. Felker, W. A. Gattis, K. F. Adams, and C. M. O'Connor
Reply
J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1550 - 1551.
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J Am Coll CardiolHome page
T. O. Cheng
Is There an Optimal Hematocrit Value for Cardiac Patients?
J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1549 - 1549.
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Nephrol Dial TransplantHome page
S. Philipp, H. Ollmann, T. Schink, R. Dietz, F. C. Luft, and R. Willenbrock
The impact of anaemia and kidney function in congestive heart failure and preserved systolic function
Nephrol. Dial. Transplant., May 1, 2005; 20(5): 915 - 919.
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Br J AnaesthHome page
T. S. Walsh, D. B. McClelland, R. J. Lee, M. Garrioch, C. R. Maciver, F. McArdle, S. L. Crofts, I. Mellor, and for the ATICS Study Group
Prevalence of ischaemic heart disease at admission to intensive care and its influence on red cell transfusion thresholds: multicentre Scottish Study
Br. J. Anaesth., April 1, 2005; 94(4): 445 - 452.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
A. Ishani, E. Weinhandl, Z. Zhao, D. T. Gilbertson, A. J. Collins, S. Yusuf, and C. A. Herzog
Angiotensin-converting enzyme inhibitor as a risk factor for the development of anemia, and the impact of incident anemia on mortality in patients with left ventricular dysfunction
J. Am. Coll. Cardiol., February 1, 2005; 45(3): 391 - 399.
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JAMAHome page
K. Maiese, F. Li, and Z. Z. Chong
New Avenues of Exploration for Erythropoietin
JAMA, January 5, 2005; 293(1): 90 - 95.
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Eur J Heart FailHome page
P. van der Meer, E. Lipsic, R. H. Henning, R. A. de Boer, A. J.H. Suurmeijer, D. J. van Veldhuisen, and W. H. van Gilst
Erythropoietin improves left ventricular function and coronary flow in an experimental model of ischemia-reperfusion injury
Eur J Heart Fail, December 1, 2004; 6(7): 853 - 859.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
L. Fried, C. Solomon, M. Shlipak, S. Seliger, C. Stehman-Breen, A. J. Bleyer, P. Chaves, C. Furberg, L. Kuller, and A. Newman
Inflammatory and Prothrombotic Markers and the Progression of Renal Disease in Elderly Individuals
J. Am. Soc. Nephrol., December 1, 2004; 15(12): 3184 - 3191.
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The Annals of PharmacotherapyHome page
K. Caiola and J. W. Cheng
Use of Erythropoietin in Heart Failure Management
Ann. Pharmacother., December 1, 2004; 38(12): 2145 - 2149.
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BloodHome page
J. M. Guralnik, R. S. Eisenstaedt, L. Ferrucci, H. G. Klein, and R. C. Woodman
Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia
Blood, October 15, 2004; 104(8): 2263 - 2268.
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J Am Coll CardiolHome page
G.M. Felker, K. F. Adams Jr, W. A. Gattis, and C. M. O'Connor
Anemia as a risk factor and therapeutic target in heart failure
J. Am. Coll. Cardiol., September 1, 2004; 44(5): 959 - 966.
[Abstract] [Full Text] [PDF]


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HeartHome page
A J S Coats
Anaemia and heart failure
Heart, September 1, 2004; 90(9): 977 - 979.
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J Am Coll CardiolHome page
P. van der Meer, A. A. Voors, E. Lipsic, T. D. J. Smilde, W. H. van Gilst, and D. J. van Veldhuisen
Prognostic value of plasma erythropoietin on mortality in patients with chronic heart failure
J. Am. Coll. Cardiol., July 7, 2004; 44(1): 63 - 67.
[Abstract] [Full Text] [PDF]


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Eur Heart JHome page
R. Sharma, D. P Francis, B. Pitt, P. A Poole-Wilson, A. J.S Coats, and S. D Anker
Haemoglobin predicts survival in patients with chronic heart failure: a substudy of the ELITE II trial
Eur. Heart J., June 2, 2004; 25(12): 1021 - 1028.
[Abstract] [Full Text] [PDF]


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JAMAHome page
S. Z. Pantilat and A. E. Steimle
Palliative Care for Patients With Heart Failure
JAMA, May 26, 2004; 291(20): 2476 - 2482.
[Abstract] [Full Text] [PDF]


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Nephrol Dial TransplantHome page
D. Silverberg, D. Wexler, M. Blum, D. Schwartz, and A. Iaina
The use of androgens in anaemia resistant to erythropoietin and i.v. iron in patients with heart and renal failure
Nephrol. Dial. Transplant., April 1, 2004; 19(4): 1021 - 1021.
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Eur Heart JHome page
P. van der Meer, A. A. Voors, E. Lipsic, W. H. van Gilst, and D. J. van Veldhuisen
Erythropoietin in cardiovascular diseases
Eur. Heart J., February 2, 2004; 25(4): 285 - 291.
[Abstract] [Full Text] [PDF]


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BloodHome page
F. H. Bahlmann, K. de Groot, J.-M. Spandau, A. L. Landry, B. Hertel, T. Duckert, S. M. Boehm, J. Menne, H. Haller, and D. Fliser
Erythropoietin regulates endothelial progenitor cells
Blood, February 1, 2004; 103(3): 921 - 926.
[Abstract] [Full Text] [PDF]


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J. Am. Soc. Nephrol.Home page
S. D. Roger, L. P. McMahon, A. Clarkson, A. Disney, D. Harris, C. Hawley, H. Healy, P. Kerr, K. Lynn, A. Parnham, et al.
Effects of Early and Late Intervention with Epoetin {alpha} on Left Ventricular Mass among Patients with Chronic Kidney Disease (Stage 3 or 4): Results of a Randomized Clinical Trial
J. Am. Soc. Nephrol., January 1, 2004; 15(1): 148 - 156.
[Abstract] [Full Text] [PDF]


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Eur Heart JHome page
H. Reinecke, T. Trey, J. Wellmann, J. Heidrich, M. Fobker, T. Wichter, M. Walter, G. Breithardt, and R. M. Schaefer
Haemoglobin-related mortality in patients undergoing percutaneous coronary interventions
Eur. Heart J., December 1, 2003; 24(23): 2142 - 2150.
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Postgrad. Med. J.Home page
D B McKenzie and A J Cowley
Drug therapy in chronic heart failure
Postgrad. Med. J., November 1, 2003; 79(937): 634 - 642.
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