CLINICAL STUDY
Anemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure
Tamara B. Horwich, MD*,
Gregg C. Fonarow, MD, FACC ,*,
Michele A. Hamilton, MD, FACC,
W. Robb MacLellan, MD, FACC and
Jeff Borenstein, MD
* Department of Medicine, University of California, Los Angeles, USA
Ahmanson–University of California Cardiomyopathy Center, Los Angeles, USA
Cedars–Sinai Health System, Los Angeles, California, USA
Manuscript received December 28, 2001;
revised manuscript received March 4, 2002,
accepted March 11, 2002.
* Reprint requests and correspondence: Dr. Gregg C. Fonarow, Ahmanson–UCLA Cardiomyopathy Center, UCLA Division of Cardiology, 47-123 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095-1679, USA.
gfonarow{at}mednet.ucla.edu
OBJECTIVES: This study aimed to evaluate the relationship between anemia and heart failure (HF) prognosis.
BACKGROUND: Although it is known that chronic diseases, including HF, may be associated with anemia, the impact of hemoglobin (Hb) level on symptoms and survival in HF has not been fully defined.
METHODS: We analyzed a cohort of 1,061 patients with advanced HF (New York Heart Association [NYHA] functional class III or IV and left ventricular ejection fraction [LVEF] <40%) referred to a single center for evaluation and management. The Hb level was drawn at time of initial evaluation. Patients were divided into quartiles of Hb: Hb <12.3; Hb 12.3 to 13.6; Hb 13.7 to 14.8; Hb >14.8 g/dl.
RESULTS: Mean Hb was 13.6, and values ranged from 7.1 to 19.0 g/dl. The Hb groups were similar in age, medication profile, LVEF, hypertension, diabetes, smoking status and serum sodium. Lower Hb was associated with an impaired hemodynamic profile, higher blood urea nitrogen and creatinine, and lower albumin, total cholesterol and body mass index. Patients in the lower Hb quartiles were more likely to be NYHA functional class IV (p < 0.0001) and have lower peak oxygen consumption (PKVO2) (p < 0.0001). Survival at one year was higher with increased Hb quartile (55.6%, 63.9%, 71.4% and 74.4% for quartiles 1, 2, 3 and 4, respectively). On multivariate analysis adjusting for known HF prognostic factors, low Hb proved to be an independent predictor of mortality (relative risk 1.131, confidence interval 1.045 to 1.224 for each decrease of 1 g/dl).
CONCLUSIONS: In chronic HF, relatively mild degrees of anemia are associated with worsened symptoms, functional status and survival.
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Abbreviations and Acronyms
| | BMI | | body mass index | | CAD | | coronary artery disease | | CI | | confidence interval | | ESRD | | end-stage renal disease | | Hb | | hemoglobin | | Hct | | hematocrit | | HF | | heart failure | | LVEF | | left ventricular ejection fraction | | MI | | myocardial infarction | | NYHA | | New York Heart Association | | PKVO2 | | peak oxygen consumption | | RR | | relative risk | | SOLVD | | Studies Of Left Ventricular Dysfunction |
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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]
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A J S Coats
Anaemia and heart failure
Heart,
September 1, 2004;
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[Full Text]
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E. Nikolsky, E. D. Aymong, A. Halkin, C. L. Grines, D. A. Cox, E. Garcia, R. Mehran, J. E. Tcheng, J. J. Griffin, G. Guagliumi, et al.
Impact of anemia in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: Analysis from the controlled abciximab and device investigation to lower late angioplasty complications (cadillac) trial
J. Am. Coll. Cardiol.,
August 4, 2004;
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[Abstract]
[Full Text]
[PDF]
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M. G. Shlipak, G. L. Smith, S. S. Rathore, B. M. Massie, and H. M. Krumholz
Renal Function, Digoxin Therapy, and Heart Failure Outcomes: Evidence from the Digoxin Intervention Group Trial
J. Am. Soc. Nephrol.,
August 1, 2004;
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[Abstract]
[Full Text]
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R. S. McKechnie, D. Smith, C. Montoye, E. Kline-Rogers, M. J. O'Donnell, A. C. DeFranco, W. L. Meengs, R. McNamara, J. G. McGinnity, K. Patel, et al.
Prognostic Implication of Anemia on In-Hospital Outcomes After Percutaneous Coronary Intervention
Circulation,
July 20, 2004;
110(3):
271 - 277.
[Abstract]
[Full Text]
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I. Anand, J. J.V. McMurray, J. Whitmore, M. Warren, A. Pham, M. A. McCamish, and P. B.J. Burton
Anemia and Its Relationship to Clinical Outcome in Heart Failure
Circulation,
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110(2):
149 - 154.
[Abstract]
[Full Text]
[PDF]
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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;
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[Abstract]
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T. R. Wessel, C. B. Arant, and C. J. Pepine
Commentary on "New and Emerging Theories of Cardiovascular Disease"
Biol Res Nurs,
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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.,
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[Abstract]
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C. B. Arant, T. R. Wessel, M. B. Olson, C. N. Bairey Merz, G. Sopko, W. J. Rogers, B. L. Sharaf, S. E. Reis, K. M. Smith, B. D. Johnson, et al.
Hemoglobin level is an independent predictor for adverse cardiovascular outcomes in women undergoing evaluation for chest pain: Results from the National Heart, Lung, and Blood Institute women's ischemia syndrome evaluation study
J. Am. Coll. Cardiol.,
June 2, 2004;
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[Abstract]
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J. H. Shuhaiber
Intraoperative hematocrit and cardiopulmonary bypass
J. Thorac. Cardiovasc. Surg.,
April 1, 2004;
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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.,
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[Abstract]
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H. K. Eltzschig, R. Ehlers, S. K. Shernan, W. Rodriguez, S. M. Silver, D. Schoevaerdts, C. Swine, D. Vanpee, M. Jessup, and S. Brozena
Heart Failure
N. Engl. J. Med.,
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K. J Smith, A. J Bleyer, W. C Little, and D. C Sane
The cardiovascular effects of erythropoietin
Cardiovasc Res,
September 1, 2003;
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[Abstract]
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K. Schroecksnadel, B. Wirleitner, D. Fuchs, W. Steinborn, P. Ponikowski, S. Anker, P. van der Meer, W. H. van Gilst, D. J. van Veldhuisen, J. Ezekowitz, et al.
Anemia and Congestive Heart Failure * Response
Circulation,
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T. Not, E. Faleschini, A. Tommasini, A. Repetto, M. Pasotti, V. Baldas, A. Spano, D. Sblattero, R. Marzari, C. Campana, et al.
Celiac disease in patients with sporadic and inherited cardiomyopathies and in their relatives
Eur. Heart J.,
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[Abstract]
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D. Mozaffarian, R. Nye, and W. C. Levy
Anemia predicts mortality in severe heart failure: The prospective randomized amlodipine survival evaluation (PRAISE)
J. Am. Coll. Cardiol.,
June 4, 2003;
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[Abstract]
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D. Silverberg
Outcomes of anaemia management in renal insufficiency and cardiac disease
Nephrol. Dial. Transplant.,
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[Abstract]
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M. C. Thomas, R. J. MacIsaac, C. Tsalamandris, D. Power, and G. Jerums
Unrecognized Anemia in Patients With Diabetes: A cross-sectional survey
Diabetes Care,
April 1, 2003;
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[Abstract]
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J. A. Ezekowitz, F. A. McAlister, and P. W. Armstrong
Anemia Is Common in Heart Failure and Is Associated With Poor Outcomes: Insights From a Cohort of 12 065 Patients With New-Onset Heart Failure
Circulation,
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[Abstract]
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A.-S. Androne, S. D. Katz, L. Lund, J. LaManca, A. Hudaihed, K. Hryniewicz, and D. M. Mancini
Hemodilution Is Common in Patients With Advanced Heart Failure
Circulation,
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[Abstract]
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D. S. Silverberg, D. Wexler, M. Blum, J. Z. Tchebiner, D. Sheps, G. Keren, D. Schwartz, R. Baruch, T. Yachnin, M. Shaked, et al.
The effect of correction of anaemia in diabetics and non-diabetics with severe resistant congestive heart failure and chronic renal failure by subcutaneous erythropoietin and intravenous iron
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[Abstract]
[Full Text]
[PDF]
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J. K. Ghali
Anemia and poor prognosis in advanced heart failure
J. Am. Coll. Cardiol.,
December 18, 2002;
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[Full Text]
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G. C. Fonarow, T. B. Horwich, M. A. Hamilton, and W. R. MacLellan
Reply
J. Am. Coll. Cardiol.,
December 18, 2002;
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