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Repeat IV Iron in HF — EECC MCQ

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EasyHeart FailureRepeat IV Iron in HFEECC

A 70-year-old man with HFrEF on GDMT has persistent fatigue. He is euvolaemic with stable weight and normal BP. His Hb is 102 g/L, ferritin 85 microg/L, and TSAT 16%. Iron studies are consistent with iron deficiency. His last IV iron was 12 months ago. Should IV iron be repeated?

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Correct answer: B — Yes — iron deficiency in HF often recurs and requires repeat treatment; the ESC HF Guidelines recommend periodic re-assessment of iron status (every 3-6 months) and repeat IV iron when criteria are met again (ferritin <100 or ferritin 100-299 with TSAT <20%)

Iron deficiency in HF is a recurrent condition (due to chronic inflammation, hepcidin elevation reducing iron absorption, and ongoing losses). The ESC 2023 HF Guidelines recommend: (1) baseline iron status assessment in ALL HF patients (ferritin, TSAT, Hb); (2) IV iron replacement when criteria met (ferritin <100, or 100-299 with TSAT <20%) — Class I for symptom improvement, LOE A; (3) periodic reassessment every 3-6 months; (4) repeat IV iron when deficiency recurs. The IRONMAN trial (ferric derisomaltose) showed a trend toward reduced HF hospitalisations with IV iron (significant in pre-COVID analysis). IV iron is preferred over oral (poorly absorbed in HF due to intestinal oedema, elevated hepcidin, and inflammatory state — IRONOUT-HF showed oral iron was ineffective in HFrEF). Ferric carboxymaltose and ferric derisomaltose are both recommended formulations.

Reference: ESC (2023): HF Guidelines; IRONMAN Trial