O'Meara Eileen, de Denus Simon
Montreal Heart Institute, 5000 Belanger Street, Montreal, QC, Canada, H1T 1C8,
Curr Treat Options Cardiovasc Med. 2010 Dec;12(6):532-48. doi: 10.1007/s11936-010-0095-4.
Anemia is independently associated with an increased risk of mortality and morbidity in patients with heart failure (HF). The diagnosis of anemia should prompt assessment of the underlying cause(s), first by using routine laboratory measurements (i.e., serum creatinine and estimated glomerular filtration rate [eGFR], serum iron, transferrin saturation, ferritin, vitamin B12, folic acid, and thyroid stimulating hormone). In clinical practice, it remains unclear whether using levels of the soluble transferrin receptor in HF patients to assess iron deficiency is warranted. Further investigation should follow these simple tests when judged appropriate (e.g., if occult gastrointestinal blood losses are suspected). Hemodilution may contribute significantly to anemia in patients with advanced HF and may be suspected when signs of hypervolemia are present. Euvolemia should be the first goal in such cases (as always), followed by optimization of the disease-modifying therapies used in HF (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, or aldosterone antagonists and cardiac resynchronization therapy in selected cases). Erythropoiesis-stimulating agents (ESA) can be used to improve functional capacity in patients with significant chronic kidney disease (CKD), a frequent comorbidity in HF patients. ESA and iron therapy is recommended in patients with moderate-to-severe CKD (eGFR < 60 mL/min/1.73 m(2)), with a target hemoglobin level of 11.0 g/dL. In a recent randomized, placebo-controlled clinical trial, weekly administration of intravenous iron significantly improved symptoms, New York Heart Association class, quality of life, and exercise capacity in both anemic and non-anemic HF patients. A trend toward fewer hospitalizations was seen in the group treated with intravenous iron. The rates of adverse events were similar in the treatment and the placebo groups. Larger-scale and longer-term studies are needed to establish the safety and efficacy profile of intravenous iron in non-CKD HF patients and in HF patients without anemia. Studies designed to further unravel the pathophysiology of anemia in HF are essential in order to determine 1) novel treatment targets and 2) whether and how the treatment of anemia could improve outcomes.
贫血与心力衰竭（HF）患者死亡率和发病率的增加独立相关。贫血的诊断应促使对潜在病因进行评估，首先通过常规实验室检测（即血清肌酐和估算肾小球滤过率[eGFR]、血清铁、转铁蛋白饱和度、铁蛋白、维生素B12、叶酸和促甲状腺激素）。在临床实践中，尚不清楚在HF患者中使用可溶性转铁蛋白受体水平来评估缺铁是否合理。在判断合适时（例如，怀疑有隐匿性胃肠道失血），应在这些简单检测之后进行进一步调查。血液稀释可能在晚期HF患者的贫血中起重要作用，当出现血容量过多迹象时可能会被怀疑。在这种情况下（一如既往），正常血容量应是首要目标，随后优化用于HF的疾病改善疗法（血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、β受体阻滞剂，或在特定情况下使用醛固酮拮抗剂和心脏再同步治疗）。促红细胞生成素（ESA）可用于改善患有严重慢性肾脏病（CKD）患者的功能能力，CKD是HF患者常见的合并症。对于中度至重度CKD（eGFR＜60 mL/min/1.73 m²）患者，建议使用ESA和铁剂治疗，目标血红蛋白水平为11.0 g/dL。在最近一项随机、安慰剂对照临床试验中，每周静脉注射铁剂显著改善了贫血和非贫血HF患者症状、纽约心脏协会分级、生活质量和运动能力。静脉注射铁剂治疗组的住院次数有减少趋势。治疗组和安慰剂组的不良事件发生率相似。需要进行更大规模和更长期的研究，以确定静脉注射铁剂在非CKD HF患者和无贫血HF患者中的安全性和有效性。旨在进一步阐明HF中贫血病理生理学的研究对于确定1）新的治疗靶点和2）贫血治疗是否以及如何改善预后至关重要。
