Intravenous iron for heart failure, iron deficiency definitions, and clinical response: the IRONMAN trial

Background and Aims What is the relationship between blood tests for iron deficiency, including anaemia, and the response to intravenous iron in patients with heart failure? Methods In the IRONMAN trial, 1137 patients with heart failure, ejection fraction <= 45%, and either serum ferritin < 100 mu g/L or transferrin saturation (TSAT) < 20% were randomized to intravenous ferric derisomaltose (FDI) or usual care. Relationships were investigated between baseline anaemia severity, ferritin and TSAT, to changes in haemoglobin from baseline to 4 months, Minnesota Living with Heart Failure (MLwHF) score and 6-minute walk distance achieved at 4 months, and clinical events, including heart failure hospitalization (recurrent) or cardiovascular death. Results The rise in haemoglobin after administering FDI, adjusted for usual care, was greater for lower baseline TSAT (P-interaction < .0001) and ferritin (P-interaction = .028) and more severe anaemia (P-interaction = .014). MLwHF scores at 4 months were somewhat lower (better) with FDI for more anaemic patients (overall P-interaction = .14; physical P-interaction = .085; emotional P-interaction = .043) but were not related to baseline TSAT or ferritin. Blood tests did not predict difference in achieved walking distance for those randomized to FDI compared to control. The absence of anaemia or a TSAT >= 20% was associated with lower event rates and little evidence of benefit from FDI. More severe anaemia or TSAT < 20%, especially when ferritin was >= 100 mu g/L, was associated with higher event rates and greater absolute reductions in events with FDI, albeit not statistically significant. Conclusions This hypothesis-generating analysis suggests that anaemia or TSAT < 20% with ferritin > 100 mu g/L might identify patients with heart failure who obtain greater benefit from intravenous iron. This interpretation requires confirmation. [GRAPHICS] .