Survey Reports Heterogeneity in Iron Deficiency Management in Heart Failure


Online survey data underlines notable discrepancies across various aspects of ID screening and supplementation in clinical practice for patients with HF.

| Image Credit: LinkedIn

Massimiliano Camilli

Credit: LinkedIn

Key findings from the online IRON-HF international survey recognized the need for more consistent iron deficiency (ID) screening and treatment strategies among patients with heart failure (HF).1

In the survey, most physician respondents confirmed routinely screening HF patients for ID but still demonstrated an underutilization of ID supplementation strategies. These discrepancies in screening and supplementation across clinical practice could be attributable to the recent acknowledgment of ID as a key factor in HF management.2

“Of importance, most critical issues emerged in our survey seem to relate to whether screening for ID is routinely performed in HF patients, how iron supplementation is managed once ID is diagnosed, and the timing of ID re-testing,” wrote the investigative team, led by Massimiliano Camilli, department of cardiovascular and pulmonary sciences, Catholic University of the Sacred Heart.1

Patients with cardiovascular diseases commonly experience ID, which has been linked to higher mortality and recurrent hospitalizations in patients with HF, irrespective of anemia status.3 Intravenous iron supplementation has been shown to reduce the risk of HF hospitalization and benefit exercise capacity and quality of life in those with an ejection fraction <50%.4

Acknowledging the lag between guideline recommendations and clinical implementation5, Camilli and colleagues surveyed cardiologists’ knowledge, attitudes, and willingness to screen for ID and prescribed intravenous iron compounds in patients with HF.1

The online survey comprised 23 questions on practices related to ID screening and supplementation and perspective on ID as a public health concern. The survey was available from March to June 2023. Overall, 256 board-certified cardiologists (77.7%) and cardiology fellows (22.3%) completed the survey, of which the majority (59.8%) were male.

Upon analysis, nearly all physicians (98.4%) defined ID according to the current recommendations from the European Society of Cardiology (ESC) guidelines. Most (64.5%) survey respondents reported the prevalence of ID in HF to be approximately 50%.

A majority of clinicians (68.4%) reported screening for ID in >50% of their patients, with HF specialists more likely to screen compared with other subspecialties (86.4% vs. 51.1%; P <.001). However, periodic screening strategies were reported by only 54.3% of respondents, with most (55.4%) screening every 6 months.

Meanwhile, an active role in prescribing and administering iron supplementation was reported by only 51.6% of physicians. Approximately 41% of respondents prescribed iron supplementation without directly performing administration and 7.0% only performed screening.

Intravenous iron was the preferred method of administration (86.3%) for iron supplementation. After the supplementation, most respondents (67.6%) reported reassessing for ID at 3–6 months, while others assessed at 1 month (23.8%).

Overall, most survey respondents (93.8%) considered ID an underestimated issue in the treatment of HF patients. These respondents indicated appropriate education on screening and treating ID is required to address these concerns.

In their conclusion, Camilli and colleagues indicated age, training status, subspeciality, and work setting were notable factors associated with heterogeneity in the survey responses.

“Commitment by scientific societies to the diffusion of standardized screening and treatment protocols, as well as the development of comprehensive HF education programs, are pivotal to bridge these gaps in care,” Camilli and colleagues wrote.


  1. Camilli M, Ballacci F, Rossi VA, et al. Iron deficiency and supplementation in patients with heart failure: Results from the IRON-HF international survey. Eur J Heart Fail. Published online July 4, 2024. doi:10.1002/ejhf.3356
  2. Authors/Task Force Members:, McDonagh TA, Metra M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2022;24(1):4-131. doi:10.1002/ejhf.2333
  3. Savarese G, von Haehling S, Butler J, Cleland JGF, Ponikowski P, Anker SD. Iron deficiency and cardiovascular disease [published correction appears in Eur Heart J. 2023 May 7;44(18):1607. doi: 10.1093/eurheartj/ehad043]. Eur Heart J. 2023;44(1):14-27. doi:10.1093/eurheartj/ehac569
  4. Graham FJ, Pellicori P, Kalra PR, Ford I, Bruzzese D, Cleland JGF. Intravenous iron in patients with heart failure and iron deficiency: an updated meta-analysis. Eur J Heart Fail. 2023;25(4):528-537. doi:10.1002/ejhf.2810
  5. Savarese G, Kishi T, Vardeny O, et al. Heart Failure Drug Treatment-Inertia, Titration, and Discontinuation: A Multinational Observational Study (EVOLUTION HF) [published correction appears in JACC Heart Fail. 2023 Dec;11(12):1773. doi: 10.1016/j.jchf.2023.11.001]. JACC Heart Fail. 2023;11(1):1-14. doi:10.1016/j.jchf.2022.08.009
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