Clinical Characteristics of Iron Deficiency in Patients with Chronic Heart Failure at a Major Referral Centre in Southern Nigeria

Main Article Content

Aisha O Ajala
Boma Oyan
Prudence Ikejiofor
Sotonye Dodiyi-manuel
Edeogu Julius
Chineme Ekeh
Maclean Akpa

Keywords

Iron-deficiency, heart failure, anemia, ferritin, severity, NT-Pro-BNP, hs-CRP

Abstract

Background. Iron deficiency (ID) is a common comorbidity in patients with heart failure (HF) and is associated with reduced functional capacity, diminished quality of life, and increased mortality. This study aimed to determine the prevalence of ID and its clinical characteristics.


Methods. This descriptive cross-sectional study involved 136 patients with chronic HF at the University of Port-Harcourt Teaching Hospital. Informed consent was obtained. Blood samples were collected for a full blood count and serum ferritin analysis, while echocardiography was performed for all study participants.


Results. The mean age was 59.2±14.9years, with 51% being males. Notably, 41% of the patients exhibited low ferritin levels (≤100ng/ml), indicating the presence of ID. Among patients with ID, 19.7% had anemia. Although patients aged 65 years and above tended to have lower ferritin levels, this difference was not statistically significant (p=0.141). In contrast, statistically significant associations were observed between ID and gender, with females being more susceptible to iron deficiency (p=0.036). However, normal levels of N-Terminal-prohormone-Brain Natriuretic Peptide (NT-Pro-BNP) and high sensitivity – C Reactive Protein(hs-CRP) were significantly linked to ID (p=0.001 & p=0.004, respectively), and there was no significant correlation between ejection fraction and ferritin levels.


Conclusion. Iron deficiency, with or without anemia, is prevalent in chronic heart failure patients, particularly among females and even in persons who have normal levels of markers of HF severity such as hs-CRP and NT-pro-BNP. Regular screening for ID is vital to identify and manage this comorbidity, as iron correction can lead to improved functional capacity and reduced morbidity and mortality associated with heart failure.

Abstract 4 | PDF Downloads 0 EPUB Downloads 0

References

Ogah OS, Kushimo OA, Adebiyi A, Onyema CT, Uchenna OC, Adebayo BE, et al. Heart failure in Nigeria: protocol for a systematic review and meta-analysis. African Health Sciences [Internet]. 2023 Jul 13 [cited 2023 Nov 28];23(2):530–6. Available from: [https://www.ajol.info/index.php/ahs/article/view/250750](https://www.ajol.info/index.php/ahs/article/view/250750)

Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global Burden of Heart failure: a Comprehensive and Updated Review of Epidemiology. Cardiovascular Research [Internet]. 2023 Feb 12;118(17). Available from: [https://pubmed.ncbi.nlm.nih.gov/35150240/](https://pubmed.ncbi.nlm.nih.gov/35150240/)

Oyan B, Abere S, Ajala AO, Orupabo F, Nyeche OE, Nwosu JC, et al. Patterns and outcomes of cardiovascular disease admissions in the medical wards of the Rivers State University Teaching Hospital, Port Harcourt, Nigeria: A two-year review. PubMed [Internet]. 2024 Oct 14 [cited 2024 Nov 18];65(4):479–89. Available from: [https://nigerianmedjournal.org/index.php/nmj/article/view/467](https://nigerianmedjournal.org/index.php/nmj/article/view/467)

Malik A, Chhabra L, Shams P. Congestive heart failure [Internet]. National Library of Medicine. StatPearls Publishing; 2025. Available from: [https://www.ncbi.nlm.nih.gov/books/NBK430873/](https://www.ncbi.nlm.nih.gov/books/NBK430873/)

Anghel L, Dinu C, Patraș D, Ciubară A, Chiscop I. Iron Deficiency Treatment in Heart Failure—Challenges and Therapeutic Solutions. Journal of Clinical Medicine [Internet]. 2025 Apr 24 [cited 2025 Apr 28];14(9):2934. Available from: [https://www.mdpi.com/2077-0383/14/9/2934](https://www.mdpi.com/2077-0383/14/9/2934)

von Haehling S, Ebner N, Evertz R, Ponikowski P, Anker SD. Iron Deficiency in Heart Failure. JACC: Heart Failure. 2019 Jan;7(1):36–46.

Sun H, Wang Q, Han W, Chen C, Wang T, Zhong J. Iron deficiency: prevalence, mortality risk, and dietary relationships in general and heart failure populations. Frontiers in Cardiovascular Medicine [Internet]. 2024 Mar 18 [cited 2024 Nov 21];11. Available from: [https://pmc.ncbi.nlm.nih.gov/articles/PMC10982413/#s1](https://pmc.ncbi.nlm.nih.gov/articles/PMC10982413/#s1)

Nwako OF, Ogah OS, Odia OJ, Nwako CA, Nwako AB, Iheanacho MC, et al. Prevalence of Iron Deficiency Anaemia among Chronic Heart Failure Patients in Owerri, Nigeria. PubMed [Internet]. 2025 Jul 24 [cited 2025 Jul 29];66(2):480–8. Available from: [https://www.nigerianmedjournal.org/index.php/nmj/article/view/630](https://www.nigerianmedjournal.org/index.php/nmj/article/view/630)

Anker SD, Comin Colet J, Filippatos G, Willenheimer R, Dickstein K, Drexler H, et al. Ferric Carboxymaltose in Patients with Heart Failure and Iron Deficiency. New England Journal of Medicine [Internet]. 2009 Dec 17;361(25):2436–48. Available from: [https://www.nejm.org/doi/full/10.1056/NEJMoa0908355](https://www.nejm.org/doi/full/10.1056/NEJMoa0908355)

Ponikowski P, van Veldhuisen DJ, Comin-Colet J, Ertl G, Komajda M, Mareev V, et al. Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency. European Heart Journal [Internet]. 2015 Mar 14;36(11):657–68. Available from: [https://academic.oup.com/eurheartj/article/36/11/657/491882](https://academic.oup.com/eurheartj/article/36/11/657/491882)

Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterology and Hepatology From Bed to Bench [Internet]. 2024;6(1):14. Available from: [https://pmc.ncbi.nlm.nih.gov/articles/PMC4017493/#CIT0004](https://pmc.ncbi.nlm.nih.gov/articles/PMC4017493/#CIT0004)

Amaechi UM, Aiwuyo HO, Ewelukwa C, Ilerhunmwuwa N, Osarenkhoe JO, Kweki AG, et al. Assessing Iron Status in Chronic Heart Failure Patients by Using Serum Ferritin and Transferrin Saturation Levels: A Cross-Sectional Descriptive Study. Cureus [Internet]. 2023 Winter;15(5):e39425. Available from: [https://pubmed.ncbi.nlm.nih.gov/37362450/](https://pubmed.ncbi.nlm.nih.gov/37362450/)

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Journal of Heart Failure [Internet]. 2022 Jan;24(1):4–131. Available from: [https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.2333](https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.2333)

Makubi A, Hage C, Lwakatare J, Mmbando B, Kisenge P, Lund LH, et al. Prevalence and prognostic implications of anaemia and iron deficiency in Tanzanian patients with heart failure. Heart. 2014 Dec 24;101(8):592–9.

Johns I, Moschonas KE, Medina J, Ossei-Gerning N, Kassianos G, Halcox JP. Risk classification in primary prevention of CVD according to QRISK2 and JBS3 “heart age”, and prevalence of elevated high-sensitivity C reactive protein in the UK cohort of the EURIKA study. Open Heart. 2018 Nov;5(2):e000849.

Welsh P, Campbell RT, Mooney L, Kimenai DM, Hayward C, Campbell A, et al. Reference Ranges for NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) and Risk Factors for Higher NT-proBNP Concentrations in a Large General Population Cohort. Circulation: Heart Failure. 2022 Oct;15(10).

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. 2023 Aug 25;44(37).

Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography [Internet]. 2015 Jan;28(1):1-39.e14. Available from: [https://asecho.org/wp-content/uploads/2015/01/ChamberQuantification2015.pdf](https://asecho.org/wp-content/uploads/2015/01/ChamberQuantification2015.pdf)

Singer CE, Vasile CM, Popescu M, Popescu AIS, Marginean IC, Iacob GA, et al. Role of Iron Deficiency in Heart Failure—Clinical and Treatment Approach: An Overview. Diagnostics. 2023 Jan 13;13(2):304.

Pezel T, Audureau E, Mansourati J, Baudry G, Ben Driss A, Durup F, et al. Diagnosis and Treatment of Iron Deficiency in Heart Failure: OFICSel study by the French Heart Failure Working Group. ESC Heart Failure. 2021 Feb 22;8(2):1509–21.

Przybylowski P, Wasilewski G, Golabek K, Bachorzewska-Gajewska H, Dobrzycki S, Koc-Zorawska E, et al. Absolute and Functional Iron Deficiency Is a Common Finding in Patients With Heart Failure and After Heart Transplantation. Transplantation Proceedings [Internet]. 2016;48(1):173–6. Available from: [https://pubmed.ncbi.nlm.nih.gov/26915864/#:~:text=Functional%20iron%20deficiency%20(defined%20as](https://pubmed.ncbi.nlm.nih.gov/26915864/#:~:text=Functional%20iron%20deficiency%20%28defined%20as)

Núñez J, Comín-Colet J, Miñana G, Núñez E, Santas E, Mollar A, et al. Iron deficiency and risk of early readmission following a hospitalization for acute heart failure. European Journal of Heart Failure. 2016 Mar 30;18(7):798–802.

Sharma SK, Agarwal SK, Bhargava K, Sharma M, Chopra K, Arumugam G. Prevalence and spectrum of iron deficiency in heart failure patients in south Rajasthan. Indian Heart Journal. 2016 Jul;68(4):493–7.

Cohen-Solal A, Damy T, Terbah M, Kerebel S, Baguet JP, Hanon O, et al. High prevalence of iron deficiency in patients with acute decompensated heart failure. European Journal of Heart Failure. 2014 Jul 28;16(9):984–91.

Moreira AC, Mesquita G, Gomes MS. Ferritin: An Inflammatory Player Keeping Iron at the Core of Pathogen-Host Interactions. Microorganisms. 2020 Apr 18;8(4):589.

Vanarsa K, Ye Y, Han J, Xie C, Mohan C, Wu T. Inflammation associated anemia and ferritin as disease markers in systemic lupus erythematosus. Arthritis Research & Therapy. 2012;14(4):R182.

Lismawati N, Yusra N, Effendy D, Kurniawan L, Lydia A. Role of soluble transferrin receptor – An Iron marker in hemodialysis patients. Indian journal of nephrology/Indian Journal of Nephrology. 2022 Jan 1;32(6):555–5.

Singh B, Bajaj N, Singh P, Kumar Ghosh A, Anathakrishnan R, Singh N. Iron deficiency in patients of heart failure with reduced ejection fraction. Medical Journal Armed Forces India. 2022 Oct;78(4):463–8.

Hartupee J, Mann DL. Neurohormonal activation in heart failure with reduced ejection fraction. Nature Reviews Cardiology [Internet]. 2018 Oct 6;14(1):30–8. Available from: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5286912/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5286912/)

Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, et al. Identification of three mechanistic pathways for iron-deficient heart failure. European Heart Journal. 2024 May 11;45(26):2281–93.

Jankowska EA, Rozentryt P, Witkowska A, Nowak J, Hartmann O, Ponikowska B, et al. Iron Deficiency Predicts Impaired Exercise Capacity in Patients With Systolic Chronic Heart Failure. Journal of Cardiac Failure. 2011 Nov;17(11):899–906.

Klip IjT, Comin-Colet J, Voors AA, Ponikowski P, Enjuanes C, Banasiak W, et al. Iron deficiency in chronic heart failure: An international pooled analysis. American Heart Journal. 2013 Apr;165(4):575-582.e3.

Beale AL, Warren JL, Roberts N, Meyer P, Townsend NP, Kaye D. Iron deficiency in heart failure with preserved ejection fraction: a systematic review and meta-analysis. Open Heart. 2019 Apr;6(1):e001012.

Petrosyan I, Blaison G, Andrès E, Federici L. Anaemia in the elderly: An aetiologic profile of a prospective cohort of 95 hospitalised patients. European Journal of Internal Medicine. 2012 Sep;23(6):524–8.

Andrès E, Serraj K, Federici L, Vogel T, Kaltenbach G. Anemia in elderly patients: New insight into an old disorder. Geriatrics & Gerontology International. 2012 Dec 17;13(3):519–27.

Tkaczyszyn M, Comín-Colet J, Voors AA, van Veldhuisen DJ, Enjuanes C, Moliner-Borja P, et al. Iron deficiency and red cell indices in patients with heart failure. European Journal of Heart Failure [Internet]. 2018 Jan 1 [cited 2020 Sep 19];20(1):114–22. Available from: [https://pubmed.ncbi.nlm.nih.gov/28386910/](https://pubmed.ncbi.nlm.nih.gov/28386910/)