Overview

Anemia is very common in patients with heart disease: about one-third of congestive heart failure (CHF) patients and 10 to 20 percent of coronary heart disease (CHD) patients are anemic, though prevalence estimates vary according to the definition used and illness burden in the population being studied. The etiology of anemia in heart disease remains incompletely understood, though there are a number of factors that likely contribute including: comorbid chronic kidney disease, blunted erythropoietin production, hemodilution, aspirin-induced gastrointestinal blood loss, the use of renin-angiotensin-aldosterone system (RAAS) blockers, cytokine-mediated inflammation (anemia of chronic disease), and gut malabsorption with consequent nutritional deficiency. Iron deficiency is also common. Cytokine mediated sequestration of iron in the reticuloendothelial system may contribute to a functional iron deficiency, while an absolute deficiency can result from decreased oral iron absorption associated with cytokine induced hepcidin synthesis. Anemia is associated with poor outcomes in patients with heart disease, but it is unclear whether anemia directly and independently contributes to these poor outcomes, or whether it simply reflects more severe underlying illness and comorbidities. Strategies to correct anemia and/ or iron deficiency have included erythropoiesis-stimulating agents, iron supplementation, and red blood cell transfusions. The purpose of this systematic review is to summarize the health outcome effects of each of these treatment strategies in adult medicine patients with heart disease. The objective of this evidence review is to evaluate the balance of benefit and harms of these treatments. We conducted a systematic review to address the following key questions: In patients with CHF or CHD, Key Question #1. What are the health outcome benefits and harms of treating anemia with ESAs? Key Question #2. What are the health outcome benefits and harms of using iron to treat iron deficiency with or without anemia? Key Question #3. What are the health outcome benefits and harms of treating anemia with red blood cell transfusions?

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