Studies indicate that anemia occurs in about one-third of patients with congestive heart failure and up to 20% of those with coronary heart disease (CHD). The condition has been linked to an increased risk for hospitalizations, decreases in exercise capacity, a poorer quality of life, and higher mortality. The risks and benefits of treating anemia in patients with heart disease are important to understand.

Providing Guidance

In the Annals of Internal Medicine, the American College of Physicians (ACP) published guidelines that presented the current evidence and provided clinical recommendations on the treatment of anemia and iron deficiency in adults with heart disease. The guideline was based on a review of the literature on anemia and iron deficiency published from 1947 to 2013.

The first recommendation made in the guideline was to use a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7 to 8 g/dL, compared with a higher hemoglobin level) in hospitalized patients with CHD. “When compared with a restrictive transfusion strategy, there is low-quality evidence that showed no benefit of using a liberal transfusion strategy in which the trigger threshold for hemoglobin levels was greater than 10 g/dL,” says Amir Qaseem, MD, PhD, who was lead author of the ACP guideline. “This strategy will likely be a slight shift from the aggressive approaches clinicians have used in the past.”


ACP also recommends against the use of erythropoiesis-stimulating agents (ESAs) in patients with mild-to-moderate anemia and congestive heart failure or CHD. “This is a strong recommendation that was made on moderate-quality evidence,” says Dr. Qaseem. “We found that the harms of treating patients with mild-to-moderate anemia and congestive heart failure or CHD with ESAs outweigh the benefits. Treatment with ESAs in this patient population did not improve mortality, cardiovascular events, hospitalizations, exercise tolerance or duration, or quality of life in the studies we reviewed. Serious harms associated with ESAs included increased mortality and thromboembolic events.”

Existing Needs

Dr. Qaseem says that more research is needed on the use of intravenous (IV) iron treatment for patients with anemia and heart disease. “Three studies showed that IV treatment improved exercise tolerance and quality of life and reduced mortality and hospitalizations,” he says, “but these data were primarily derived from just one large trial. We need more data on the benefits and harms of IV iron treatment before making a recommendation.” With only low-quality evidence available on the use of a restrictive versus liberal transfusion strategy, more research is also required to provide higher-quality evidence. In the meantime, clinicians should refer to the ACP guideline when treating their patients with anemia and heart disease.


Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2013;159:770-779. Available at:

Kosiborod M, Smith GL, Radford MJ, Foody JM, Krumholz HM. The prognostic importance of anemia in patients with heart failure. Am J Med. 2003;114:112-119.

Kansagara D, Dyer E, Englander H, Fu R, Freeman M, Kagen D. Treatment of anemia in patients with heart disease. A systematic review. Ann Intern Med. 2013;159:746-757.

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