Clinical Research in Cardiology

, Volume 108, Issue 2, pp 203–211 | Cite as

Iron deficiency in patients with heart failure with preserved ejection fraction and its association with reduced exercise capacity, muscle strength and quality of life

  • Tarek BekfaniEmail author
  • Pierpaolo Pellicori
  • Daniel Morris
  • Nicole Ebner
  • Miroslava Valentova
  • Anja Sandek
  • Wolfram Doehner
  • John G. Cleland
  • Mitja Lainscak
  • P. Christian Schulze
  • Stefan D. Anker
  • Stephan von Haehling
Original Paper



The prevalence of iron deficiency (ID) in outpatients with heart failure with preserved ejection fraction (HFpEF) and its relation to exercise capacity and quality of life (QoL) is unknown.


190 symptomatic outpatients with HFpEF (LVEF 58 ± 7%; age 71 ± 9 years; NYHA 2.4 ± 0.5; BMI 31 ± 6 kg/m2) were enrolled as part of SICA-HF in Germany, England and Slovenia. ID was defined as ferritin < 100 or 100–299 µg/L with transferrin saturation (TSAT) < 20%. Anemia was defined as Hb < 13 g/dL in men, < 12 g/dL in women. Low ferritin-ID was defined as ferritin < 100 µg/L. Patients were divided into 3 groups according to E/e′ at echocardiography: E/e′ ≤ 8; E/e′ 9–14; E/e′ ≥ 15. All patients underwent echocardiography, cardiopulmonary exercise test (CPX), 6-min walk test (6-MWT), and QoL assessment using the EQ5D questionnaire.


Overall, 111 patients (58.4%) showed ID with 89 having low ferritin-ID (46.84%). 78 (41.1%) patients had isolated ID without anemia and 54 patients showed anemia (28.4%). ID was more prevalent in patients with more severe diastolic dysfunction: E/e′ ≤ 8: 44.8% vs. E/e′: 9–14: 53.2% vs. E/e′ ≥ 15: 86.5% (p = 0.0004). Patients with ID performed worse during the 6MWT (420 ± 137 vs. 344 ± 124 m; p = 0.008) and had worse exercise time in CPX (645 ± 168 vs. 538 ± 178 s, p = 0.03). Patients with low ferritin-ID had lower QoL compared to those without ID (p = 0.03).


ID is a frequent co-morbidity in HFpEF and is associated with reduced exercise capacity and QoL. Its prevalence increases with increasing severity of diastolic dysfunction.


Heart failure with preserved ejection fraction Iron deficiency Exercise capacity Quality of life 



Analysis of variance


Adenosine triphosphate


Body mass index


Cardiopulmonary exercise test


Dual energy X-ray absorptiometry




Heart failure


Heart failure with preserved ejection fraction


Heart failure with reduced ejection fraction


Iron deficiency


Left atrial volume index


Left ventricular


6-min walk test


New York Heart Association


Quality of life


Standard deviation


Studies investigating co-morbidities aggravating heart failure


Transferrin saturation



The study was funded by the European Commission’s 7th Framework program (FP7/2007–2013) under grant agreement number 241558 (

Compliance with ethical standards

Conflict of interest

SvH is consulting and has received honoraria for speaking from Solartium Dietetics, Professional Dietetics, Vifor, Novartis, Respicardia, Sorin, and Pfizer. SDA is consulting, has received honoraria for speaking and/or attended advisory boards for Amgen Inc, Professional Dietetics, Psioxus Therapeutics, GTx, Helsinn, GSK, Sanofi, Regeneron, Novartis, Takeda, Servier, Chugai and Vifor. All other authors report no conflict of interest.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Tarek Bekfani
    • 1
    • 2
    Email author
  • Pierpaolo Pellicori
    • 3
  • Daniel Morris
    • 1
  • Nicole Ebner
    • 4
  • Miroslava Valentova
    • 4
    • 5
  • Anja Sandek
    • 4
  • Wolfram Doehner
    • 1
    • 6
  • John G. Cleland
    • 3
  • Mitja Lainscak
    • 7
  • P. Christian Schulze
    • 2
  • Stefan D. Anker
    • 8
    • 9
  • Stephan von Haehling
    • 1
    • 4
  1. 1.Department of Cardiology, Campus Virchow-KlinikumCharité Medical SchoolBerlinGermany
  2. 2.Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, Department of Internal Medicine I, University Hospital JenaFriedrich-Schiller-UniversityJenaGermany
  3. 3.Department of CardiologyUniversity of HullHullUK
  4. 4.Department of Cardiology and PneumologyUniversity of Göttingen Medical CenterGöttingenGermany
  5. 5.Department of Internal MedicineComenius UniversityBratislavaSlovakia
  6. 6.Center for Stroke Research BerlinCharité Medical SchoolBerlinGermany
  7. 7.Department of CardiologyGolnik UniversityGolnikSlovenia
  8. 8.Division of Cardiology and Metabolism-Heart Failure, Cachexia and Sarcopenia, Department of Cardiology, Campus Virchow-KlinikumCharité Medical SchoolBerlinGermany
  9. 9.Berlin-Brandenburg Center for Regenerative Therapies (BCRT)Charité Medical School BerlinBerlinGermany

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