Anemia in Heart Failure: Still Relevant?

One-third of all patients with heart failure have anemia, and its presence is associated with more symptoms, increased rates of hospitalization, and increased mortality. The etiology of anemia is multifactorial, complex, and varies between patients. The most important factors leading to anemia in heart failure are inadequate erythropoietin production resulting from renal failure, intrinsic bone marrow defects, medication use, and nutritional deficiencies such as iron deficiency. Erythropoiesis-stimulating agents (ESAs) have been proven to successfully correct hemoglobin levels, albeit without significant improvement in clinical outcome. On the contrary, the use of ESAs has led to increased rates of thromboembolic events and ischemic stroke. This use of ESAs for the treatment of anemia in heart failure, therefore, cannot be recommended. In addition, these results question whether anemia is a therapeutic target or merely a marker of disease severity. Other therapies are being studied and include agents targeting the erythropoietin receptor, hepcidin pathway, or iron availability. This review focuses on the pathophysiology of anemia in heart failure, explains why investigated therapies might not have led to the desired results, and discusses promising future therapies.