Table 7.6. Recommendations for use of intravenous iron in HFrEF patients.

Recommendation	Class	LE	Comments	Table 2018	Ref.
Intravenous ferric carboxymaltose replacement in patients with HFrEF and iron deficiency (serum ferritin below 100 ng/mL or between 100-299 ng/mL with transferrin saturation below 20%), even in the absence of anemia, to increase physical exercise capacity, improve quality of life, and reduce hospitalization rates.	IIa	A	2018 recommendation remains current.	Item 11.11 (page 470)	See 2018
Intravenous ferric carboxymaltose replacement in patients with HFrEF hospitalized for decompensated HF with iron deficiency (serum ferritin below 100 ng/mL or between 100-299 ng/mL with transferrin saturation below 20 percent) after clinical stabilization to reduce hospital readmission rates.	IIa	B	NEW: A multicenter randomized trial supports the recommendation.	New	105
In patients with chronic HF and iron deficiency, the use of intravenous ferric carboxymaltose led to improvements in symptoms, quality of life and hospitalization rates in previous meta-analyses and randomized trials.106–108 More recently, the multicenter, randomized, placebo-controlled AFFIRM-AHF trial assessed the effect of intravenous ferric carboxymaltose in 1,132 patients with HFrEF and iron deficiency (stable after an episode of HF decompensation and with iron deficiency — ferritin < 100 ng/mL or serum ferritin between 109 and 299 ng/mL associated with transferrin saturation below 20 percent) and found it to be safe and to reduce hospitalization for HF (217 vs. 294 hospitalizations; RR = 0.74; 95% CI 0.58-0.94, p = 0.013), though it had no direct impact on decreasing cardiovascular mortality.105,109

HF: heart failure; HFrEF: heart failure with reduced ejection fraction.