Physicians' Academy for Cardiovascular Education

TSAT as marker for iron deficiency best predicts response to intravenous iron in patients with HFrEF

News - May 30, 2023

IRONMAN: Which marker of iron deficiency best predicts response to intravenous iron in patients with heart failure?

Presented at the ESC Heart Failure 2023 by: John Cleland, MD, PhD - Glasgow, UK

Introduction and methods

At the moment there are variations in the definition of iron deficiency (ID) according to different clinical organizations. The WHO defines ID as serum ferritin <15 µg/L, whereas many clinical laboratories use a cut-off of <30 µg/L. The ESC guidelines, however, define ID as serum ferritin <100 µg/L or between 100-299 µg/L and a TSAT <20%.

There are paradoxical data with regard to the clinical prognosis and ID in patients with HFrEF. Data suggest that in patients with HFrEF serum ferritin <100 µg/L is associated with better prognosis, whereas a TSAT <20% is associated with a worse prognosis. In this analysis of IRONMAN, it was determined which marker of ID (TSAT, ferritin or anemia) best predicts clinical prognosis and response to intravenous iron in patients with HFrEF.

IRONMAN was a prospective, randomized, open-label trial with 1137 patients with HFrEF. Patients were randomized to ferric derisomaltose (FDI) or usual care. Eligible patients had ferritin <100 µg/L or TSAT <20%. Exclusion criteria were: ferritin >400 µg/L; Hb <9.0 g/dL or >13 g/dL in women or >14 g/dL in men; and eGFR <15 ml/min/1.73m². The primary endpoint was a composite of recurrent HF hospitalizations or CV death.

Main results


Using data from IRONMAN, it was shown that the risk of events is higher in patients with anemia or TSAT <20%, but lower in patients with serum ferritin <100 µg/L. The effect of FDI on CV events was best predicted by TSAT <20%, especially in patients with serum ferritin of 100-400 µg/dL.

John Cleland concludes his presentation by saying that ‘TSAT could certainly simplify the inclusion criteria and stop confusion if we moved to a new definition [of ID]’.

-Our reporting is based on the information provided at ESC Heart Failure 2023 –

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