Recommendation 115: We recommend that IV iron therapy be considered for patients with HFrEF and iron deficiency, in view of improving exercise tolerance, quality of life, and reducing HF hospitalizations (Strong Recommendation, Moderate Quality of Evidence).

Values and preferences: The CONFIRM-HF trial, 3 meta-analyses and the recent EFFECT-HF trial have improved the quality of evidence regarding benefits of IV iron therapy on the above outcome measures but there is yet no evidence regarding benefits on mortality. Given the rapid rate of iron repletion using the IV route and the available evidence, this treatment should be considered rather than PO iron repletion. Ongoing hospitalization can provide a good opportunity to facilitate IV iron administration.

Iron deficiency can be difficult to diagnose in patients with HF and diagnosis should ideally be done in a clinically stable state. The most widely accepted definition is a serum ferritin < 100 mg/L or ferritin between 100 and 299 mg/L and transferrin saturation < 20%. New biomarkers, such as soluble transferrin receptor, hepcidin and reticulocyte Hb may improve the sensitivity and specificity for the diagnosis of iron deficiency; but their clinical utility has yet to be demonstrated.