Clinical Guideline

Treatment of Anemia in Patients With Heart Disease: A Clinical

Practice Guideline From the American College of Physicians
Amir Qaseem, MD, PhD, MHA; Linda L. Humphrey, MD, MPH; Nick Fitterman, MD; Melissa Starkey, PhD; and
Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*

Description: The American College of Physicians (ACP) developed

this guideline to present the evidence and provide clinical recommendations on the treatment of anemia and iron deficiency in adult
patients with heart disease.
Methods: This guideline is based on published literature in the
English language on anemia and iron deficiency from 1947 to July
2012 that was identified using MEDLINE and the Cochrane Library.
Literature was reassessed in April 2013, and additional studies were
included. Outcomes evaluated for this guideline included mortality;
hospitalization; exercise tolerance; quality of life; and cardiovascular
events (defined as myocardial infarction, congestive heart failure
exacerbation, arrhythmia, or cardiac death) and harms, including
hypertension, venous thromboembolic events, and ischemic cerebrovascular events. The target audience for this guideline includes
all clinicians, and the target patient population is anemic or iron-

nemia is common in patients with heart disease. It is

present in approximately one third of patients with
congestive heart failure (CHF) and 10% to 20% of patients with coronary heart disease (CHD) (13). The cause
of anemia in heart disease is not fully understood. Several
factors probably contribute, including iron deficiency, comorbid chronic kidney disease, blunted erythropoietin
production, hemodilution, aspirin-induced gastrointestinal
blood loss, use of reninangiotensinaldosterone system
blockers, cytokine-mediated inflammation (anemia of
chronic disease), and gut malabsorption with consequent
nutritional deficiency.
Anemia can worsen cardiac function and is associated
with poor outcomes, including increased risk for hospitalization and death, decreased exercise capacity, and poor

See also:
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Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-32
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deficient adult patients with heart disease. This guideline grades the
evidence and recommendations using the ACPs clinical practice
guidelines grading system.
Recommendation 1: ACP recommends using a restrictive red
blood cell transfusion strategy (trigger hemoglobin threshold of 7 to
8 g/dL compared with higher hemoglobin levels) in hospitalized
patients with coronary heart disease. (Grade: weak recommendation; low-quality evidence)
Recommendation 2: ACP recommends against the use of
erythropoiesis-stimulating agents in patients with mild to moderate
anemia and congestive heart failure or coronary heart disease.
(Grade: strong recommendation; moderate-quality evidence)
Ann Intern Med. 2013;159:770-779.
For author affiliations, see end of text.

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quality of life. However, it is not clear whether anemia

directly and independently leads to these poor outcomes or
whether it reflects more severe underlying illness (4 6).
Treatments for anemia in patients with heart disease include erythropoiesis-stimulating agents (ESAs), red blood
cell (RBC) transfusion, and iron replacement, although it
is unclear whether these strategies improve outcomes.
The purpose of this American College of Physicians
(ACP) guideline is to present current evidence on the treatment of anemia in patients with heart disease or iron deficiency. The target audience for this guideline includes all
clinicians, and the target patient population is anemic or
iron-deficient adult patients with heart disease. These recommendations are based on a background paper (7) and a
systematic evidence review sponsored by the U.S. Department of Veterans Affairs (8).

METHODS
This guideline is based on a systematic evidence review
and summary paper (7, 8) that addressed the following key
questions related to the treatment of anemia in patients
with heart disease:
1. In patients with CHF or CHD, what are the health
benefits and harms of treating anemia with RBC
transfusions?

* This paper, written by Amir Qaseem, MD, PhD, MHA; Linda L. Humphrey, MD, MPH; Nick Fitterman, MD; Melissa Starkey, PhD; and Paul Shekelle, MD, PhD, was developed
for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its
approval were: Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Molly Cooke, MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Paul Dallas, MD; Nick Fitterman, MD;
Mary Ann Forciea, MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schunemann, MD, PhD; Donna E. Sweet, MD; and Timothy Wilt, MD, MPH. Approved
by the ACP Board of Regents on 30 July 2013.
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This article has been corrected. The specific correction appears on the last page of this document. The original version (PDF) is available at www.annals.org.

Treating Anemia in Patients With Heart Disease

Table 1. The American College of Physicians Guideline

Grading System*
Strength of Recommendation

Quality of
Evidence

High
Moderate
Low

Benefits Clearly Outweigh

Risks and Burden or Risks
and Burden Clearly
Outweigh Benefits

Benefits Finely Balanced

With Risks and Burden

Strong
Strong
Strong

Weak
Weak
Weak

Insufficient evidence to determine net benefits or risks

* Adopted from the classification developed by the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) workgroup.

2. In patients with CHF or CHD, what are the health

benefits and harms of treating anemia with ESAs?
3. In patients with CHF or CHD, what are the health
benefits and harms of using iron to treat iron deficiency
with or without anemia?
The systematic evidence review was conducted by the
Evidence-based Synthesis Program Center at the Portland
Veterans Affairs Medical Center. The literature search included English-language studies published from 1947 to
July 2012 identified by using MEDLINE and the Cochrane Library. Additional information from the search
came from systematic reviews; reference lists of pertinent
studies, reviews, and editorials; by consulting experts and
ClinicalTrials.gov; and by contacting pharmaceutical companies directly. In April 2013, the literature was reassessed,
and 2 studies originally reported as in-progress were subsequently published and are included in this review (9, 10).
Two reviewers assessed study quality according to a Cochrane protocol, and the Cochran Q test and I2 statistic
were used to assess statistical heterogeneity (11). The outcomes of interest included mortality (all-cause and diseasespecific), hospitalization (all-cause and disease-specific), exercise tolerance (any metric, most commonly the New
York Heart Association [NYHA] functional class and the
6-minute walk test), quality of life, and cardiovascular
events (myocardial infarction [MI], exacerbation of heart
failure, and need for revascularization). More details of the
methods can be found in the article and full report (7, 8).
This guideline rates the evidence and recommendations by using ACPs guideline grading system (Table 1).
Details of the ACP guideline development process can be
found in the methods paper (12).

BENEFITS OF TREATMENT
RBC TRANSFUSIONS

OF

ANEMIA WITH

Medical and Surgical Patients Combined

Mortality

Low-quality evidence from 6 studies of medical and

noncardiac surgical patients (10, 1317) assessed the effect
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Clinical Guideline

of RBC transfusions to treat anemia in patients with heart

disease and showed no mortality benefit for liberal RBC
transfusion (hemoglobin level 10 g/dL) compared with
restrictive RBC transfusion (hemoglobin level 10 g/dL)
(relative risk [RR], 0.94 [95% CI, 0.61 to 1.42]; I2
16.8%). A recent randomized pilot trial of patients with
unstable and stable CHD having cardiac catheterization
found that a liberal transfusion strategy was associated with
fewer major cardiac events and deaths. The group assigned
to the restrictive transfusion strategy was older and had
more patients with unstable CHD, but inclusion of these
results in the meta-analysis still did not result in a statistically significant improvement in outcomes (10).
Cardiovascular Events

Low-quality evidence (1317) showed that liberal

RBC transfusions were associated with reduced cardiovascular events (RR, 0.64 [CI, 0.38 to 1.09]; I2 0.0%),
although the data were not statistically significant.
Exercise Tolerance and Duration

Evidence was insufficient to determine the effect of

RBC transfusions on exercise tolerance and duration.
Quality of Life

Evidence was insufficient to determine the effect of

RBC transfusions on quality of life.
Nonsurgical Patients
Mortality

Low-quality evidence from 3 trials (16, 18, 19)

showed no mortality benefit with a higher RBC transfusion threshold in nonsurgical patients with acute MI or
known ischemic heart disease. One study of 838 euvolemic, nonbleeding, critically ill patients with hemoglobin
levels less than 9 g/dL defined restrictive transfusion as a
hemoglobin threshold of 7 g/dL with goal hemoglobin levels of 7 to 9 g/dL and a liberal strategy threshold as 10 g/dL
with a goal of 10 to 12 g/dL (19). The study did not find
any statistically significant difference between the 2 groups
in hospital mortality or at 30 days after treatment. Post hoc
subgroup analysis of patients with ischemic heart disease
showed a nonstatistically significant higher mortality in the
restrictive transfusion group (30-day mortality of 21.2%
vs. 26.1% for liberal vs. restrictive strategies, respectively;
P 0.38) (16). The other study (18) of 45 patients with
acute MI and hematocrit less than 30 defined conservative
transfusion as a trigger of 24 with a target hematocrit of 24
to 27, whereas the liberal strategy was defined as a trigger
of 30 with a target hematocrit of 30 to 33. This study
showed that the liberal strategy was associated with a
higher rate of the composite outcome of in-hospital death,
recurrent MI, or new or worsening heart failure (38% vs.
13%; P 0.046). Pooled data from the 2 studies showed
no mortality benefit for aggressive compared with conservative RBC transfusion protocols (RR, 1.00 [CI, 0.68 to
1.46]; I2 0.0%).
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Exercise Tolerance and Duration

The Acute Coronary Syndrome or MI

Evidence was insufficient to determine the effect of

RBC transfusions on exercise tolerance and duration.

Twelve observational studies (25, 26, 32, 34 43) evaluated transfusion in patients with the acute coronary syndrome or MI. Overall, the data suggested that transfusion
provides no benefit and may harm patients with heart disease and hemoglobin levels greater than 10 g/dL. Furthermore, patients with nonST-segment elevation MI and hemoglobin levels ranging from 8 to 9 g/dL also do not have
improved outcomes with transfusions.

Quality of Life

Evidence was insufficient to determine the effect of

RBC transfusions on quality of life.
Surgical Patients
Mortality

Low-quality evidence from 3 studies (13, 14, 20) assessed short-term mortality in hip fracture and vascular
surgery patients treated with liberal RBC transfusion (hemoglobin trigger, 10 g/dL) compared with restrictive transfusion (hemoglobin trigger, 8 to 9 g/dL) and found no
difference in outcomes between the 2 treatments (RR, 1.35
[CI, 0.80 to 2.25]; I2 0.0%). Observational studies also
failed to find a mortality benefit with aggressive transfusion
(14, 21, 22).
Cardiovascular Events

Subgroup analysis in 1 study in vascular surgery patients found an increase in MI in patients transfused at a
hemoglobin level of 9 g/dL or more compared with those
transfused at hemoglobin levels ranging from 7 to 9 g/dL
(21). Low-quality evidence from 2 studies (10, 15) did not
find a statistically significant difference between liberal and
restrictive RBC transfusion protocols in cardiovascular complications of MI (RR, 0.60 [CI, 0.34 to 1.03]; I2 0.0%).
Exercise Tolerance and Duration

Evidence was insufficient to determine the effect of

RBC transfusions on exercise tolerance and duration.
Quality of Life

Evidence was insufficient to determine the effect of

RBC transfusions on quality of life.
Observational Studies of RBC Transfusions in Different
Populations of Patients With Heart Disease

Because few randomized, controlled trials assessed

RBC transfusions for treatment of anemia in patients with
heart disease, the evidence review also included observational studies in various patient populations. For more information on the descriptions, quality, and outcomes of
the individual studies, refer to the background evidence
review (8).
Percutaneous Coronary Intervention

Nine observational studies (2333) evaluated blood

transfusion in patients having percutaneous coronary intervention. The mean nadir hemoglobin levels across the
studies were 8 to 9 g/dL. Overall, most studies showed that
transfusion was associated with a higher mortality risk in
the percutaneous coronary intervention population and
suggested that this risk may be higher in nonbleeding anemic patients.
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Heart Failure

Evidence from 2 observational studies (44, 45) that

assessed transfusion in patients with acute decompensated
heart failure reported conflicting results on mortality.

HARMS OF TREATMENT
RBC TRANSFUSIONS

OF

ANEMIA WITH

Adverse events potentially associated with RBC transfusions have been described in other patient populations
and include CHF, fever, and transfusion-related acute lung
injury. Reporting of harms for RBC transfusions for anemic patients with heart disease was sparse. No trials reported excess adverse events for liberal compared with restrictive transfusion.

BENEFITS

OF

TREATMENT

OF

ANEMIA WITH ESAS

Overall evidence from 16 randomized, controlled trials

(9, 46 61) evaluating the effect of ESAs in patients with
heart disease did not show that ESA use improved health
outcomes (Table 2). The baseline hemoglobin levels for
study patients ranged from 9 to 10 g/dL.
Mortality

High-quality evidence showed that ESA treatment did

not improve mortality in anemic patients with stable CHF.
Pooled data from 11 studies of patients with CHF or
CHD (hemoglobin target levels, 12 to 15 g/dL) suggested
an increased risk for mortality (RR, 1.07 [CI, 0.98 to
1.16]; I2 0.0%) for patients receiving ESA treatment
compared with control patients (9, 46, 49, 50, 5357,
60, 62).
Cardiovascular Events

High-quality evidence showed that ESAs do not affect

cardiovascular events in patients with stable CHF. Pooled
data from 7 studies (reported in 8 publications) (47, 48,
54 57, 60, 61) showed no difference in the risk for cardiovascular events when comparing ESA treatment with
control (RR, 0.94 [CI, 0.82 to 1.08]; I2 41.5%). Hemoglobin target levels ranged from 9.0 to 15.0 g/dL in the
studies.
Exercise Tolerance and Duration

Moderate-quality evidence showed that ESA treatment

had no effect on exercise tolerance and duration in patients
with stable CHF. Pooled data from 9 studies (46, 49, 50,
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Treating Anemia in Patients With Heart Disease

Clinical Guideline

Table 2. Evidence for the Effects of RBC Transfusions, ESAs and IV Iron for the Treatment of Anemia in Patients With Heart
Disease
Treatment

Patient Population

Outcome

Effect* Data

Quality of
Evidence

RBC transfusions

Stable CHD (all patients)

Mortality
Cardiovascular events
Mortality
Cardiovascular events
Mortality
Cardiovascular events
Mortality
Cardiovascular events
Quality of life
Exercise tolerance and duration

()
()
()
()
()
()
()
()
()
()

Low
Low
Low
Low
Low
Low
High
High
Moderate
Moderate

Hospitalizations
Harms, including hypertension
and cerebrovascular and
thrombotic events
Mortality
Cardiovascular events
Quality of life
Venous thrombosis
Mortality
Cardiovascular events
Exercise tolerance and duration
Quality of life
Serious harms

()
()

ACS
Noncardiac surgery
ESAs

Stable CHF

Stable CHD

IV iron

Stable CHF

()
()
()
()
()
()
()
()
()

RR, 0.86 (95% CI, 0.46 to 1.62)

RR, 0.60 (CI, 0.34 to 1.03)
RR, 0.23 (CI, 0.05 to 1.02)
RR, 0.70 (CI, 0.24 to 2.07)
RR, 1.44 (CI, 0.81 to 2.54)
RR, 0.52 (CI, 0.27 to 1.01)
RR, 1.07 (CI, 0.98 to 1.16)
RR, 0.94 (CI, 0.82 to 1.08)
No consistent differences
Mean difference in NYHA, 0.77
(CI, 1.21 to 0.32)
RR, 0.97 (CI, 0.87 to 1.10)
Hypertension: RR, 1.20 (CI, 0.90 to 1.59)
Ischemic stroke: RR, 1.33 (CI, 0.93 to 1.89)
VTE: RR, 1.36 (CI, 1.17 to 1.58)
Increased mortality
No effect
No effect
Increased risk for venous thrombosis
NA
27.6% vs. 50.2% (P 0.01)
Improvements in NYHA class and 6-min walk test
Improvement on various scales
No differences, although harms were sparsely reported

High
Moderate

Low
Low
Low
Low
Insufficient
Low
Moderate
Moderate
Moderate

ACS acute coronary syndrome; CHD coronary heart disease; CHF congestive heart failure; ESA erythropoiesis-stimulating agent; IV intravenous; NA not
applicable; NYHA New York Heart Association; RBC red blood cell; RR relative risk; VTE venous thromboembolism.
*Effect: () indicates that treatment provided benefit; () indicates that treatment resulted in harm; () indicates mixed findings or no effect.
Patients included in these studies had advanced kidney disease and/or end-stage renal disease, so the application to other patient populations is unclear.

52, 53, 5557, 59) showed that treatment with ESAs in

patients with CHF (hemoglobin target levels, 12.0 to 15.0
g/dL) resulted in improved NYHA functional class scores
compared with control patients (mean difference, 0.77
[CI, 1.12 to 0.32]; I2 96%). However, the results
were generally inconsistent and the studies were highly heterogeneous. Limiting the analysis to the 4 methodologically rigorous studies (50, 53, 56, 57) showed no statistically significant difference in NYHA scores (NYHA score,
0.15 [CI, 0.36 to 0.06]; I2 62.1%). Pooled data
from 4 studies (51, 52, 56, 58) (hemoglobin target levels,
12.5 to 15.0 g/dL) showed that ESA treatment resulted in
a nonstatistically significant increase in the 6-minute walk
test, and the studies were heterogeneous (mean change in
distance walked, 74.4 m [CI, 0.16 to 149.0 m]; I2
88.7%). Reported clinically important differences in the
6-minute walk test range from 43 to 54 m (63). Two
studies used the Naughton protocol to assess change in
exercise treadmill time. The smaller trial showed a slight
increase in exercise duration with ESA treatment (62);
however, the larger trial showed no difference (53).
Quality of Life

Moderate-quality evidence from 6 studies (51, 53,

56 58) showed that treatment with ESAs did not improve
quality of life in anemic patients with stable CHF (hemoglobin target levels, 13.0 to 15.0 g/dL in the studies). The
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sistencies in the results limited analysis of this outcome.

Two of the 4 trials (53, 56 58) that used the Patient
Global Assessment scale showed that ESA treatment improved scores. One trial (58) had methodological flaws,
and 1 study (57) found no significant differences in the
Kansas City Cardiomyopathy Questionnaire and Minnesota Living With Heart Failure Questionnaire scores. One
of the 4 trials (53, 56 58) that evaluated the Minnesota
Living With Heart Failure Questionnaire scores showed
improvement with treatment, although this study had a
high risk of bias (58). Of the 3 studies (51, 56, 57) that
evaluated patients by using the Kansas City Cardiomyopathy Questionnaire, 1 study reported an improvement
from baseline total symptom score (56), whereas another
study reported improvements in functional score and
summary score (51). Low-quality evidence from 1 study
of patients with CHD and end-stage renal disease showed
no improvement in quality of life (60).
Hospitalization

High-quality evidence showed that hospitalizations

were not statistically significantly different for patients with
stable CHF. Limiting the analysis to the 3 trials with a low
risk of bias (53, 54, 57, 60) showed no difference in hospitalizations (RR, 0.97 [CI, 0.87 to 1.10]; I2 0.0%).
Pooling data from all 8 studies showed that ESA treatment
was associated with a reduction in hospitalizations compared with control (RR, 0.69 [CI, 0.52 to 0.93]; I2
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Clinical Guideline

Treating Anemia in Patients With Heart Disease

37.7%); however, pooling data from only the larger and

higher-quality studies showed no effect. Hemoglobin target levels in the studies ranged from 13.0 to 15.0 g/dL.

HARMS

OF

TREATMENT

OF

ANEMIA WITH ESAS

Hypertension

Moderate-quality evidence pooled from 7 studies of

patients with CHF (48, 50 53, 56, 57) showed that ESA
treatment was associated with a nonstatistically significant
increased risk for hypertension compared with control
(RR, 1.20 [CI, 0.90 to 1.59]; I2 0.0%) (hemoglobin
target levels, 9.0 to 15.0 g/dL).
Cerebrovascular Events

Moderate-quality evidence from 4 studies (5153, 57)

reported on cerebrovascular events in patients with CHF.
However, few events were reported, and no difference between ESA and control groups was shown (RR, 1.33 [CI,
0.93 to 1.89]; I2 15.9%) (hemoglobin target levels, 12.5
to 14.0 g/dL).
Venous Thrombosis

Moderate-quality evidence from 4 studies in patients

with CHF showed that ESAs (hemoglobin target levels,
12.5 to 15.0 g/dL) increased the risk for venous thrombosis, with 1 trial reporting on patients with chronic kidney disease and diabetes (RR, 1.36 [CI, 1.17 to 1.58]). A
recent randomized, double-blind trial of patients with
systolic heart failure and anemia found a significant increase in thromboembolic events in those treated with
darbepoetin- to a goal hemoglobin level greater than 13
mg/dL (9).

INFLUENCE OF HEMOGLOBIN TARGET LEVELS

OUTCOMES

ON

No studies assessed the effects of moderate compared

with lower hemoglobin target levels on outcomes in patients with heart disease. All of the small trials comparing
ESAs with placebo in patients with heart failure included
patients with moderate anemia and a mean baseline hemoglobin level within the narrow range (10 to 12 g/dL). In all
case patients, ESA use was associated with a statistically
significant increase in hemoglobin level (mean range, 1.6
to 2.8 g/dL).
Three studies (47, 48, 54) evaluated the titration of
ESAs to target normal hemoglobin levels compared with
lower targets (9 to 11.3 g/dL) in patients with comorbid
chronic kidney disease and heart disease and found no benefit from aggressive ESA use. Two of the studies (48, 54)
showed that aggressive ESA use to normalize hemoglobin
level increased the risk for venous thromboembolic events
and suggested increased mortality rates (48, 54).
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BENEFITS OF USING INTRAVENOUS IRON TO TREAT

IRON DEFICIENCY WITH OR WITHOUT ANEMIA
Three studies (64 66) assessed the effect of intravenous (IV) iron in patients with heart failure. Data were
primarily derived from 1 large study, which included patients with and without anemia and found similar results
for both groups (64) (Table 2).
Mortality

Evidence was insufficient to determine the effect of IV

iron treatment on mortality.
Cardiovascular Events

Low-quality evidence from 1 study (64) found that

27.6% of patients treated with IV iron carboxymaltose had
cardiovascular events compared with 50.2% of patients receiving placebo (P 0.01). However, this end point was
not prespecified in the study, and the definition of the
outcome was unclear.
Exercise Tolerance and Duration

Moderate-quality evidence showed that IV iron administration increased exercise tolerance and duration in
patients with stable CHF and chronic kidney disease no
worse than stage 3. The largest trial, FAIR-HF (Ferinject
Assessment in Patients With Iron Deficiency and Chronic
Heart Failure) included anemic and nonanemic patients,
with most patients having ferritin levels less than 100 g/L
(64). This trial showed that 200 mg of IV ferric carboxymaltose increased 6-minute walk distance (313 m vs. 277
m) compared with IV saline (64). A second study found
that among patients with iron deficiency, anemia, chronic
heart failure, and chronic kidney disease, treatment with
200 mg of IV iron sucrose weekly for 5 weeks increased
6-minute walk distance compared with saline (66). The
FERRIC-HF (Ferric Iron Sucrose in Heart Failure) (65)
study showed that patients who received 200 mg of IV iron
sucrose had improved exercise duration compared with
placebo. However, this trial had a high risk of bias due to
lack of patient blinding.
Quality of Life

Moderate-quality evidence showed that IV iron improved quality of life in patients with anemia or iron deficiency, stable CHF, and chronic kidney disease no worse
than stage 3. The FAIR-HF study showed that IV iron
treatment improved Patient Global Assessment scores compared with control patients (50% vs. 28%; odds ratio, 2.51
[CI, 1.75 to 3.61]) and improved NYHA functional class
(odds ratio for improvement by 1 class, 2.40 [CI, 1.55 to
3.71]), regardless of anemia status (hemoglobin level 12
g/dL) (64). This trial also showed improved quality-of-life
scores as assessed by the European Quality of Life5 Dimensions (EQ-5D) (63 vs. 67) (64). Two other studies
showed that patients who received 200 mg of IV iron sucrose had improved Minnesota Living With Heart Failure
Questionnaire and NYHA scores (65, 66).
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Treating Anemia in Patients With Heart Disease

HARMS OF USING INTRAVENOUS IRON TO TREAT IRON

DEFICIENCY WITH OR WITHOUT ANEMIA
Moderate-quality evidence from 3 studies (64 66)
found no statistically significant difference in serious harms
between IV iron treatment and control. However, harms
were sparsely reported, and there is no available evidence
on long-term outcomes.

SUMMARY
Management of patients with heart disease and anemia
might appropriately differ from that of the general population. Hence, understanding the evidence base and using
clinical judgment are critical when managing these patients. Anemia is associated with worse outcomes in patients with CHF or CHD. However, it is uncertain if anemia is the cause of poorer outcomes or if it is a marker of
poor outcomes and reflects advanced cardiovascular disease. See Table 2 for a summary of the evidence reviewed
in this guideline.
Low-quality evidence found that RBC transfusion using restrictive compared with liberal transfusion protocols
had no effect on mortality in patients with CHD. Observational studies suggested that transfusion is not beneficial
and may be harmful among patients with heart disease and
hemoglobin levels greater than 10 g/dL. A recently published trial indicated a trend toward improved cardiovascular outcomes in patients with anemia and unstable or stable
CHD (10). However, differences in the baseline characteristics of the study groups and the small size of this pilot
study do not answer the key clinical questions above, even
after inclusion in the meta-analysis.
Overall, moderate-quality evidence showed no benefit
from ESAs for improving exercise tolerance and duration
or quality of life, and high-quality evidence showed no
mortality benefit. Serious harms associated with the treatment include mortality and vascular thrombosis. A recently
published trial showed no benefit across all subgroups studied and showed increased harms among those treated to a
goal hemoglobin level greater than 13 g/dL (9). The evidence for ESA use is most applicable to patients with CHF
and systolic dysfunction.
Few studies addressed IV iron therapy for patients
with heart disease, and data on long-term harms were unavailable. One good-quality study among patients with
chronic stable systolic heart failure showed that IV iron
carboxymaltose improved exercise tolerance, quality of life,
and exercise duration. Overall, moderate-quality evidence
showed that IV iron therapy reduced cardiovascular events,
and low-quality evidence found a mortality benefit. The
evidence for IV iron therapy is most applicable to patients
with NYHA class III heart failure and low ferritin levels.
Refer to the Figure for a summary of the recommendations
and clinical considerations.
Recommendation 1: ACP recommends using a restrictive
red blood cell transfusion strategy (trigger hemoglobin threshold of 7 to 8 g/dL compared with higher hemoglobin levels) in
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Clinical Guideline

hospitalized patients with coronary heart disease. (Grade:

weak recommendation; low-quality evidence)
Low-quality evidence showed no mortality benefit of
liberal compared with restrictive transfusion strategies
across the patient populations studied. Most evidence did
not show a substantial difference in benefit between liberal
and restrictive RBC transfusions. In addition, low-quality
evidence showed conflicting results for cardiovascular
events. Low-quality evidence showed no mortality benefit
of a higher (liberal) transfusion threshold (hemoglobin levels 10 g/dL) and fewer cardiovascular events with a lower
(restrictive) transfusion threshold (hemoglobin levels of 7
to 8 g/dL) in noncardiac surgery patients. Studies showed
no short-term mortality benefit in hip fracture and vascular
surgery patients treated with liberal RBC transfusion compared with restrictive transfusion and found no difference
in outcomes. Observational studies also failed to find a
mortality benefit with aggressive liberal transfusion. For
noncardiac surgeries other than hip fracture surgery, data
are inconclusive. Low-quality evidence showed that patients with the acute coronary syndrome who received liberal RBC transfusions (hemoglobin threshold of 10 g/dL)
had a mortality benefit compared with those who received
more restrictive transfusion thresholds. However, this result was from a small study that included patients with
stable and unstable CHD, and the difference was not statistically significant. Harms were sparsely reported, and no
trials reported a difference in adverse events for liberal
compared with restrictive transfusions.
Recommendation 2: ACP recommends against the use of
erythropoiesis-stimulating agents in patients with mild to
moderate anemia and congestive heart failure or coronary
heart disease. (Grade: strong recommendation; moderatequality evidence)
The harms outweigh the benefits for treating patients
with mild to moderate anemia using ESAs. The potential
harms associated with ESA therapy include increased risk
for thromboembolic events shown in 3 studies and a suggestion of increased stroke rates in 1 study. Although anemia is common in patients with CHF and CHD, highquality evidence showed that treatment with ESAs did not
improve mortality or affect cardiovascular events or hospitalizations, and moderate-quality evidence showed no improvement for quality of life. Baseline hemoglobin levels
for study patients ranged from 9 to 10 g/dL.

INCONCLUSIVE AREAS

OF

EVIDENCE

Emerging evidence shows a short-term benefit from IV

iron carboxymaltose in patients with CHF and ferritin levels less than 100 g/L. However, evidence is lacking on
long-term outcomes, and evidence on harms was sparsely
reported. The effect of oral administration of iron and how
it compares with IV iron for treating anemic patients with
heart disease is unknown. Current evidence suggests that
IV iron treatment improves exercise tolerance and quality
3 December 2013 Annals of Internal Medicine Volume 159 Number 11 775

Clinical Guideline

Treating Anemia in Patients With Heart Disease

Figure. Summary of the American College of Physicians guideline on treatment of anemia in patients with heart disease.

ACP Clinical Practice

American College of Physicians

GUIDELINES
Summary of the American College of Physicians Guideline on
Treatment of Anemia in Patients With Heart Disease
Disease/Condition
Target Audience
Target Patient Population
Interventions
Outcomes

Benefits of Treatment

Harms of Treatment

Recommendations

High Value Care

Clinical Considerations

Anemia and heart disease

Internists, family physicians, and other clinicians
Adult patients with symptomatic CHF (with or without reduced systolic function) or CHD (acute coronary syndrome,
postacute coronary syndrome, or a history of MI or angina) and anemia or iron deficiency
Red blood cell transfusion, ESAs with or without iron (including erythropoietin and darbepoetin), and intravenous iron
Mortality (all-cause and disease-specific); cardiovascular events (MI, CHF exacerbation, arrhythmia, or cardiac death);
exercise tolerance (any metric, most commonly NYHA class, 6-min walk test); quality of life; hospitalization (all-cause and
disease-specific); and harms, including hypertension, venous thromboembolic events, and ischemic cerebrovascular events
Red blood cell transfusion: no benefits shown when comparing liberal to restrictive transfusion
ESAs: no benefit
Intravenous iron: increased exercise tolerance, improved quality of life
Red blood cell transfusion: adverse events potentially associated with red blood cell transfusions, such as fever, transfusionrelated acute lung injury, and congestive heart failure
ESAs: hypertension and venous thrombosis
Intravenous iron: no harms identified but sparsely reported
Recommendation 1: ACP recommends using a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold
of 78 g/dL compared with higher hemoglobin levels) in hospitalized patients with coronary heart disease. (Grade: weak
recommendation; low-quality evidence)
Recommendation 2: ACP recommends against the use of erythropoiesis-stimulating agents in patients with mild to
moderate anemia and congestive heart failure or coronary heart disease. (Grade: strong recommendation; moderate-quality
evidence)
Current evidence does not support the benefit of liberal blood transfusions in patients with asymptomatic anemia and heart
disease. Therefore, the ACP does not support the liberal use of blood transfusions in the management of mild to moderate
anemia in patients with cardiovascular disease. The probability that transfusion may be beneficial is higher in patients with
lower hemoglobin levels (<7 g/dL) and lower in less anemic patients (hemoglobin >10 g/dL) (67). The ACP does not
support the use of ESAs for treating patients with mild to moderate anemia and heart disease because the harms outweigh
the benefits for these patients.
Patients with heart disease may have anemia because of iron deficiency, use of ACE inhibitors, renal insufficiency, and poor
nutrition.
Presence of anemia is associated with increased mortality and morbidity. However, it is uncertain if anemia is an independent
risk factor for poor outcomes or if it is a marker of more severe illness.
The impact of oral administration of iron and how it compares with IV iron for treating anemic patients with heart disease is
unknown.

ACE angiotensin-converting enzyme; CHD coronary heart disease; CHF congestive heart failure; ESA erythropoiesis-stimulating agent; MI
myocardial infarction; NYHA New York Heart Association.

of life and reduces mortality and hospitalizations. Although

the evidence is intriguing and positive, it is limited to only
3 studies at this time, and the data were primarily derived
from 1 large trial that included patients with and without
anemia. Note that at the time of writing of this guideline,
ferrous carboxymaltose was not yet approved for IV treatment of anemic patients in the United States.

ACP HIGH-VALUE CARE

Current evidence does not support the benefit of liberal blood transfusions in patients with asymptomatic anemia and heart disease. Therefore, ACP does not support
this practice for management of mild to moderate anemia
in patients with cardiovascular disease. The probability
776 3 December 2013 Annals of Internal Medicine Volume 159 Number 11

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that transfusion may be beneficial is greater in patients

with lower hemoglobin levels (7 g/dL) and lower in less
anemic patients (hemoglobin levels 10 g/dL) (67). The
ACP does not support use of ESAs in cases of mild to
moderate anemia and heart disease because the harms outweigh the benefits for these patients.
From the American College of Physicians, Philadelphia, Pennsylvania;
Oregon Health and Science University, Portland, Oregon; Huntington
Hospital, Pasadena, California; and West Los Angeles Veteran Affairs
Medical Center, Los Angeles, California.
Note: Clinical practice guidelines are guides only and may not apply to
all patients and clinical situations. Thus, they are not intended to override clinicians judgment. All ACP clinical practice guidelines are conwww.annals.org

Treating Anemia in Patients With Heart Disease

sidered automatically withdrawn or invalid 5 years after publication or
once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents,
including any clinical or treatment recommendations. No statement in
this article should be construed as an official position of the U.S. Department of Veterans Affairs.
Financial Support: Financial support for the development of this guide-

line comes exclusively from the ACP operating budget.

Potential Conflicts of Interest: Dr. Shekelle: Grants: Agency for
Healthcare Research and Quality, Veterans Affairs, Centers for Medicare
& Medicaid Services, Office of the National Coordinator for Health Information Technology; Personal fees: ECRI Institute, Veterans Affairs,
UpToDate. All other authors have no disclosures. Disclosures can also be
viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms
.do?msNumM13-1830. A record of conflicts of interest is kept for
each Clinical Guidelines Committee meeting and conference call and
can be viewed at www.acponline.org/clinical_information/guidelines
/guidelines/conflicts_cgc.htm.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, Amer-

ican College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected].
Current author addresses and author contributions are available at www
.annals.org.

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Clinical Guideline

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Ad Libitum
He Lectures at the Heritage Association Dinner
After dessert, the women
arranged themselves upstairs
in a private room. He began
by presenting the usual
distinction between letting
a patient die and killing.
His examples generated
a spark that ignited
tiny firecrackers behind
a dozen faces and waving
hands rose, Doctor! Doctor!
A husband suffering torture
long after his body
gave outa physicians
hubris. An injured brother
severed from machines too soon
by doctors who had stolen
his wifes consent. Passion
took hold of the group.
Anger and urgency tore
great hunks of experience
from the womens hearts
and grief uncovered its roots.
Having sprung the hinges
of ethics, he sampled
the best dose in his cabinet
silence. When passion subsided,
the president praised the talk
that had not been given
and thanked him profusely
for sharing his wisdom.
Jack Coulehan, MD, MPH
Setauket, New York
Current Author Address: Jack Coulehan, MD, MPH, e-mail, [email protected].
2013 American College of Physicians
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3 December 2013 Annals of Internal Medicine Volume 159 Number 11 779

Current Author Addresses: Drs. Qaseem and Starkey: 190 N. Indepen-

dence Mall West, Philadelphia, PA 19106.

Dr. Humphrey: Oregon Health and Science University, 3710 SW U.S.
Veterans Hospital Road, Portland, OR 97201.
Dr. Fitterman: Huntington Hospital, 270 Park Avenue, Huntington,
NY 11743.
Dr. Shekelle: West Los Angeles Veterans Affairs Medical Center, 11301
Wilshire Boulevard, Los Angeles, CA 90073.

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Author Contributions: Conception and design: A. Qaseem, N. Fitterman, P. Shekelle.

Analysis and interpretation of the data: A. Qaseem, L.L. Humphrey, N.
Fitterman, M. Starkey.
Drafting of the article: A. Qaseem, N. Fitterman, M. Starkey.
Critical revision of the article for important intellectual content: A.
Qaseem, L.L. Humphrey, N. Fitterman, M. Starkey, P. Shekelle.
Final approval of the article: A. Qaseem, L.L. Humphrey, N. Fitterman,
P. Shekelle.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, M. Starkey.
Collection and assembly of data: A. Qaseem.

3 December 2013 Annals of Internal Medicine Volume 159 Number 11

CORRECTION
Correction: Treatment of Anemia in Patients With
Heart Disease
The figure in a recent guideline (1) was incorrect. The correct
version appears below.

ACP Clinical Practice

American College of Physicians

GUIDELINES
Summary of the American College of Physicians Guideline on
Treatment of Anemia in Patients With Heart Disease
Disease/Condition
Target Audience
Target Patient Population
Interventions
Outcomes

Benefits of Treatment

Harms of Treatment

Recommendations

High Value Care

Clinical Considerations

Anemia and heart disease

Internists, family physicians, and other clinicians
Adult patients with symptomatic CHF (with or without reduced systolic function) or CHD (acute coronary syndrome,
postacute coronary syndrome, or a history of MI or angina) and anemia or iron deficiency
Red blood cell transfusion, ESAs with or without iron (including erythropoietin and darbepoetin), and intravenous iron
Mortality (all-cause and disease-specific); cardiovascular events (MI, CHF exacerbation, arrhythmia, or cardiac death);
exercise tolerance (any metric, most commonly NYHA class, 6-min walk test); quality of life; hospitalization (all-cause and
disease-specific); and harms, including hypertension, venous thromboembolic events, and ischemic cerebrovascular events
Red blood cell transfusion: no benefits shown when comparing liberal to restrictive transfusion
ESAs: no benefit
Intravenous iron: increased exercise tolerance, improved quality of life
Red blood cell transfusion: adverse events potentially associated with red blood cell transfusions, such as fever, transfusionrelated acute lung injury, and congestive heart failure
ESAs: hypertension and venous thrombosis
Intravenous iron: no harms identified but sparsely reported
Recommendation 1: ACP recommends using a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold
of 78 g/dL compared with higher hemoglobin levels) in hospitalized patients with coronary heart disease. (Grade: weak
recommendation; low-quality evidence)
Recommendation 2: ACP recommends against the use of erythropoiesis-stimulating agents in patients with mild to
moderate anemia and congestive heart failure or coronary heart disease. (Grade: strong recommendation; moderate-quality
evidence)
Current evidence does not support the benefit of liberal blood transfusions in patients with asymptomatic anemia and heart
disease. Therefore, the ACP does not support the liberal use of blood transfusions in the management of mild to moderate
anemia in patients with cardiovascular disease. The probability that transfusion may be beneficial is higher in patients with
lower hemoglobin levels (<7 g/dL) and lower in less anemic patients (hemoglobin >10 g/dL) (67). The ACP does not
support the use of ESAs for treating patients with mild to moderate anemia and heart disease because the harms outweigh
the benefits for these patients.
Patients with heart disease may have anemia because of iron deficiency, use of ACE inhibitors, renal insufficiency, and poor
nutrition.
Presence of anemia is associated with increased mortality and morbidity. However, it is uncertain if anemia is an independent
risk factor for poor outcomes or if it is a marker of more severe illness.
The impact of oral administration of iron and how it compares with IV iron for treating anemic patients with heart disease is
unknown.

This has been corrected in the online version.

Reference
1. Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P, for the Clinical
Guidelines Committee of the American College of Physicians. Treatment of anemia in
patients with heart disease: a clinical practice guideline from the American College of
Physicians. Ann Intern Med. 2013;159:770-9.

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