Real-world implementation of iron deficiency screening in heart failure

Background Iron deficiency (ID) is a common and relevant comorbidity in heart failure (HF), associated with impaired functional capacity and adverse outcomes. Current guidelines recommend periodic iron assessment, yet real-world implementation remains insufficiently characterised. Purpose To evaluate adherence to guideline-recommended ID screening in HF and explore real-world patterns of ID detection, treatment initiation, and reassessment in a large contemporary quality care registry in the Netherlands. Methods TITRATE-HF is a prospective, multicentre registry of patients with LVEF <50% (inclusion 2022-2024). Patients were categorised as de novo (<3 months since diagnosis), chronic (>6 months), or worsening HF (>6 months with recent HF hospitalisation). ID screening was defined as documented iron testing at baseline, or at 6- and 12-month follow-up (± 6 months). ID was defined as ferritin <100 µg/L, or ferritin 100–299 µg/L with transferrin saturation <20%. Testing rates were compared across outpatient care settings (general cardiology vs dedicated HF clinics). Among screened patients, ID prevalence, treatment initiation, and post-treatment reassessment were evaluated. Multivariable logistic regression identified independent predictors of performing ID screening. Results Among 4,283 patients with HF and documented outpatient care setting, 63% (n= 2,686) underwent ID screening. Testing was performed in 67% of patients in dedicated HF outpatient clinics versus 40% in general cardiology outpatient clinics (p<0.001) (Figure 1). At baseline, ID was identified in 994 patients (47% of those tested). Among patients with ID, 38% received iron supplementation, predominantly intravenous (84%). Reassessment after therapy remained limited (26% within 6 months; 44% within 12 months). In the de novo HF cohort (n=1,728), 56% underwent ID screening at baseline, of whom 41% had ID. Among worsening HF patients (n=316), 48% underwent ID screening. Of those tested, 60% had ID, of whom 44% received iron supplementation. Assessment of iron status occurred in 14% of patients within 7 days and in 22% within 30 days of HF hospitalisation. Higher NYHA class, lower baseline LVEF, and lower heamoglobin levels were independently associated with increased odds of ID screening, whereas chronic and worsening HF (vs de novo HF) were associated with reduced odds (Figure 2). Management in a dedicated HF outpatient clinic was the strongest independent predictor of ID screening (OR 2.87, 95% CI 2.39–3.44; p<0.001). Conclusion In this contemporary HF cohort, challenges in the optimal implementation of guideline-directed ID screening remain, with more than one-third of patients remaining untested for ID. Performing ID screening was associated not only with disease severity but also with organisational structure of care, particularly management within dedicated HF clinics. Still, initiation of iron therapy and reassessment of iron parameters show room for improvement.Figure 1Figure 2