Clinical research study
Anemia and Heart Failure: A Community Study

https://doi.org/10.1016/j.amjmed.2008.03.039Get rights and content

Abstract

Purpose

Anemia is an important comorbidity in heart failure and has been associated with increased mortality. The goals of this study were to define the prevalence of anemia in a community population with heart failure, examine trends in prevalence over time, and evaluate the role of anemia in patients with heart failure with preserved and reduced ejection fraction.

Methods

Two cohorts of Olmsted County residents with heart failure were examined. The retrospective cohort included incident heart failure cases from 1979 to 2002 (n = 1063). The prospective cohort included active heart failure cases from 2003 to 2006 (n = 677). Clinical characteristics were collected. Anemia was defined by World Health Organization criteria.

Results

The prevalence of anemia was 40% in the retrospective cohort and 53% in the prospective cohort. Anemia prevalence increased by an estimated 16% between 1979 and 2002 (P = .008) and was higher in those with preserved (≥50%) versus reduced (<50%) ejection fraction (58% vs 48%, respectively, P < .001) from 2003 to 2006. Anemia was associated with a large increase in the risk of death (P < .001 both cohorts). The relationship between mortality and hemoglobin followed a J-shaped curve, with increased mortality with hemoglobin levels less than 14 mg/dL and greater than 16 mg/dL. In the prospective cohort, after adjustment for clinical characteristics, the hazard ratios (95% confidence interval) for death were 3.07 (1.26-6.82) in those with a hemoglobin level of 16 mg/dL or more and 2.39 (1.37-4.27) in those with a hemoglobin level less than 10 mg/dL, using hemoglobin 14 to 16 mg/dL as the referent.

Conclusion

In the community, half of patients with heart failure are anemic, and the prevalence of anemia has increased over time. Anemia is more prevalent in heart failure with preserved ejection fraction and is associated with a large increase in mortality.

Section snippets

Study Design and Setting

This is a population-based study conducted in Olmsted County, Minnesota, using the resources of the Rochester Epidemiology Project. According to the US Census Bureau (www.census.gov), the 2005 Olmsted County population is estimated at 135,189, the majority of whom are white (90.2%) and 50.8% of whom are women.

We used 2 complementary study designs in this analysis: a retrospective cohort including patients with incident heart failure diagnosed from 1979 to 2002 and a prospective cohort enrolling

Patient Populations

There were 1063 patients with heart failure in the retrospective cohort and 677 patients in the prospective cohort. Age and sex distributions in both cohorts were similar. The prospective cohort had an increased proportion of patients with higher BMI, hypertension, diabetes, coronary artery disease, smoking, chronic obstructive pulmonary disease, and malignancy (P < .001 for all).

Retrospective Cohort

The prevalence of anemia was 40% and increased over time (Figure 1), with an estimated increase of 0.67% annually.

Discussion

In community patients with heart failure, the prevalence of anemia is high and increasing over time. Currently, anemia is present in more than half of patients with heart failure and is considerably more prevalent in those with preserved ejection fraction. Anemia is associated with a large increase in mortality independently of known clinical characteristics. The relationship between hemoglobin and mortality is not linear, because both reduced (<14 mg/dL) and elevated (≥16 mg/dL) hemoglobin are

Conclusions

More than half of community patients with heart failure are currently anemic and the prevalence is increasing over time. Patients with heart failure with preserved ejection fraction have an increased prevalence of anemia compared with patients with reduced ejection fraction. Anemia is associated with increased mortality, but hemoglobin follows a J-shaped curve, with increased mortality at both low and very high hemoglobin levels. Further work is needed to investigate the increasing prevalence

Acknowledgments

We thank Ellen Koepsell, RN, and Kay Traverse, RN, for study support.

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    This study was supported by grants from the National Institute of Health (RO1 HL 59205, RO1 HL 72435) and by an American Heart Association Postdoctoral Greater Midwest Fellowship Award to Dr Dunlay. Dr Roger is an Established Investigator of the American Heart Association.

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