{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T16:29:18Z","timestamp":1788193758499,"version":"build-2803163510"},"reference-count":165,"publisher":"Oxford University Press (OUP)","issue":"6","license":[{"start":{"date-parts":[[2025,12,5]],"date-time":"2025-12-05T00:00:00Z","timestamp":1764892800000},"content-version":"vor","delay-in-days":574,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2024,5,10]],"date-time":"2024-05-10T00:00:00Z","timestamp":1715299200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,6,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>According to current guidelines, iron deficiency is defined by a serum ferritin level &amp;lt;100\u2009ng\/ml or a transferrin saturation (TSAT) &amp;lt;20% if the serum ferritin level is 100\u2013299\u2009\u03bcg\/L. These criteria were developed to encourage the use of intravenous iron as an adjunct to erythropoiesis-stimulating agents in the treatment of renal anaemia. However, in patients with heart failure, these criteria are not supported by any pathophysiological or clinical evidence that they identify an absolute or functional iron deficiency state. A low baseline TSAT\u2014but not serum ferritin level\u2014appears to be a reliable indicator of the effect of intravenous iron to reduce major heart failure events. In randomized controlled trials, intravenous iron decreased the risk of cardiovascular death or total heart failure hospitalization in patients with a TSAT &amp;lt;20% (risk ratio 0.67 [0.49\u20130.92]) but not in patients with a TSAT \u226520% (risk ratio 0.99 [0.74\u20131.30]), with the magnitude of the risk reduction being proportional to the severity of hypoferraemia. Patients who were enrolled in clinical trials solely because they had a serum ferritin level &amp;lt;100\u2009\u03bcg\/L showed no significant benefit on heart failure outcomes, and it is noteworthy that serum ferritin levels of 20\u2013300\u2009\u03bcg\/L lie entirely within the range of normal values for healthy adults. Current guidelines reflect the eligibility criteria of clinical trials, which inadvertently adopted unvalidated criteria to define iron deficiency. Reliance on these guidelines would lead to the treatment of many patients who are not iron deficient (serum ferritin level\u2009&amp;lt;100\u2009\u03bcg\/L but normal TSAT) and ignores the possibility of iron deficiency in patients with a low TSAT but with serum ferritin level of &amp;gt;300\u2009\u03bcg\/L. Importantly, analyses of benefit based on trial eligibility-driven guidelines substantially underestimate the magnitude of heart-failure-event risk reduction with intravenous iron in patients who are truly iron deficient. Based on all available data, we recommend a new mechanism-based and trial-tested approach that reflects the totality of evidence more faithfully than the historical process adopted by clinical investigators and by the guidelines. Until additional evidence is forthcoming, an iron deficiency state in patients with heart failure should be defined by a TSAT &amp;lt;20% (as long as the serum ferritin level is &amp;lt;400\u2009\u03bcg\/L), and furthermore, the use of a serum ferritin level &amp;lt;100\u2009\u03bcg\/L alone as a diagnostic criterion should be discarded.<\/jats:p>","DOI":"10.1002\/ejhf.3237","type":"journal-article","created":{"date-parts":[[2024,5,10]],"date-time":"2024-05-10T11:00:17Z","timestamp":1715338817000},"page":"1298-1312","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":25,"title":["Critical Re-Evaluation of the Identification of Iron Deficiency States and Effective Iron Repletion Strategies in Patients with Chronic Heart Failure"],"prefix":"10.1093","volume":"26","author":[{"given":"Milton","family":"Packer","sequence":"first","affiliation":[{"name":"Baylor University Medical Center , Dallas, TX ,","place":["USA"]},{"name":"Imperial College , London ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan D.","family":"Anker","sequence":"additional","affiliation":[{"name":"Department of Cardiology of German Heart Center Charit\u00e9, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, Partner Site Berlin, Charit\u00e9 Universit\u00e4tsmedizin , Berlin ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javed","family":"Butler","sequence":"additional","affiliation":[{"name":"Baylor Scott and White Research Institute, Baylor University Medical Center , Dallas, TX ,","place":["USA"]},{"name":"University of Mississippi Medical Center , Jackson, MS ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John G.F.","family":"Cleland","sequence":"additional","affiliation":[{"name":"British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow , Glasgow ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul R.","family":"Kalra","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Portsmouth Hospitals University NHS Trust , Portsmouth ,","place":["UK"]},{"name":"College of Medical, Veterinary & Life Sciences, University of Glasgow , Glasgow ,","place":["UK"]},{"name":"Faculty of Science and Health, University of Portsmouth , Portsmouth ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert J.","family":"Mentz","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Duke University School of Medicine, and Duke Clinical Research Institute , Durham, NC ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Piotr","family":"Ponikowski","sequence":"additional","affiliation":[{"name":"Institute of Heart Diseases, Wroclaw Medical University , Wroclaw ,","place":["Poland"]},{"name":"Institute of Heart Diseases, University Hospital , Wroclaw ,","place":["Poland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khawaja M.","family":"Talha","sequence":"additional","affiliation":[{"name":"University of Mississippi Medical Center , Jackson, MS ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2024,5,10]]},"reference":[{"key":"2026010913062696200_ejhf3237-bib-0001","doi-asserted-by":"crossref","first-page":"2436","DOI":"10.1056\/NEJMoa0908355","article-title":"Ferric carboxymaltose in patients with heart failure and iron deficiency","volume":"361","author":"Anker","year":"2009","journal-title":"N Engl J Med"},{"key":"2026010913062696200_ejhf3237-bib-0002","doi-asserted-by":"crossref","first-page":"1895","DOI":"10.1016\/S0140-6736(20)32339-4","article-title":"Ferric carboxymaltose for iron deficiency at discharge after acute heart failure: A 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