Heart Failure due to Anemia

Can anyone tell me the effects of severe anemia on the heart, what exactly happens before it fails or how you can tell it is failing.  I am asking moreso about the effects of anemia on the heart and not necessarily the iron.  That is, someone who is or has been poorly transfused over several years, and how this would impact the heart.  Thanks.

Hi dlevy,

As you might already know that Anemia is the deficiency of blood (RBCs or the HB in them). Which means that the supply of oxygen to the other parts is reduced. The heart then has to work overdrive to meet the demand of oxygen for the body. This excessive exertion can take a toll on the heart muscles and it can "tire out" that leads to heart failure. Iron overload can add to the trouble and damage the heart muscles and make them fail a lot earlier.

I think a cardiologist can tell the condition of the heart by doing tests like Echo Cardio Gram or something like that which measures several parameters of the heart.

Do you know which tests specifically will show the effects of anemia on the heart, and not necessarily the iron (which I know is T2*).  Is it LVEF or something else?

Sorry, I don't know the details.

Like I said a cardiologist might tell you better what's going on with the heart's health.

I previously thought that a high pulse rate was a sign that the heart is working too hard (which makes quite a sense). I have a pretty high pulse rate and when I got my Echo done I was given an "all clear" and told me that most Thals. have high pulse and there is nothing to worry about.

Hi David,

LVEF stands for left ventricular ejection fraction. This test is commonly used to test heart function in thalassemia.
 From http://www.hcoa.org/hcoacme/chf-cme/chf00048.htm

LVEF is a good clinical indicator of left ventricular systolic function. LVEF may be determined either by echocardiograph or radionuclide ventriculography.

The calculation of LVEF is relatively simple in concept, although the calculations of volumes from echocardiographic images is more complex. Conceptually, an estimation is made of the volume of blood in the ventricle at the end of diastole (on left) and the volume of blood remaining in the ventricle at the end of systole (on right).

As Sajid pointed out, anemia causes the heart to work harder. From http://www.heartfailure.org/eng_site/whats_new_anemia.asp

Patients with congestive heart failure (CHF) may have an associated problem of anemia, a decrease in the number of red blood cells (RBC) - the component of blood that carries oxygen. Even by itself, anemia can cause symptoms of shortness of breath and fatigue, similar to the symptoms of heart failure. A low RBC count (hematocrit) limits the amount of oxygen being carried to the body, which makes the heart work harder. In fact, as the severity of CHF progresses, the findings of anemia increase; and severe anemia due to any cause can worsen CHF. Because of this relationship, anemia treatment may be an important part of CHF.

Two medications erythropoietin and darbepoetin alfa, stimulate RBC growth and production in the bone marrow. These medicines require being given by a shot (like insulin) usually every 1-4 weeks. This can help people with heart failure correct their anemia, when it is due to inadequate bone marrow production.
In general, severe anemia may also be treated with vitamins or blood transfusions

However, as usual, nothing is simple.

From http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.105.582577v1

Conclusions--Anemia was common in heart failure, regardless of LVEF. Lower hemoglobin was associated with higher LVEF yet was an independent predictor of adverse mortality and morbidity outcomes. In heart failure, the causes of anemia and the associations between anemia and outcomes are probably multiple and complex.

I know you don't have thal but have you ever been treated at any of the comprehensive care thal centers, such as Chicago Children's Memorial Hospital? Has your case ever been the subject of any study?
   

Hi Andy,

Yes, I've seen Dr. Thompson at Children's Memorial several times, but I am not eligible for any experimental studies because I do not have thal, and the incidence of my disease is even more rare than thal so no researchers are recruiting patients for it.  I was managed largely as an intermedia, and am now being managed like a major ... whereas I should have been managed like a major all along, and have now run into a bunch of problems.  As a result I have some of the things intermedias experience when they are not adequately transfused and chelated, namely very large bone marrow expansion and very high liver and heart iron content even though serrum ferritin levels have remained reasonably low.  It is a case of negligence in my instance, and one that could have been managed much better. 

It should be noted that while iron is perhaps the number one killer of patients, anemia for patients who have been inadequately transfused also contributes greatly to death, and so the tests of anemia on the heart should be identified as well (similar to what T2* tells you if you are at risk for heart failure due to iron overload).  If it is not LVEF, I am not sure what it could be then, since a holter moitor will not show it, and neither will an EKG, in my opinion.  If anyone knows the answer, it would be greatly appreciated. 

David,

I don't know if there is a test to specifically determine the damage to the heart from anemia alone. The LVEF measures the heart function of the left ventricle. Reduced function can be caused by many things, such as anemia, iron overload and chemotherapy. The specific cause of the reduced heart function can often be determined by the nature of the problems that the patient has. What may be most important for you, is that the heart function can be restored by eliminating the anemia. In your case, the more frequent transfusions should be of benefit. Obviously, eliminating the iron overload is also essential. Are you making progress in that area?

Yes, very much so.  In fact I had so much iron in my liver that my R2 scan was 21.5 and after continuous IV desferal it has gone down to 4.66.  My T2* was 38.5 last year and now it is 50.  So the desferal has been working. Since I have been going every 3 weeks now for blood, my hemoglobin levels are also higher and there is less strain on my heart.  However, from all the years that it has been running at a low hemoglobin, is has been very hard to recover, and even now that I am doing all that I can, there is still a great strain on my heart every day ... even to do ordinary activities.  I am actually worried that it might fail, not because of the iron load, but because of the anemia itself (of course in combination with the iron) ... which thickens the heart muscles wall, and eventually weakens it, causing it to fail.  I was just wondering if there is a test to show how your heart is being affected by the anemia (whether it is improving or not, if there is a number of value), similar to how the T2* is available to show if the iron load in the heart is increasing or decreasing.

David,

It's good to hear your ferritin is dropping.

I think ultrasound is used to measure the thickness of the heart. Repeat scans over time should be able to measure any changes in the thickness of the walls and also its function. An annual echo cardiogram may suffice.