Iron deficiency, diabetes and gout in HFrEF — case discussion

Presentation

Practice case (not a real patient). A 71-year-old man in Brisbane has HFrEF with an LVEF of 30% and NYHA class III fatigue and breathlessness on an ARNI, a beta-blocker and spironolactone; dapagliflozin was started 2 weeks ago.^[1][2] He also has type 2 diabetes, chronic kidney disease (eGFR 40 mL/min/1.73 m²) and gout, and he is euvolaemic at review.^[1] His GP recently added saxagliptin, and he has been taking ibuprofen for a painful knee.^[1]

Step 1 — Screen the comorbidities

Discussion:

• The ESC 2026 key messages say patients with HF should be routinely screened and treated for non-cardiovascular comorbidities (such as diabetes, CKD, obesity, iron deficiency, anxiety and depression) and for frailty.^[1]
• When HF is first suspected, ESC 2026 already recommends iron status (TSAT and ferritin), HbA1c, kidney function and a full blood count among the screening tests for comorbidities (Class I, Level C).^[1]
• His results: haemoglobin 121 g/L, ferritin 70 ng/mL, TSAT 12%, potassium 5.0 mmol/L.^[5][1]
• He is anaemic by the WHO definition used by NHFA/CSANZ 2018 (Hb <130 g/L in males), and iron deficient by both the previous ESC definition and TSAT <20%.^[5][1]

Step 2 — Treat the iron deficiency

Discussion:

• ESC 2026 recommends intravenous iron in symptomatic HFrEF with iron deficiency to alleviate HF symptoms and improve QoL (Class I, Level B1), and says it should be considered to reduce the risk of HF hospitalisation (Class IIa, Level B1).^[1]
• ESC 2026 names ferric carboxymaltose or ferric derisomaltose for the hospitalisation aim and says patients with TSAT <20% might benefit most.^[1]
• Oral iron is not the answer: AHA/ACC/HFSA 2022 says intravenous repletion of iron has been shown to improve exercise capacity and QoL, whereas IRONOUT HF showed no such improvement with oral iron supplementation, and calls oral iron not adequate to treat iron deficiency anaemia in HF.^[2]
• Because he is iron deficient, and especially as he is also anaemic, the 2018 Australian guideline advises considering investigation for gastrointestinal pathology, including peptic ulcer and malignancy.^[5]
• After intravenous iron, the same guideline advises rechecking iron studies after 4 months.^[5]

Step 3 — Review the diabetes drugs

Discussion:

• Saxagliptin should be stopped: ESC 2026 says saxagliptin and thiazolidinediones have been associated with an approximately 30% increased risk of HF hospitalisation and are contraindicated in HF.^[1]
• Dapagliflozin stays: ESC 2026 recommends an SGLT2 inhibitor in symptomatic HF independent of LVEF to reduce the risk of HF hospitalisation or CV death (Class I, Level A) and says SGLT2 inhibitors are recommended in all patients with HF and T2DM.^[1]
• If more glycaemic control is needed, the 2026 CKM guideline says adding metformin to an SGLT2 inhibitor can be beneficial to help achieve glycaemic targets in T2D with stable HF and eGFR ≥30 mL/min/1.73 m² when HbA1c is above the individualised goal (COR 2a, LOE B-NR).^[3]
• ESC 2026 says insulin, if needed, calls for monitoring for worsening HF after it is started.^[1]

Step 4 — Gout and the anti-inflammatory

Discussion:

• Ibuprofen should be stopped: ESC 2026 says NSAIDs and COX-2 inhibitors are not recommended in HF because they increase the risk of HF worsening and HF hospitalisation (Class III, Level B2).^[1]
• ESC 2026 says hyperuricaemia and gout attacks can be frequent in patients with HF, mainly caused or precipitated by diuretic treatment; it recommends allopurinol as the first choice to lower uric acid chronically in HF, and says colchicine can be used for acute gout attacks.^[1]

Step 5 — Kidney function and potassium

Discussion:

• Four weeks after dapagliflozin was started, his creatinine is 20% above baseline with eGFR 33 mL/min/1.73 m², and potassium is 5.6 mmol/L.^[1]
• ESC 2026: a transient decrease in kidney function after starting an SGLT2 inhibitor should not prompt its interruption, and a creatinine rise of <50% above baseline is considered acceptable as long as eGFR remains >15 mL/min/1.73 m².^[1]
• ESC 2026 says hyperkalaemia, and the fear of inducing it, often results in under-use, dose reduction or discontinuation of ACE-I/ARNI/ARB and MRAs, compromising their cardio-kidney benefit in HF.^[1]
• With CKD, HFrEF and eGFR >30 mL/min/1.73 m², the 2026 CKM guideline says novel oral potassium binders may be reasonable to reduce risk of hyperkalaemia and allow use of RAAS inhibition (COR 2b, LOE B-R); ESC 2026 makes no specific recommendation on binders.^[3][1]

Step 6 — Sleep, weight and mood

Discussion:

• His wife reports witnessed apnoeas; ESC 2026 says suspected sleep-disordered breathing should be referred for overnight polysomnography to document whether central or obstructive apnoea predominates.^[1]
• If central sleep apnoea predominates, adaptive servo-ventilation is not recommended in HFrEF (ESC 2026, Class III, Level A), because of an increased risk of CV and all-cause death.^[1]
• He has lost 8% of his weight without oedema, which meets the weight-loss threshold by which ESC 2026 Table S17 says cachexia can be defined (weight loss >7.5% in the absence of oedema).^[1]
• The ESC 2026 HF guideline says assessment of anxiety, depression and frailty should be considered in HF to support personalised care plans and to identify factors that may contribute to adverse outcomes (Class IIa, Level C); the ESC 2026 cardiac rehabilitation guideline recommends psychological screening (depression, anxiety) for comprehensive risk assessment in patients with heart disease to guide appropriate referral, intervention and management (Class I, Level C).^[1][6]
• The same cardiac rehabilitation table recommends psychological interventions for patients with CAD and HF to improve mental functioning (reduce anxiety and depressive symptoms) and HRQoL, and cognitive behaviour therapy for CAD, HF or an implanted ICD to improve mental functioning and reduce cardiovascular risk (each Class I, Level B1).^[6]
• Telemonitoring and computer or cell phone-based psychosocial education and training should be considered in CAD and HF to reduce anxiety and depression symptoms (Class IIa, Level B1).^[6]
• AHA/ACC/HFSA 2022 says screening for depression, social isolation, frailty and low health literacy as risk factors for poor self-care is reasonable to improve management (COR 2a, LOE B-NR).^[2]

Take-home points

• Iron deficiency is defined by ferritin and TSAT, and ESC 2026 supports TSAT <20% alone; intravenous iron has a Class I, Level B1 row for symptoms and QoL in symptomatic HFrEF.^[1]
• ESC 2026 says saxagliptin and thiazolidinediones are contraindicated in HF, and NSAIDs and COX-2 inhibitors are not recommended because they increase the risk of HF worsening and HF hospitalisation.^[1]
• After starting ACE-I/ARNI/ARB, MRA or SGLT2 inhibitor, a creatinine rise of <50% above baseline is considered acceptable as long as eGFR remains >15 mL/min/1.73 m² (ESC 2026).^[1]