HF comorbidities — short answer questions

SAQ 1 (10 marks)

Practice scenario. A 64-year-old man has HFrEF with an LVEF of 32% and NYHA class II–III fatigue and breathlessness despite optimal foundational medical therapy.^[1][2] Bloods show haemoglobin 118 g/L, ferritin 150 ng/mL and TSAT 14%. He is euvolaemic.^[5][1]

1. Is he iron deficient under the previous ESC definition and under the TSAT definition supported by the ESC 2026 Task Force? Give both definitions. (2)^[1]
2. State the two ESC 2026 intravenous iron rows with class and level, and the agents ESC 2026 names in its text for the hospitalisation aim. (2)^[1]
3. State the 2022 AHA/ACC/HFSA intravenous iron row with its COR and LOE, and explain why oral iron is not used. (2)^[2]
4. Give two practical points from the 2018 NHFA/CSANZ guideline once iron deficiency is found. (2)^[5]
5. Is he anaemic by the WHO definition used by NHFA/CSANZ 2018, and what do the guidelines say about erythropoietin-stimulating agents? (2)^[5][1][2]

Model answers — SAQ 1

1. Previous definition: ferritin <100 ng/mL, or ferritin 100–299 ng/mL with TSAT <20%; his ferritin of 150 ng/mL with TSAT 14% meets it (1 mark).^[1] Alternative definition supported by the ESC 2026 Task Force: TSAT <20%; his TSAT of 14% meets it as well (1 mark).^[1]
2. Intravenous iron is recommended in symptomatic HFrEF and iron deficiency to alleviate HF symptoms and improve QoL (Class I, Level B1) (1 mark).^[1] In the same patients, intravenous iron should be considered to reduce the risk of HF hospitalisation (Class IIa, Level B1), with ferric carboxymaltose or ferric derisomaltose, taking into account that patients with TSAT <20% might benefit most (1 mark).^[1]
3. In HFrEF and iron deficiency with or without anaemia, intravenous iron replacement is reasonable to improve functional status and QoL (COR 2a, LOE B-R) (1 mark).^[2] Intravenous repletion of iron has been shown to improve exercise capacity and QoL, but IRONOUT HF showed no such improvement with oral iron supplementation, which AHA/ACC/HFSA 2022 attributes to poor absorption of oral iron and its inadequacy to replete iron stores in HF (1 mark).^[2]
4. Any two (1 mark each): consider investigation for gastrointestinal pathology, including peptic ulcer and malignancy, especially if also anaemic; recheck iron studies after 4 months; in congested patients monitor fluid status and favour a lower-volume infusion.^[5]
5. Yes: the WHO definition is Hb <120 g/L in females and <130 g/L in males, so 118 g/L in a man is anaemia (1 mark).^[5] ESC 2026 says erythropoietin-stimulating agents should be avoided for anaemia related to HF, and AHA/ACC/HFSA 2022 says they should not be used to improve morbidity and mortality (COR 3: Harm, LOE B-R) (1 mark).^[1][2]

SAQ 2 (10 marks)

Practice scenario. A 58-year-old woman has HFrEF (LVEF 35%, NYHA class II), type 2 diabetes and chronic kidney disease with an eGFR of 42 mL/min/1.73 m².^[1][3] Her partner reports pauses in her breathing at night. Overnight polysomnography shows sleep-disordered breathing with predominant central sleep apnoea.^[1]

1. Give the ESC 2026 statement and one North American row, with COR and LOE, for SGLT2 inhibitors in HF with type 2 diabetes. (2)^[1][2][3]
2. Four weeks after an SGLT2 inhibitor and an MRA are started, her creatinine has risen by 25% and her eGFR is 34 mL/min/1.73 m². What does ESC 2026 advise? (2)^[1]
3. Her potassium later reaches 5.6 mmol/L on the MRA, with eGFR still 34 mL/min/1.73 m². Compare what ESC 2026 and the 2026 CKM guideline say about potassium binders. (2)^[1][3]
4. What are the ESC 2026 and AHA/ACC/HFSA 2022 rows on adaptive servo-ventilation for her sleep study result, and on which trial does ESC 2026 base its row? (2)^[1][2]
5. Her GP proposes adding saxagliptin for glycaemic control. What does ESC 2026 say, and name one other drug class ESC 2026 contraindicates for the same reason. (2)^[1]

Model answers — SAQ 2

1. ESC 2026: SGLT2 inhibitors are recommended in all patients with HF and T2DM, independently of HbA1c or other glucose-lowering agents (text; no class or level given) (1 mark).^[1] AHA/ACC/HFSA 2022: in HF with type 2 diabetes, SGLT2i are recommended for hyperglycaemia and to reduce HF-related morbidity and mortality (COR 1, LOE A); or CKM 2026: in CKM stage 4 with T2D and HF, SGLT2i should be prioritised as first-line cardioprotective glucose-lowering medications to reduce cardiovascular death and HF hospitalisations (COR 1, LOE A) (1 mark).^[2][3]
2. A transient decrease in kidney function after starting these drugs should not prompt their interruption (1 mark).^[1] A creatinine rise of <50% above baseline is considered acceptable as long as eGFR remains >15 mL/min/1.73 m², so a 25% rise with an eGFR of 34 mL/min/1.73 m² is within that limit (1 mark).^[1]
3. ESC 2026 includes no specific recommendation for potassium binders, due to insufficient evidence for clinical benefit (1 mark).^[1] CKM 2026: in CKM stage 4 with CKD and HFrEF with eGFR >30 mL/min/1.73 m², novel oral potassium-binding agents may be reasonable to reduce risk of hyperkalaemia and allow RAAS inhibition (COR 2b, LOE B-R) (1 mark).^[3]
4. ESC 2026: adaptive servo-ventilation is not recommended in HFrEF with predominant central sleep apnoea because of an increased risk of CV and all-cause death (Class III, Level A); AHA/ACC/HFSA 2022: in NYHA class II to IV HFrEF with central sleep apnoea it causes harm (COR 3: Harm, LOE B-R) (1 mark).^[1][2] ESC 2026 bases its row on SERVE-HF, which showed an increase in both all-cause and CV death in chronic HF with LVEF ≤45% and sleep-disordered breathing with predominant central sleep apnoea (1 mark).^[1]
5. ESC 2026 says saxagliptin has been associated with an approximately 30% increased risk of HF hospitalisation and is contraindicated in HF (1 mark).^[1] Thiazolidinediones (glitazones) are contraindicated for the same reason (1 mark).^[1]