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26ANEMIA AND THE HEARTThe serum creatinine did not change in A but increasedby 20% in B. Most important, the need for oral andintravenous furosemide decreased by 51 and 91%, respectively,in A, but increased 20%, respectively, in B. Lengthof hospital stay decreased significantly in A (79%), butincreased 57% in B.Horwich et al. analyzed a cohort of 1061 patients withsevere heart failure. The survival at one year was higher inpatients with increased hemoglobin levels. They concludedthat in chronic heart failure relatively mild degrees ofanemia are associated with worsened symptoms, functionalclass, and survival.Mozaffarian et al., using a prospective cohort design,evaluated the relationship between baseline serum hematocritand mortality among 1130 patients with a leftventricular ejection fraction less than 30% treated withACE inhibitors, diuretics, and digitalis. Follow up at 15months showed 407 deaths in those with a hematocrit of25–37%; these patients had a 52% higher risk of deathcompared with those with a normal hematocrit of 46–58%. In patients with severe heart failure, anemia is asignificant independent risk factor for death with a progressivelyhigher risk with increasing severity of anemia.The etiology, prevention, and treatment of anemia insevere heart failure require further investigation to improvesurvival rates.Correction of anemia in patients with heart failure hasbeen shown in this study to be most beneficial. Treatmentwith EPO and intravenous iron caused marked improvementin heart function and was associated with a significantreduction in hospitalization, renal impairment,and the need for diuretics. Correction of the anemiaalso enhances the standard therapy for heart failure.Silverberg et al. stated that it is surprising, judgingfrom the literature on heart failure, that such an obvioustreatment for improving heart failure is so rarelyconsidered.BIBLIOGRAPHYAnand, I., McMurray, J. J. V., Whitmore, J. et al. Anemia and itsrelationship to clinical outcome in heart failure. Circulation,110:149–154, 2004.Ezekowitz, J. A., McAlister, F. A., Armstrong, P. W. et al. Anemia iscommon in heart failure and is associated with poor outcomes:Insights from a cohort of 12,065 patients with new-onset heart failure.Circulation, 107:223–225, 2003.Horwich, T. B., Fonarow, G. C., Hamilton, M. A. et al. Anemia isassociated with worse symptoms, greater impairment in functionalcapacity and a significant increase in mortality in patients withadvanced heart failure. J. Am. Coll. Cardiol., 39:1780, 2002.Ishani, A., Weinhandl, E., Zhao, Z., Gilbertson, D. T., Collins, A. J.,Yusuf, S., Herzog, C. A. et al. Angiotensin-converting enzymeinhibitor as a risk factor for the development of anemia, and theimpact of incident anemia on mortality in patients with left ventriculardysfunction. JACC, 45:391–399.Mancini, D. M., Katz, S. D., Lang, C. C. et al. Effect of erythropoietin onexercise capacity in patients with moderate to severe chronic heartfailure. Circulation, 107:294–299, 2003.Mozaffarian, D., Nye, R., and Levy, W. C. Anemia predicts mortality insevere heart failure. J. Am. Coll. Cardiol., 41:19, 33–9, 2003.Schroecksnadel, Wirleitner, K. B., Fuchs, D. et al. Anemia and congestiveheart failureo response. Circulation, 108:41–42, 2003.Silverberg, D. S., Wexler, D., Sheps, D. et al. The effect of correctionof mild anemia in severe resistant congestive heart failure usingsubcutaneous erythropoietin and intravenous iron: A randomizedcontrolled study. J. Am. Coll. Cardiol., 37:1775, 2001.