Abstract
BACKGROUND: Iron deficiency (ID) is frequent in chronic heart failure (HF). Among HF-ID patients those with impaired iron transport (IIT) (Transferrin saturation (TSAT) < 20 %) have the worst prognosis. In HF survival is strictly related to exercise limitation but the link between IIT, exercise limitation and survival is at present undefined. METHODS: We evaluated in 999 consecutive patients hospitalized for worsening HF whether IIT affects prognosis through cardiopulmonary exercise test (CPET), i.e. peak oxygen uptake (VO(2)) and ventilation vs. carbon dioxide (VE/VCO(2)) slope. In all patients at stabilization iron metabolism and maximal CPET were performed. Survival was assessed as all cause death, urgent LVAD and heart transplant were considered death equivalents. The causal relationship between survival and IIT, peakVO(2) and VE/VCO(2)slope was assessed applying path analysis. RESULTS: PeakVO(2,) VE/VCO(2)slope and TSAT were 68 ± 44 %pred, 35 ± 9 and 24.4 ± 12.9, respectively. PeakVO(2) and(,) VE/VCO(2)slope were 61 ± 18 vs. 72 ± 53 %pred and 38 ± 10 vs. 33 ± 8, in IIT vs. non IIT patients (p < 0.0001 in both). At univariable and multivariable analysis a correlation between survival and VO(2), VE/VCO(2)slope and TSAT was observed; at Kaplan-Myer lower peakVO(2), higher VE/VCO(2)slope and lower TSAT showed worst survival; at path analysis IIT showed both an important effect on survival independent from peakVO(2) and VE/VCO(2)slope (48 %) and an effect on survival independently mediated by VE/VCO(2)slope and peakVO(2) (52 %), contributing to the IIT negative effect on survival. CONCLUSIONS: The adverse impacts of low TSAT on prognosis are in part direct and in part mediated by mechanisms related to reduced peakVO(2) and increased @VE/VCO(2)slope.