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Original Investigation
May 16, 2017

Effect of Oral Iron Repletion on Exercise Capacity in Patients With Heart Failure With Reduced Ejection Fraction and Iron Deficiency: The IRONOUT HF Randomized Clinical Trial

Author Affiliations
  • 1Massachusetts General Hospital, Boston
  • 2Duke Clinical Research Institute, Durham, North Carolina
  • 3Emory University, Atlanta, Georgia
  • 4Duke Heart Center, Duke University School of Medicine, Durham, North Carolina
  • 5Cleveland Clinic, Cleveland, Ohio
  • 6Washington University School of Medicine, St Louis, Missouri
  • 7Mayo Clinic, Rochester, Minnesota
  • 8Brigham and Women’s Hospital, Boston, Massachusetts
  • 9University of Vermont Medical Center, Burlington
  • 10Thomas Jefferson University, Philadelphia, Pennsylvania
  • 11National Heart, Lung, and Blood Institute, Bethesda, Maryland
  • 12Stony Brook Medical Center, Stony Brook, New York
JAMA. 2017;317(19):1958-1966. doi:10.1001/jama.2017.5427
Key Points

Question  Does therapy with oral iron improve exercise capacity in patients with heart failure and iron deficiency?

Findings  In this randomized clinical trial of 225 adults with heart failure and reduced ejection fraction, oral iron polysaccharide minimally repleted iron stores and had no significant effect on exercise capacity at 16 weeks compared with placebo (+23 mL/min for oral iron polysaccharide vs −2 mL/min for placebo).

Meaning  These findings do not support the use of oral iron supplementation in patients with heart failure and reduced left ventricular ejection fraction and iron deficiency.


Importance  Iron deficiency is present in approximately 50% of patients with heart failure with reduced left ventricular ejection fraction (HFrEF) and is an independent predictor of reduced functional capacity and mortality. However, the efficacy of inexpensive readily available oral iron supplementation in heart failure is unknown.

Objective  To test whether therapy with oral iron improves peak exercise capacity in patients with HFrEF and iron deficiency.

Design, Setting, and Participants  Phase 2, double-blind, placebo-controlled randomized clinical trial of patients with HFrEF (<40%) and iron deficiency, defined as a serum ferritin level of 15 to 100 ng/mL or a serum ferritin level of 101 to 299 ng/mL with transferrin saturation of less than 20%. Participants were enrolled between September 2014 and November 2015 at 23 US sites.

Interventions  Oral iron polysaccharide (n = 111) or placebo (n = 114), 150 mg twice daily for 16 weeks.

Main Outcomes and Measures  The primary end point was a change in peak oxygen uptake (V̇o2) from baseline to 16 weeks. Secondary end points were change in 6-minute walk distance, plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and health status as assessed by Kansas City Cardiomyopathy Questionnaire (KCCQ, range 0-100, higher scores reflect better quality of life).

Results  Among 225 randomized participants (median age, 63 years; 36% women) 203 completed the study. The median baseline peak V̇o2 was 1196 mL/min (interquartile range [IQR], 887-1448 mL/min) in the oral iron group and 1167 mL/min (IQR, 887-1449 mL/min) in the placebo group. The primary end point, change in peak V̇o2 at 16 weeks, did not significantly differ between the oral iron and placebo groups (+23 mL/min vs −2 mL/min; difference, 21 mL/min [95% CI, −34 to +76 mL/min]; P = .46). Similarly, at 16 weeks, there were no significant differences between treatment groups in changes in 6-minute walk distance (−13 m; 95% CI, −32 to 6 m), NT-proBNP levels (159; 95% CI, −280 to 599 pg/mL), or KCCQ score (1; 95% CI, −2.4 to 4.4), all P > .05.

Conclusions and Relevance  Among participants with HFrEF with iron deficiency, high-dose oral iron did not improve exercise capacity over 16 weeks. These results do not support use of oral iron supplementation in patients with HFrEF.

Trial Registration  clinicaltrials.gov Identifier: NCT02188784