Published online before print January 6, 2003, doi: 10.1161/01.CIR.0000052622.51963.FC
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2003;107:223.)
© 2003 American Heart Association, Inc.
Brief Rapid Communications |
Anemia Is Common in Heart Failure and Is Associated With Poor Outcomes
Insights From a Cohort of 12 065 Patients With New-Onset Heart Failure
From the Division of Cardiology (J.A.E., P.W.A.) and the Division of General Internal Medicine (F.A.M.), University of Alberta, Edmonton, Alberta, Canada.
Correspondence to Paul W. Armstrong, MD, 2-51 Medical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2H7. E-mail paul.armstrong{at}ualberta.ca
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background— Although previous work has suggested that anemia is associated with an increased mortality in selected patients with congestive heart failure (CHF), little is known about the prevalence and predictors of anemia, or whether anemia is an independent prognostic factor in unselected, community-based patients with CHF.
Methods and Results— We analyzed a population-based cohort of patients with new-onset CHF from a database of patients discharged from 138 acute-care hospitals in Alberta, Canada, between April 1993 and March 2001. Logistic regression, Kaplan-Meier survival analyses, and Cox proportional hazards model were used. Among the 12 065 patients with CHF (median age 78 years), 17% had anemia, 58% of whom had anemia of chronic disease. After adjustment for clinical and demographic variables, patients with anemia were more likely to be older (odds ratio [OR] 1.01 per year) and female (OR 1.2 [95% confidence interval 1.1 to 1.3]) and to have a history of chronic renal insufficiency (OR=3.2 [95% confidence interval 2.8 to 3.6]), or hypertension (OR 1.3 [95% confidence interval 1.2 to 1.5]). Hazard ratios for mortality, adjusting for covariates, were 1.34 (1.24 to 1.46) in anemic patients, and 1.36 (1.23 to 1.50) in those patients with anemia of chronic disease.
Conclusions— In this large cohort of community-dwelling patients with CHF, anemia is common and an independent prognostic factor for mortality. Further research into the mechanisms of anemia in CHF and randomized controlled trials to test whether correction of anemia improves prognosis in CHF are needed.
Key Words: anemia • heart failure • epidemiology
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Despite remarkable advances in diagnosis and therapy over the past decade, the prognosis of patients with heart failure remains poor. Identification of factors that adversely affect quality of life or survival in heart failure may not only aid in better definition of prognosis but could also potentially provide new opportunities for novel therapeutic strategies in these patients.
Although anemia (and its correction) is a well-recognized comorbidity in a variety of conditions, including myocardial ischemia, its role in heart failure has only recently received attention.1–4 Two studies have examined the prevalence and prognosis of anemia in highly selected CHF populations; prevalence was 4% in clinical trial participants (n=6797) with asymptomatic or mild left ventricular dysfunction (relative risk [RR] for death was 1.03 [95% confidence interval (CI) 1.02 to 1.04] for each 1% drop in hematocrit in this sample),1 whereas 30% of patients (n=1061) followed-up in a specialized clinic for advanced heart failure had anemia (RR 1.13 [95% CI 1.05 to 1.22] for mortality).2 In a small population-based cohort (n=633) of Medicare beneficiaries admitted to hospital for CHF, 14% had an admission hematocrit <30%, and these anemic patients had increased mortality at 1 year (RR 1.60 [95% CI 1.19 to 2.16]) compared with those with a hematocrit 
40%.3 Little is known about the prevalence or prognostic importance of anemia in a large unselected population of patients with heart failure.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
We examined a population-based cohort of 12 065 patients with new-onset heart failure in Alberta, Canada (total population 3.06 million). We used hospital discharge data to identify all patients hospitalized at least once for a most responsible diagnosis of heart failure (International Classification of Diseases [ICD]-9 code 428.x) between April 1993 and March 2001, and collated their co-morbidities. The accuracy of our data acquisition and the use of discharge coding to identify cases and comorbidities have been described elsewhere.5,6 To establish a cohort of incident cases, we excluded patients hospitalized for heart failure in the 12 months preceding the index hospitalization, as well as those who died during the index hospitalization.
We linked the study sample to the Alberta Health Care Insurance Registry, which tracks the vital status of all individuals in the province, and followed-up with all patients from the date of their index hospitalization until the date of their death or September 30, 2001, whichever came first. We determined the prevalence of anemia at the time of initial diagnosis of heart failure (using ICD-9 codes 280 to 289 to capture "all anemia" and 285.9 to capture "anemia of chronic disease") and examined for differences between patients who did and did not have anemia at baseline (Table). Continuous variables were compared using ANOVA adjusted for multiple comparisons by Tukey’s test, and ordinal and dichotomous variables were compared using the 
2 test. Mortality rates of patients who were anemic when heart failure was diagnosed and those without anemia were compared using the Cox proportional hazards model, controlling for comorbidities and the known prognostic factors in heart failure (listed in the Table). Data for regression analysis is presented as odds or hazard ratio with 95% confidence intervals. In a sensitivity analysis to minimize confounding by unmeasured comorbidities, we examined the associations between anemia and outcomes in the youngest and healthiest subgroup (patients <65 years without documented comorbidities).
|
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The median age of our 12 065 patients was 78 years; 17% had anemia (21% iron deficiency, 8% other deficiency, 13% assorted other identifiable causes, and 58% had anemia of chronic disease). Baseline features are outlined in the Table. On multiple logistic regression analysis, anemia was more common in older patients (odds ratio [OR] 1.01 per year, P=0.002), women (OR 1.2 [1.1 to 1.3]), patients with chronic renal insufficiency (OR 3.2 [2.8 to 3.6]), or hypertensive patients (OR 1.3 [1.2 to 1.5]).
Median follow-up was 573 days (interquartile range 155 to 1224 days), and the 1-year and 5-year mortality rates were 38% and 59% in those with anemia, respectively, compared with 27% and 50% for those without anemia. The survival of patients with anemia was worse even after adjustment for the known prognostic factors and comorbidities in the Table (Figure). Cox proportional hazard ratios for mortality were 1.34 (1.24 to 1.46) in anemic patients, and 1.36 (1.23 to 1.50) in the subset of patients with anemia of chronic disease. As a sensitivity analysis, we restricted this analysis to the youngest and healthiest subgroup (n=654) and found that anemia was even more strongly associated with mortality (OR 2.4 [1.2 to 4.6]).
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The key novel findings of our study are the demonstration among a large population-based cohort of CHF patients that anemia is common, that it is an independent prognostic factor, and that the majority of heart failure patients with anemia have anemia of chronic disease. There are several possible explanations for our findings. First, reduced hemoglobin may merely be a marker for the epiphenomena of advanced heart failure (such as hemodilution due to volume overload, malnutrition from cardiac cachexia, or renal insufficiency). An earlier study in patients with New York Heart Association class III or IV failure demonstrated, however, that hemoglobin was an important prognostic factor independent of the pulmonary capillary wedge pressure, body mass index, serum albumin, or serum creatinine.2 Furthermore, anemia was an independent predictor of mortality independent of serum creatinine in 2 previous studies.1,3 Second, because angiotensin-converting enzyme (ACE) inhibitors may inhibit hematopoietic cell proliferation, it is possible that anemia may be a marker for patients receiving higher doses of ACE inhibitors.7,8 This seems unlikely, however, as the presence of anemia seems to be independent of ACE inhibitor use (and dosing).1,2 Third, although anemia may predispose at-risk patients to myocardial ischemia, the prognostic impact of anemia was independent of a diagnosis of ischemic heart disease in our data. Finally, inflammation, characterized by increases in cytokines such as tumor necrosis factor-
,9 is now thought to be a pathophysiological modulator of heart failure. Hence, we believe it is reasonable to hypothesize that heart failure may cause anemia of chronic disease through cytokine-mediated bone marrow suppression.7 As this is an observational study, some potential limitations deserve discussion. The limitations of administrative databases are well known and described elsewhere.5 However, previous studies have confirmed the accuracy of our data sources and coding for heart failure.5,6 Further, all of our analyses were adjusted for known prognostic factors in heart failure, and we confirmed the robustness of our findings in a sensitivity analysis in the youngest and healthiest subgroup, where unmeasured confounding would presumably be minimized.10
We believe efforts to better detect anemia in heart failure patients, discern the pathophysiology of, and test new therapies for anemia in heart failure should be a future priority. Indeed, small open-label studies have shown improvements in functional capacity and ejection fraction with correction of anemia using erythropoietin with intravenous iron.4,11 There is clearly a need for an appropriately powered randomized trial with meaningful clinical endpoints, such as hospitalizations and mortality, to evaluate the impact of such therapies in anemic heart failure patients.
|
Acknowledgments |
|---|
This study was supported in part by a grant-in-aid from the Medical Services Innovation Fund from the Alberta Medical Association and Alberta Health and Wellness. Dr McAlister is a Population Health Investigator of the Alberta Heritage Foundation for Medical Research. J. Ezekowitz is a Canadian Institutes of Health Research Strategic Training Fellow in TORCH (Tomorrow’s Research Cardiovascular Health Professionals). No funding agency had input into the design, conduct, analysis or reporting of this study. We thank Nicole Franjic and Wei-Ching Chang for their assistance with data management and statistical support.
Received October 23, 2002; revision received December 3, 2002; accepted December 4, 2002.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Al Ahmad A, Rand WM, Manjunath G, et al. Reduced kidney function and anemia as risk factors for mortality in patients with left ventricular dysfunction. J Am Coll Cardiol. 2001; 38: 955–962.
[Abstract/Free Full Text]
- Horwich TB, Fonarow GC, Hamilton MA, et al. Anemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure. J Am Coll Cardiol. 2002; 39: 1780–1786.
[Abstract/Free Full Text]
- McClellan WM, Flanders WD, Langston RD, et al. Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study. J Am Soc Nephrol. 2002; 13: 1928–1936.
[Abstract/Free Full Text]
- Silverberg DS, Wexler D, Blum M, et al. The use of subcutaneous erythropoietin and intravenous iron for the treatment of the anemia of severe, resistant congestive heart failure improves cardiac and renal function and functional cardiac class, and markedly reduces hospitalizations. J Am Coll Cardiol. 2000; 35: 1737–1744.
[Abstract/Free Full Text]
- Sin D, McAlister FA. The impact of beta-blockers on morbidity and mortality in a population-based cohort of 11 942 elderly patients with congestive heart failure. Am J Med. In press.
- Goff DC Jr, Pandey DK, Chan FA, et al. Congestive heart failure in the United States: is there more than meets the I (CD code)? The Corpus Christi Heart Project. Arch Intern Med. 2000; 160: 197–202.
[Abstract/Free Full Text]
- Iversen PO, Woldbaek PR, Tonnessen T, et al. Decreased hematopoiesis in bone marrow of mice with congestive heart failure. Am J Physiol Regul Integr Comp Physiol. 2002; 282: R166–R172.
[Abstract/Free Full Text]
- Macdougall IC. The role of ACE inhibitors and angiotensin II receptor blockers in the response to epoetin. Nephrol Dial Transplant. 1999; 14: 1836–1841.
[Free Full Text]
- Levine B, Kalman J, Mayer L, et al. Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N Engl J Med. 1990; 323: 236–241.[Abstract]
- Wen SW, Hernandez R, Naylor CD. Pitfalls in nonrandomized outcomes studies: the case of incidental appendectomy with open cholecystectomy. JAMA. 1995; 274: 1687–1691.[Abstract]
- Silverberg DS, Wexler D, Sheps D, et al. The effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study. J Am Coll Cardiol. 2001; 37: 1775–1780.
[Abstract/Free Full Text]
This article has been cited by other articles:
 |
|
 |
|
  P. van der Meer, D. J. Lok, J. L. Januzzi, P. W. B.-A. de la Porte, E. Lipsic, J. van Wijngaarden, A. A. Voors, W. H. van Gilst, and D. J. van Veldhuisen Adequacy of endogenous erythropoietin levels and mortality in anaemic heart failure patients Eur. Heart J., June 2, 2008; 29(12): 1510 - 1515. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Kazory and E. A. Ross Contemporary Trends in the Pharmacological and Extracorporeal Management of Heart Failure: A Nephrologic Perspective Circulation, February 19, 2008; 117(7): 975 - 983. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W.H. W. Tang, W. Tong, A. Jain, G. S. Francis, C. M. Harris, and J. B. Young Evaluation and long-term prognosis of new-onset, transient, and persistent anemia in ambulatory patients with chronic heart failure. J. Am. Coll. Cardiol., February 5, 2008; 51(5): 569 - 576. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Nybo, M. Benn, R. Mogelvang, J. S. Jensen, P. Schnohr, J. F. Rehfeld, and J. P. Goetze Impact of Hemoglobin on Plasma Pro-B-Type Natriuretic Peptide Concentrations in the General Population Clin. Chem., November 1, 2007; 53(11): 1921 - 1927. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Bruch, C. Bruch, J. Sindermann, G. Breithardt, and R. Gradaus Prevalence and prognostic impact of comorbidities in heart failure patients with implantable cardioverter defibrillator Europace, August 1, 2007; 9(8): 681 - 686. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members, J.-P. Bassand, C. W. Hamm, D. Ardissino, E. Boersma, A. Budaj, F. Fernandez-Aviles, K. A.A. Fox, D. Hasdai, E. M. Ohman, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology Eur. Heart J., July 1, 2007; 28(13): 1598 - 1660. [Full Text] [PDF]
|
|
|
|
 |
|
 J D Newton and I B Squire Glucose and haemoglobin in the assessment of prognosis after first hospitalisation for heart failure Heart, October 1, 2006; 92(10): 1441 - 1446. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Hammerman-Rozenberg, J. M. Jacobs, D. Azoulay, and J. Stessman Aspirin prophylaxis and the prevalence of anaemia Age Ageing, September 1, 2006; 35(5): 514 - 517. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. M. Walker, G. Schneider, J. Yeaw, B. Nordstrom, S. Robbins, and D. Pettitt Anemia as a Predictor of Cardiovascular Events in Patients with Elevated Serum Creatinine J. Am. Soc. Nephrol., August 1, 2006; 17(8): 2293 - 2298. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. S. Go, J. Yang, L. M. Ackerson, K. Lepper, S. Robbins, B. M. Massie, and M. G. Shlipak Hemoglobin Level, Chronic Kidney Disease, and the Risks of Death and Hospitalization in Adults With Chronic Heart Failure: The Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study Circulation, June 13, 2006; 113(23): 2713 - 2723. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L Grigorian Shamagian, A Varela Roman, J M Garcia-Acuna, P Mazon Ramos, A Virgos Lamela, and J R Gonzalez-Juanatey Anaemia is associated with higher mortality among patients with heart failure with preserved systolic function Heart, June 1, 2006; 92(6): 780 - 784. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y.-D. Tang and S. D. Katz Anemia in Chronic Heart Failure: Prevalence, Etiology, Clinical Correlates, and Treatment Options Circulation, May 23, 2006; 113(20): 2454 - 2461. [Full Text] [PDF]
|
|
|
|
 |
|
 B. F. Culleton, B. J. Manns, J. Zhang, M. Tonelli, S. Klarenbach, and B. R. Hemmelgarn Impact of anemia on hospitalization and mortality in older adults Blood, May 15, 2006; 107(10): 3841 - 3846. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Cladellas, J. Bruguera, J. Comin, J. Vila, E. de Jaime, J. Marti, and M. Gomez Is pre-operative anaemia a risk marker for in-hospital mortality and morbidity after valve replacement? Eur. Heart J., May 1, 2006; 27(9): 1093 - 1099. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. A. Heidenreich, J. A. Spertus, P. G. Jones, W. S. Weintraub, J. S. Rumsfeld, S. S. Rathore, E. D. Peterson, F. A. Masoudi, H. M. Krumholz, E. P. Havranek, et al. Health Status Identifies Heart Failure Outpatients at Risk for Hospitalization or Death J. Am. Coll. Cardiol., February 21, 2006; 47(4): 752 - 756. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. O'Meara, T. Clayton, M. B. McEntegart, J. J.V. McMurray, C. C. Lang, S. D. Roger, J. B. Young, S. D. Solomon, C. B. Granger, J. Ostergren, et al. Clinical Correlates and Consequences of Anemia in a Broad Spectrum of Patients With Heart Failure: Results of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Program Circulation, February 21, 2006; 113(7): 986 - 994. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Similowski, A. Agusti, W. MacNee, and B. Schonhofer The potential impact of anaemia of chronic disease in COPD Eur. Respir. J., February 1, 2006; 27(2): 390 - 396. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. J. Pocock, D. Wang, M. A. Pfeffer, S. Yusuf, J. J.V. McMurray, K. B. Swedberg, J. Ostergren, E. L. Michelson, K. S. Pieper, C. B. Granger, et al. Predictors of mortality and morbidity in patients with chronic heart failure Eur. Heart J., January 1, 2006; 27(1): 65 - 75. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. L. Schrier Hematology, ASH, and the anemia of the aged Blood, November 15, 2005; 106(10): 3341 - 3342. [Full Text] [PDF]
|
|
|
|
|
|
C. Opasich, M. Cazzola, L. Scelsi, S. De Feo, E. Bosimini, R. Lagioia, O. Febo, R. Ferrari, A. Fucili, R. Moratti, et al. Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure Eur. Heart J., November 1, 2005; 26(21): 2232 - 2237. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. T. Vlagopoulos, H. Tighiouart, D. E. Weiner, J. Griffith, D. Pettitt, D. N. Salem, A. S. Levey, and M. J. Sarnak Anemia as a Risk Factor for Cardiovascular Disease and All-Cause Mortality in Diabetes: The Impact of Chronic Kidney Disease J. Am. Soc. Nephrol., November 1, 2005; 16(11): 3403 - 3410. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. A. Zakai, R. Katz, C. Hirsch, M. G. Shlipak, P. H. M. Chaves, A. B. Newman, and M. Cushman A Prospective Study of Anemia Status, Hemoglobin Concentration, and Mortality in an Elderly Cohort: The Cardiovascular Health Study Arch Intern Med, October 24, 2005; 165(19): 2214 - 2220. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Kosiborod, J. P. Curtis, Y. Wang, G. L. Smith, F. A. Masoudi, J. M. Foody, E. P. Havranek, and H. M. Krumholz Anemia and Outcomes in Patients With Heart Failure: A Study From the National Heart Care Project Arch Intern Med, October 24, 2005; 165(19): 2237 - 2244. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. van der Meer, E. Lipsic, B. D. Westenbrink, R. M.A. van de Wal, R. G. Schoemaker, E. Vellenga, D. J. van Veldhuisen, A. A. Voors, and W. H. van Gilst Levels of Hematopoiesis Inhibitor N-Acetyl-Seryl-Aspartyl-Lysyl-Proline Partially Explain the Occurrence of Anemia in Heart Failure Circulation, September 20, 2005; 112(12): 1743 - 1747. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. S. Anand, M. A. Kuskowski, T. S. Rector, V. G. Florea, R. D. Glazer, A. Hester, Y. T. Chiang, N. Aknay, A. P. Maggioni, C. Opasich, et al. Anemia and Change in Hemoglobin Over Time Related to Mortality and Morbidity in Patients With Chronic Heart Failure: Results From Val-HeFT Circulation, August 23, 2005; 112(8): 1121 - 1127. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. George, S. Patal, D. Wexler, A. Abashidze, H. Shmilovich, T. Barak, D. Sheps, and G. Keren Circulating Erythropoietin Levels and Prognosis in Patients With Congestive Heart Failure: Comparison With Neurohormonal and Inflammatory Markers Arch Intern Med, June 13, 2005; 165(11): 1304 - 1309. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Namiuchi, Y. Kagaya, J. Ohta, N. Shiba, M. Sugi, M. Oikawa, H. Kunii, H. Yamao, N. Komatsu, M. Yui, et al. High Serum Erythropoietin Level Is Associated With Smaller Infarct Size in Patients With Acute Myocardial Infarction Who Undergo Successful Primary Percutaneous Coronary Intervention J. Am. Coll. Cardiol., May 3, 2005; 45(9): 1406 - 1412. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. S. Sabatine, D. A. Morrow, R. P. Giugliano, P. B.J. Burton, S. A. Murphy, C. H. McCabe, C. M. Gibson, and E. Braunwald Association of Hemoglobin Levels With Clinical Outcomes in Acute Coronary Syndromes Circulation, April 26, 2005; 111(16): 2042 - 2049. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. S. Walsh, D. B. McClelland, R. J. Lee, M. Garrioch, C. R. Maciver, F. McArdle, S. L. Crofts, I. Mellor, and for the ATICS Study Group Prevalence of ischaemic heart disease at admission to intensive care and its influence on red cell transfusion thresholds: multicentre Scottish Study Br. J. Anaesth., April 1, 2005; 94(4): 445 - 452. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. C. Fonarow, K. F. Adams Jr, W. T. Abraham, C. W. Yancy, W. J. Boscardin, and for the ADHERE Scientific Advisory Committee, Stud Risk Stratification for In-Hospital Mortality in Acutely Decompensated Heart Failure: Classification and Regression Tree Analysis JAMA, February 2, 2005; 293(5): 572 - 580. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Ishani, E. Weinhandl, Z. Zhao, D. T. Gilbertson, A. J. Collins, S. Yusuf, and C. A. Herzog Angiotensin-converting enzyme inhibitor as a risk factor for the development of anemia, and the impact of incident anemia on mortality in patients with left ventricular dysfunction J. Am. Coll. Cardiol., February 1, 2005; 45(3): 391 - 399. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. M. Guralnik, W. B. Ershler, S. L. Schrier, and V. J. Picozzi Anemia in the Elderly: A Public Health Crisis in Hematology Hematology, January 1, 2005; 2005(1): 528 - 532. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. J.V. McMurray and M. A. Pfeffer The year in heart failure J. Am. Coll. Cardiol., December 21, 2004; 44(12): 2398 - 2405. [Full Text] [PDF]
|
|
|
|
 |
|
 K. Caiola and J. W. Cheng Use of Erythropoietin in Heart Failure Management Ann. Pharmacother., December 1, 2004; 38(12): 2145 - 2149. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Ezekowitz, F. A. McAlister, K. H. Humphries, C. M. Norris, M. Tonelli, W. A. Ghali, M. L. Knudtson, and APPROACH Investigators The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1587 - 1592. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Guralnik, R. S. Eisenstaedt, L. Ferrucci, H. G. Klein, and R. C. Woodman Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia Blood, October 15, 2004; 104(8): 2263 - 2268. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G.M. Felker, K. F. Adams Jr, W. A. Gattis, and C. M. O'Connor Anemia as a risk factor and therapeutic target in heart failure J. Am. Coll. Cardiol., September 1, 2004; 44(5): 959 - 966. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. C. Lee, A. S. Kini, C. Ahsan, E. Fisher, and S. K. Sharma Anemia is an independent predictor of mortality after percutaneous coronary intervention J. Am. Coll. Cardiol., August 4, 2004; 44(3): 541 - 546. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. S. McKechnie, D. Smith, C. Montoye, E. Kline-Rogers, M. J. O'Donnell, A. C. DeFranco, W. L. Meengs, R. McNamara, J. G. McGinnity, K. Patel, et al. Prognostic Implication of Anemia on In-Hospital Outcomes After Percutaneous Coronary Intervention Circulation, July 20, 2004; 110(3): 271 - 277. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. Anand, J. J.V. McMurray, J. Whitmore, M. Warren, A. Pham, M. A. McCamish, and P. B.J. Burton Anemia and Its Relationship to Clinical Outcome in Heart Failure Circulation, July 13, 2004; 110(2): 149 - 154. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|