Anaemia and iron deficiency in cardiac patients

Starts with active bleeding with haemodynamic instability or ischaemic symptoms (transfuse first, Hb thresholds do not apply), then defines and grades anaemia with the 2024 WHO haemoglobin cut-offs (including pregnancy by trimester) and diagnoses iron deficiency with the ASH 2026 ferritin thresholds (≤ 30 ng/mL in adults, including menstruation and pregnancy, instead of ≤ 15; ≤ 50 with heavy menstrual bleeding, symptoms or risk factors, planned surgery and pregnancy with anaemia; ferritin < 100 or TSAT < 20% with inflammation), beside the ESC heart failure definition (ferritin < 100 ng/mL, or 100–299 with TSAT < 20%). Calculates MCV, MCH and MCHC from Hb, Hct (PCV) and RBC, TIBC from transferrin and TSAT from serum iron and TIBC, the reticulocyte production index and the Mentzer index, then sorts the anaemia into microcytic (iron deficiency, β- or α-thalassaemia trait from HbA2/HbF, HbE, HbH, anaemia of inflammation, sideroblastic), normocytic (haemolysis including valve-related and immune, bleeding, CKD, hypoproliferative) or macrocytic (B12, folate, reticulocytosis, myelodysplasia) with the next tests. In symptomatic heart failure with LVEF < 50% it applies the ESC 2026 and ACC/AHA 2022 IV iron recommendations and gives ferric carboxymaltose (Ferinject), ferric derisomaltose (Monofer) and iron sucrose doses with the Ganzoni deficit. In cardiac patients without heart failure it sets Hb and ferritin/TSAT goals, oral versus IV iron, ARC-HBR bleeding risk on antithrombotics, preoperative correction, and transfusion thresholds in acute MI (REALITY, MINT) and stable patients, and the AABB 2023 thresholds (7, 7.5 in cardiac surgery, 8 with cardiovascular disease or orthopaedic surgery) in patients without heart disease. Iron deficiency work-up includes stool for occult blood.