Breathless, pale and in heart failure — investigating and managing anaemia in an older man

Pallor with breathlessness and signs of heart failure in an older man suggests anaemia that is causing or worsening heart failure. Anaemia itself can present with breathlessness, fatigue and heart failure.

Work on two fronts at once: stabilise the heart failure, and find the cause of the anaemia. In an older man, iron deficiency from gastrointestinal blood loss, including cancer, must be looked for.

Judge severity first: chest pain, haemodynamic instability or ongoing bleeding. Transfusion is reserved for severe symptoms or circulatory compromise.

Ask about visible blood loss (melaena, rectal bleeding, haematuria, nosebleeds), diet, previous gastrointestinal surgery, and medicines: aspirin and other antiplatelets, anticoagulants, NSAIDs and long-term proton pump inhibitors.

In older people iron deficiency is often multifactorial (poor diet, reduced absorption, hidden blood loss, medicines, and chronic diseases such as kidney disease and heart failure), so finding one cause should not end the search.

Abdominal symptoms do not reliably show whether, or where, there is gastrointestinal disease. Look for signs of iron deficiency (angular stomatitis, glossitis, koilonychia) and assess congestion.

Full blood count. Anaemia is a haemoglobin below the laboratory's lower limit of normal; heart failure studies use below 13 g/dL in men and 12 g/dL in women. A low MCH or MCV suggests iron deficiency, but both are less reliable with chronic disease, thalassaemia or B12 or folate deficiency.

Iron studies. Ferritin is the single most useful test: below 15 µg/L means iron stores are empty. Ferritin rises with inflammation, so a cut-off of 45 µg/L is more practical, and a value above 150 µg/L makes absolute iron deficiency unlikely. In heart failure, iron deficiency means ferritin below 100 ng/mL, or 100–299 ng/mL with transferrin saturation below 20%.

Vitamin B12 and folate, because their deficiency can accompany iron deficiency in older people.

Heart failure work-up: ECG, natriuretic peptide, kidney, liver and thyroid function, glucose and HbA1c, lipids, chest X-ray and echocardiography. Anaemia can itself raise natriuretic peptides, so read them alongside the echocardiogram.

Once iron deficiency is confirmed: urinalysis for haematuria, coeliac serology, and both gastroscopy and colonoscopy (CT colonography if colonoscopy is unsuitable). Cancer and dual pathology are common at this age, which supports examining both the upper and lower tract.

Weigh the risks of endoscopy against frailty, comorbidity and life expectancy, discuss this with the patient and family, and plan it with the cardiology team.

Treat the heart failure, with diuretics for congestion.

Transfuse only for severe symptoms or circulatory compromise, and restrictively: aim for a haemoglobin of 70–90 g/L, or 80–100 g/L with unstable coronary disease. A unit of red cells holds only about 200 mg of iron, so iron replacement must follow.

Intravenous iron (ferric carboxymaltose) is reasonable for iron deficiency anaemia in heart failure (class IIa), and after a recent admission with an ejection fraction below 50% it may reduce heart failure readmissions. Oral iron is poorly absorbed in heart failure and did not improve exercise capacity.

Do not use erythropoiesis-stimulating agents for unexplained anaemia in heart failure (class III): in trials darbepoetin did not improve exercise capacity or ejection fraction, and in the largest trial it increased thromboembolic events.

Treat the cause found, such as a bleeding lesion, and review antiplatelets, anticoagulants, NSAIDs and proton pump inhibitors.

Once the haemoglobin is normal, recheck the blood count every 3 months for a year and then every 6 months for 2–3 years, because recurrence can signal underlying disease.

Anaemia affects more than 20% of people over 85 and more than half of care-home residents, and worsens physical performance, cognition and frailty.

In heart failure, anaemia increases mortality and readmissions and reduces exercise capacity and quality of life. Iron deficiency without anaemia has similar effects.