59
Volume 04 Issue 03-2022
The American Journal of Medical Sciences and Pharmaceutical Research
(ISSN
–
2689-1026)
VOLUME
04
I
SSUE
03
Pages:
59-64
SJIF
I
MPACT
FACTOR
(2020:
5.
286
)
(2021:
5.
64
)
(2022:
6.
319
)
OCLC
–
1121105510
METADATA
IF
–
7.569
Publisher:
The USA Journals
ABSTRACT
Currently, cardiovascular diseases (CVDs) are leading not only in prevalence but also in mortality worldwide. It is
known that old age is characterized by polymorbidity, and all concomitant conditions change the clinical picture,
course and prognosis of CVDs. One of the exacerbating factors of CVD is the anaemic syndrome, particularly in the
case of iron deficiency. Anaemia is also an important public health problem, as it affects quality of life, mortality and
is a frequent reason for seeking medical attention. A review of the literature has demonstrated that anaemia is an
independent predictor of cardiovascular disease and adverse outcomes. Because the incidence of anaemia increases
with age, this makes it a frequent co-morbidity of cardiovascular events. A possible mechanism seems to be an
increase in sympathetic activity and cardiac output due to prolonged hypoxia-induced vasodilation, leading to left
ventricular hypertrophy and increased heart size and thus increased oxygen consumption. Also myocardial tolerance
to low haemoglobin levels is reduced in patients with CHD compared to healthy controls. Patients should therefore
be given a full examination, including obligatory determination and monitoring of haemoglobin levels. Primary
measures should be directed at the etiological factor causing anaemia of varying severity. Oral and intravenous iron,
as well as erythropoietin, are used as the main therapy. Despite the development of effective diagnostic and
treatment regimens and a wide range of effective medicines, problems in this area are still among the most pressing.
Research Article
CURRENT VIEWS ON IRON DEFICIENCY ANAEMIA IN PATIENTS WITH
CARDIOVASCULAR DISEASE
Submission Date:
February 28, 2022,
Accepted Date:
March 20, 2022,
Published Date:
March 31, 2022 |
Crossref doi:
https://doi.org/10.37547/TAJMSPR/Volume04Issue03-12
Gulbahor Aslamovna Kurbonova
Assistant Professor Of Pathophysiology Department Samarkand State Medical Institute, Uzbekistan
Zebiniso Khidirovna Lapasova
Senior Lecturer At The Department Of Pathophysiology Samarkand State Medical Institute, Uzbekistan
Journal
Website:
https://theamericanjou
rnals.com/index.php/ta
jmspr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
60
Volume 04 Issue 03-2022
The American Journal of Medical Sciences and Pharmaceutical Research
(ISSN
–
2689-1026)
VOLUME
04
I
SSUE
03
Pages:
59-64
SJIF
I
MPACT
FACTOR
(2020:
5.
286
)
(2021:
5.
64
)
(2022:
6.
319
)
OCLC
–
1121105510
METADATA
IF
–
7.569
Publisher:
The USA Journals
KEYWORDS
Polymorbidity, cardiovascular disease, iron deficiency anaemia, anaemic syndrome, sideropenic syndrome, iron-
containing drugs.
INTRODUCTION
Nowadays, polymorbidity is one of the most pressing
problems of modern medicine, especially in geriatric
practice. At the clinical examination of elderly and
senile patients at least 4-5 diseases and manifestations
of pathological processes are diagnosed. According to
G.B. Aksamentov the elderly patients in geriatric
hospitals had 4.1 diseases per one person, and 4.6
diseases per one (only clinically expressed nosological
forms, which manifested themselves for several years
were
taken
into
account).
According
to
VandenAkkeretaL., 78% of persons aged 80 years or
older have two or more chronic diseases, whereas
among children and adolescents under 19 years the
percentage of polymorbidity does not exceed 10. L.B.
Lazebnik et al., analyzed the number of diseases in
patients
in
gerontological
hospital
therapy
departments as a function of age. The authors
obtained data on the number of diseases per patient
aged 60-65 years - 5.2 ± 1.7; 66-70 years - 5.4 ± 1.4; 71-75
years -7.6 ± 1.7; 76-80 years - 5.8 ± 1.6; 81-85 years - 5.8
± 1.8; 86-90 years -4.4 ± 1.6; in long-livers 91-95 years -
3.2 ± 0.5.
The onset of polymorbidity-forming diseases and their
chronicity are predominantly in middle age, but the
result of their cumulative accumulation, i.e. the period
of vivid demonstration, begins to manifest itself in old
age. The interplay of diseases changes their classic
clinical picture, the nature of the course, increases the
number of complications and their severity, worsens
the quality of life and prognosis.
The most common polymorbid pathology in the elderly
is cardiac, which is often combined with the anaemic
syndrome of varying degrees of iron deficiency
anaemia (IDA).
Cardiovascular disease is the leading cause of death
worldwide. The WHO estimates that 17.9 million
people died from CVDs in 2016, accounting for 31% of all
deaths. Many patients with this pathology are anaemic
due to acute or chronic comorbidities. Anaemia affects
1.62 billion people, representing 24.8% of the global
population. The average prevalence of anaemia in the
elderly is 23.9%. In hospitalised patients it ranges from
36% to 80%, in 25-48% of patients with chronic heart
failure (CHF) and 10-20% in patients with IHD1. Anaemia
is a clinical and haematological syndrome based on
tissue hypoxia due to a reduction in haemoglobin levels
as a result of blood loss, impaired red cell production,
increased red cell destruction or a combination of
these causes.
Iron deficiency is the cause of anaemia in half of all
cases. Iron deficiency not only impairs erythrocyte
formation, but also impairs cellular functions related to
muscle metabolism and affects mitochondrial
function, neurotransmitters, DNA synthesis and the
immune system. Hypoxia in anemia is compensated by
a cascade of hemodynamic and hemodynamically
unassociated mechanisms, such as activation of
erythropoietin production and increased tissue oxygen
utilization. Realisation of basic haemodynamic factors
is achieved by increasing myocardial contractility,
61
Volume 04 Issue 03-2022
The American Journal of Medical Sciences and Pharmaceutical Research
(ISSN
–
2689-1026)
VOLUME
04
I
SSUE
03
Pages:
59-64
SJIF
I
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FACTOR
(2020:
5.
286
)
(2021:
5.
64
)
(2022:
6.
319
)
OCLC
–
1121105510
METADATA
IF
–
7.569
Publisher:
The USA Journals
decreasing post-load, increasing preload, and realising
positive
and
chronotropic
effects.
Increased
production
of
nitric
oxide,
hypoxia-induced
vasodilatation and decreased blood viscosity cause
vascular resistance reduction and result in decreased
post-load. Chronic anaemia stimulates angiogenesis
and the formation of new small vessels. The
development of collaterals and the microcirculatory
bed contributes to the reduction of the afterload. An
increase in venous return (preload) and left ventricular
filling contributes to an increase in left ventricular end-
diastolic volume and ejection fraction. In short-term
anaemia these changes are reversible, but with
chronicity they lead to remodelling with the formation
of eccentric left ventricular myocardial hypertrophy, as
in other forms of volume overload.
Increased cardiac output, in turn, contributes to
arterial remodelling of central elastic vessels, such as
the aorta and common carotid arteries, by increasing
the lumen and compensatory thickening of the intima-
media complex. As a consequence, systolic pressure
and inertia increase, and a larger mass of blood enters
the dilated arterial system. Activation of the
sympathetic nervous system increases the contractility
of the left ventricle and increases the heart rate. In the
presence of chronic heart disease these additional
effects, mediated by anaemia, contribute to an
increased incidence of cardiovascular complications.
According to European and American guidelines for
the management of patients with stable angina
pectoris, it is assumed that haemoglobin levels should
be determined in all patients and anaemia is
considered to be a contributing factor to coronary
heart disease. In recent guidelines on the diagnosis and
treatment of patients with CKD, American and
European experts have noted that anaemia not only
increases the symptoms of CKD, impairs quality of life,
reduces exercise tolerance, can cause acute
decompensation of CKD and increase the frequency of
hospital admissions, but is also an independent
negative predictor of prognosis. The risk of death in
CKD patients with anaemia is twice as high as that
without anaemia, even when additional variables
(renal dysfunction, severity of CKD, etc) are taken into
account. Latent iron deficiency may have a negative
impact on prognosis in CKD, making it reasonable to
determine its markers in all patients with CKD. The
B0_UE retrospective study showed that a 1% reduction
in haematocrit increased overall mortality in patients
with CKD by 2.7%. The 0RT1ME study showed a 12%
increased risk of death or rehospitalisation with a
haemoglobin level of less than 12g/dl. A more severe
functional class of heart failure (FC HF) according to
YHRL was associated with lower haemoglobin and
higher creatinine. There is evidence of a worse
prognosis of cardiovascular mortality in LDA compared
with other types of anaemia.
In acute coronary syndrome (ACS), the presence of
anaemia can increase the likelihood of death by up to
fourfold and is considered as an independent predictor
of the risk of adverse clinical outcomes. Even chest
pain syndrome in women is more prognostically poor
(doubling the risk of death) if anaemia is associated
with it. Meneveau et al., in addition to recognising
anaemia as an independent risk factor for death in ACS,
propose to include it along with other factors in the
GRACE (Global Registry of Acute Coronary Events) risk
scale for a more accurate prognosis. Studies at the
population level and in patients with CHD confirm a U-
shaped relationship between haemoglobin levels and
cardiovascular morbidity and mortality, i.e. high
haemoglobin levels (>13 g/dL) are associated with a
poor prognosis, along with low levels.
62
Volume 04 Issue 03-2022
The American Journal of Medical Sciences and Pharmaceutical Research
(ISSN
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2689-1026)
VOLUME
04
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SSUE
03
Pages:
59-64
SJIF
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(2020:
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)
(2021:
5.
64
)
(2022:
6.
319
)
OCLC
–
1121105510
METADATA
IF
–
7.569
Publisher:
The USA Journals
Daily mean diastolic blood pressure. Patients with
isolated systolic hypertension and left ventricular
hypertrophy with associated decreased haemoglobin
levels have increased cardiovascular mortality and the
incidence of acute cerebrovascular events. It has also
been found that haemoglobin levels correlate strongly
with electrocardiogram changes. Electrocardiographic
repolarisation changes (depressed BT, inversion of the
T wave, prolongation of the OT interval) are common
in anaemic patients both at rest and during exercise.
Patients with AH and anaemia have been reported in
the literature to have higher mean daily and nocturnal
systolic blood pressure and a poorer reduction in
nocturnal systolic blood pressure than those with
normal haemoglobin levels. Anaemic patients also
tended to have higher mean daily diastolic blood
pressure. Patients with isolated systolic hypertension
and left ventricular hypertrophy with concomitant
haemoglobin reduction have increased cardiovascular
mortality and acute cerebrovascular events.
It has also been found that haemoglobin levels
correlate strongly with electrocardiogram changes.
Electrocardiographic repolarisation changes (BT
segment depression, inversion of the T wave,
prolongation of the OT interval) are common in
anaemic patients both at rest and during exercise.
Lengthened OT interval is a predictor of ventricular
arrhythmias and sudden death. Hypoxia and impaired
oxygen delivery in anaemic patients may cause
myocardial repolarisation. Studies have suggested that
anaemia, macrocytosis and anisocytosis correlate with
prolongation of the OT interval in patients with arterial
hypertension and may be considered in the risk of
sudden death.
Thus, anaemia is an independent predictor of
cardiovascular disease and associated adverse
outcomes.
Anaemia is clinically manifested by anaemic and
sideropenic syndromes.
Non-specific anemic syndrome caused by hemic
hypoxia of organs and tissues is characterized by
unmotivated weakness, rapid fatigability, dizziness,
syncope and pre-syncope, dyspnea and palpitations at
light physical activity, increased irritability and
tearfulness. Objective examination reveals pale skin
and visible mucous membranes, tendency to lower
blood pressure, tachycardia, functional systolic
murmur over heart.
Sideropenic syndrome due to tissue iron deficiency,
often detectable even when hemoglobin levels are
normal, leads to a decrease in the activity of many
enzymes that comprise iron (cytochrome oxidase,
peroxidase, succinate dehydrogenase, etc.). This leads
to the very characteristic symptoms of perversion of
taste (picachLorotica) and smell. Persons with iron
deficiency have a craving for chalk, charcoal, clay, sand,
raw dough, minced meat, grits, ice and a taste for
unpleasant smells (petrol, acetone, varnish, paint, shoe
polish, etc.). In addition, patients with iron deficiency
show marked muscle weakness and fatigue, muscle
atrophy and reduced muscle strength due to deficiency
of myoglobin and tissue respiratory enzymes.
Objective examination reveals dry skin, thinning,
brittleness and transverse striation of nails,
koilonychia, angular stomatitis, glossitis ("varnished"
tongue), as well as atrophic changes in the mucosa of
the esophagus (sideropenic dysphagia), stomach and
intestine (atrophic gastritis, enteritis). There may be an
increase in div temperature to subfebrile levels
("sideropenic subfebrileitis")
63
Volume 04 Issue 03-2022
The American Journal of Medical Sciences and Pharmaceutical Research
(ISSN
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2689-1026)
VOLUME
04
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SSUE
03
Pages:
59-64
SJIF
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FACTOR
(2020:
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)
(2021:
5.
64
)
(2022:
6.
319
)
OCLC
–
1121105510
METADATA
IF
–
7.569
Publisher:
The USA Journals
TREATMENT
The aim of the treatment of WHD is to eliminate iron
deficiency and restore iron stores in the div. This can
only be done by eliminating the underlying cause of AF
and at the same time compensating for the iron
deficiency in the div.
The basic principles of treating GIHD are:
1.
It is not possible to compensate for iron deficiency
without iron medication.
2.
Treatment of ASD should be predominantly with
oral iron preparations.
3.
Treatment of ASD should not be discontinued once
haemoglobin levels are normalized.
4.
Haemotransfusions
for
ARF
should
be
administered strictly on a life-saving basis.
Diet for iron deficiency
From the current understanding of the mechanisms of
iron absorption in food, the administration of a diet
cannot be considered a valid method of correcting iron
deficiency. The bulk of iron (~90%) is absorbed in the
duodenum and the rest in the upper jejunum. In iron
deficiency conditions the absorptive surface of the
small intestine is increased. Iron is absorbed in two
forms:
Iron in haemic form (10%), whose sources are
haemoglobin and myoglobin in animal products
such as meat, fish, poultry, liver and blood;
Non-heme iron (90%), which is found in plant foods
such as vegetables, fruit, cereals and milk.
The majority of dietary iron intake is in the non-heme
form. The bioavailability of iron from cereals, legumes,
tubers, vegetables and fruits is much lower than that
from heme compounds and depends largely on factors
that inhibit or potentiate intestinal ferroabsorption.
It should also be noted that consumption of meat, liver
and fish products increases iron absorption from fruit
and vegetables. However, in general, a complete and
balanced diet can only 'cover' the physiological need
for iron, but not eliminate iron deficiency.
CONCLUSION
Anaemia correlates with worsening prognosis in
patients with cardiovascular pathology and is an
urgent therapeutic problem of modern medicine.
Cardiology patients require timely diagnosis and
treatment of anaemic syndrome, given that up to 95%
of patients do not receive adequate therapy. This
syndrome requires adequate correction of the
identified abnormalities in the specific clinical situation
and with the use of iron-containing drugs. The question
of individual therapy of anaemia in long-term
cardiovascular disease remains open. The accumulated
evidence base in these patients on the treatment of
anaemia with intravenous iron and/or erythropoietins
does not allow an unequivocal determination of the
appropriateness and safety of this use.
Until results of large studies are available, oral iron
supplementation of patients with mild to moderate
GAD is considered to be the best approach, whereas a
combination of intravenous iron and erythropoietin
may be considered in patients with severe anaemia to
allow dose reduction and side-effect reduction.
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