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Anemia and Outcomes in Patients With Heart Failure
A Study From the National Heart Care Project
Mikhail Kosiborod, MD;
Jeptha P. Curtis, MD;
Yongfei Wang, MS;
Grace L. Smith, MPH;
Frederick A. Masoudi, MD;
JoAnne M. Foody, MD;
Edward P. Havranek, MD;
Harlan M. Krumholz, MD, SM
Arch Intern Med. 2005;165:2237-2244.
Background Recent reports have suggested that anemia is associated with adverse outcomes in patients with heart failure (HF), but were unable to adjust for a broad range of comorbid conditions. As a result, whether anemia is a truly independent predictor of risk or a marker of comorbid illness in these patients is unknown.
Methods We analyzed medical records from the Centers for Medicare & Medicaid Services’ National Heart Care Project, a national sample of 50 405 patients 65 years and older admitted to acute care hospitals with a principal discharge diagnosis of HF between April 1, 1998, and March 31, 1999, or between July 1, 2000, and June 30, 2001. Multivariable logistic regression analyses were conducted to test whether hematocrit level was an independent predictor of all-cause mortality and HF-related readmission at 1 year.
Results In unadjusted analysis, lower hematocrit levels were associated with increased 1-year mortality and readmission for HF. Compared with patients with a hematocrit greater than 40% to 44%, those with a hematocrit of 24% or less had a 51% higher risk of death (relative risk [RR], 1.51; 95% confidence interval [CI], 1.35-1.68; P<.001) and a 17% higher risk of HF-related readmission (RR, 1.17; 95% CI, 1.01-1.34; P = .04). However, after adjustment for multiple comorbidities and other clinical factors, the association between lower hematocrit levels and increased 1-year mortality was markedly attenuated, even in those patients with the most severe anemia (hematocrit,  24% vs >40%-44%: RR, 1.02; 95% CI, 0.86-1.19; P = .85). The association between lower hematocrit values and HF-related readmission persisted after multivariable adjustment (hematocrit, 24% vs >40%-44%: RR, 1.21; 95% CI, 1.04-1.38; P = .01).
Conclusions Although anemia is an independent predictor of hospital readmission, its relationship with increased mortality in HF patients is largely explained by the severity of comorbid illness. These findings suggest that anemia may be predominantly a marker rather than a mediator of increased mortality risk in older patients with HF.
Author Affiliations: Section of Cardiovascular Medicine (Drs Kosiborod, Curtis, Foody, and Krumholz and Mr Wang), Robert Wood Johnson Clinical Scholars Program (Drs Kosiborod and Krumholz), Department of Medicine (Ms Smith), and Section of Health Policy and Administration, Department of Epidemiology and Public Health (Dr Krumholz), Yale University School of Medicine, New Haven, Conn; Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, Colo (Drs Masoudi and Havranek); and Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven (Dr Krumholz).
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