ORIGINAL RESEARCH Noninvasive Imaging Estimation of Myocardial Iron Repletion Following Administration of Intravenous Iron: The Myocardial-IRON Trial Julio Nu~nez, MD, PhD; Gema Mi~ nana, MD, PhD; Ingrid Cardells, MD; Patricia Palau, MD, PhD; Pau Llacer, MD, PhD; Lorenzo Facila, MD, PhD; Luis Almenar, MD, PhD; Maria P. L opez-Lereu, MD, PhD; Jose V. Monmeneu, MD, PhD; Martina Amiguet, MD; Jessika Gonzalez, MD; Alicia Serrano, MD; Vicente Montagud, MD; Raquel L opez-Vilella, MD; Ernesto Valero, MD; Sergio Garcıa-Blas, MD; Vicent Bodı, MD, PhD; Rafael de la Espriella-Juan, MD; Josep Lup on, MD, PhD; Jorge Navarro, MD, PhD; Jose Luis G orriz, MD, PhD; Juan Sanchis, MD, PhD; Francisco J. Chorro, MD, PhD; Josep Comın-Colet, MD, PhD; Antoni Bayes-Genıs, MD, PhD; and on behalf of the Myocardial-IRON Investigators* Background-—Intravenous ferric carboxymaltose (FCM) improves symptoms, functional capacity, and quality of life in heart failure and iron deficiency. The mechanisms underlying these effects are not fully understood. The aim of this study was to examine changes in myocardial iron content after FCM administration in patients with heart failure and iron deficiency using cardiac magnetic resonance. Methods and Results-—Fifty-three stable heart failure and iron deficiency patients were randomly assigned 1:1 to receive intravenous FCM or placebo in a multicenter, double-blind study. T2* and T1 mapping cardiac magnetic resonance sequences, noninvasive surrogates of intramyocardial iron, were evaluated before and 7 and 30 days after randomization using linear mixed regression analysis. Results are presented as least-square means with 95% CI. The primary end point was the change in T2* and T1 mapping at 7 and 30 days. Median age was 73 (65–78) years, with N-terminal pro-B-type natriuretic peptide, ferritin, and transferrin saturation medians of 1690 pg/mL (1010–2828), 63 ng/mL (22–114), and 15.7% (11.0–19.2), respectively. Baseline T2* and T1 mapping values did not significantly differ across treatment arms. On day 7, both T2* and T1 mapping (ms) were significantly lower in the FCM arm (36.6 [34.6–38.7] versus 40 [38–42.1], P=0.025; 1061 [1051–1072] versus 1085 [1074–1095], P=0.001, respectively). A similar reduction was found at 30 days for T2* (36.3 [34.1–38.5] versus 41.1 [38.9–43.4], P=0.003), but not for T1 mapping (1075 [1065–1085] versus 1079 [1069–1089], P=0.577). Conclusions-—In patients with heart failure and iron deficiency, FCM administration was associated with changes in the T2* and T1 mapping cardiac magnetic resonance sequences, indicative of myocardial iron repletion. Clinical Trial Registration-—URL: http://www.clinicaltrials.gov. Unique identifier: NCT03398681. ( J Am Heart Assoc. 2020;9: e014254. DOI: 10.1161/JAHA.119.014254.) Key Words: cardiac magnetic resonance • ferric carboxymaltose • heart failure • iron deficiency • myocardial iron I ron deficiency (ID) is common in patients with heart failure (HF).1 It is associated with reduced functional capacity, quality of life, and increased risk of clinical events.1–4 In patients with HF and ID (HF-ID), with or without anemia, iron treatment with intravenous ferric carboxymaltose (FCM) has consistently been shown to improve symptoms, functional From the Cardiology Department (J. Nu~nez, G.M., I.C., M.A., J.G., E.V., S.G.-B., V.B., R.d.l.E.-J., J.S., F.J.C.) and Nephrology Department (J.L.G.), Hospital Clınico Universitario de Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain; CIBER Cardiovascular (J. Nu~nez, G.M., E.V., S.G.-B., V.B., J.L., J.S., F.J.C., A.B.-G.) and Cardiology Department, Hospital General de Castellon (P.P., A.S.), Universitat Jaume I, Castellon, Spain; Internal Medicine Department, Hospital de Manises, Manises, Spain (P.L.); Cardiology Department, Hospital General Universitario de Valencia, Valencia, Spain (L.F., V.M.); Cardiology Department, Hospital Universitario La Fe de Valencia, Valencia, Spain (L.A., R.L.-V.); Unidad de Imagen Cardiaca (ERESA), Hospital Clınico Universitario de Valencia, Valencia, Spain (M.P.L.-L., J.V.M.); Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (J.L., A.B.-G.); Universitat Autonoma de Barcelona, Barcelona, Spain (J.L., A.B.-G.); Hospital Clınico Universitario de Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain (J. Navarro); Department of Cardiology, Hospital del Mar, Barcelona, Spain (J.C.-C.); Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain (J.C.-C.); Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain (J.C.-C.). Accompanying Tables S1 and S2 are available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.119.014254 *A complete list of the Myocardial-IRON Investigators can be found in the Appendix at the end of the article. Correspondence to: Julio Nun~ez, MD, PhD, Cardiology Department, Hospital Clınico Universitario de Valencia, Avda. Blasco Iba~nez 17, 46010 Valencia, Spain. E-mail: yulnunez@gmail.com Antoni Bayes-Genıs, MD, PhD, Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain. Universitat Autonoma de Barcelona, Barcelona, Spain. E-mail: abayesgenis@gmail.com Received September 18, 2019; accepted December 19, 2019. ª 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made. DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 1 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH investigator-initiated, multicenter, double-blind, randomized Clinical Perspective clinical trial was designed to evaluate the effect of intravenous FCM versus placebo on myocardial iron repletion estimated by What Is New? T2* and T1 mapping CMR sequences in patients with HF-ID. • The exact mechanism explaining the benefits of treatment The trial was conducted in 5 academic centers in Spain.20 The with ferric carboxymaltose in patients with heart failure patients provided signed informed consent before being remains not fully explained. randomized 1:1 to receive either FCM or placebo. Intramy- • This study shows that treatment with ferric carboxymaltose ocardial iron was evaluated at 3 time points: before treatment, resulted in significant short-term changes in cardiac mag- and 7 and 30 days after treatment. At 30 days, patients netic resonance sequences that are consistent with myocardial iron repletion. assigned to placebo received intravenous FCM if ID persisted. The study design was already published.20 What Are the Clinical Implications? The investigation conforms to the principles outlined in the Declaration of Helsinki and Good Clinical Practice of the • This study opens a new line of research about the utility of International Conference on Harmonization. The study proto- cardiac magnetic resonance for noninvasive quantification col was approved by Agencia Espa~nola del Medicamento y of myocardial iron status, including not only iron overload, but also iron deficiency and response to treatment Productos sanitarios (AEMPS) and by Comite  Etico de (myocardial iron repletion). Investigacion Clınica (CEIC) del Hospital Clınico Universitario de Valencia. CMR studies were performed and analyzed by a core lab at ERESA (Valencia). Laboratory parameters were capacity, and quality of life with an acceptable safety profile.5–8 analyzed in local laboratories. This study is registered at The mechanisms whereby exogenous iron repletion leads to http://clinicaltrials.gov (NCT03398681). clinical improvement in HF-ID are not completely understood. Experimental studies have shown that iron depletion Study Population impairs mitochondrial function and adenosine triphosphate (ATP) synthesis affecting systolic and diastolic properties of The study population included patients with stable chronic HF cardiomyocytes, and that all these deleterious effects are (New York Heart Association [NYHA] II–III), left ventricular reversed with iron treatment.9–12 In humans, some studies ejection fraction (LVEF) <50%, and ID (serum ferritin have also shown that myocardial iron content is decreased in <100 lg/L [absolute ID] or 100–299 lg/L with transferrin patients with advanced HF13 and this is associated with saturation [TSAT] <20% [functional ID]), and hemoglobin abnormal myocardial mitochondrial function.14 However, in <15 g/dL.21 The inclusion and exclusion criteria were pub- the clinical setting, the myocardial effects of intravenous iron lished previously20 and are reported in detail in Table S1. repletion in patients with HF-ID are largely unknown. A cardiac magnetic resonance (CMR) sequence, T2*, has Study Procedures been shown to provide a noninvasive estimation of myocardial iron overload15,16 and myocardial iron depletion.17 Native T1 Screening and eligibility assessment (visit 0) mapping has also emerged as a potential alternative tool for the In this visit, after reviewing the inclusion/exclusion criteria, the assessment of myocardial iron content.18 In a recently patients signed and dated the informed consent form. The published proof-of-concept pilot study of 8 patients with HF- following information was recorded: (1) clinical and demographic ID, our group reported an association between intravenous variables, including a complete medical history, vital signs, and a FCM administration and myocardial iron repletion estimated by complete physical examination; (2) ECG; (3) functional capacity T2* CMR.19 To further confirm these findings, the present study parameters, including NYHA functional class and 6-minute is a prospective multicenter, double-blind, randomized clinical walking test (6MWT); (4) quality of life parameters, including trial of noninvasive estimation of changes in myocardial iron Kansas City Cardiomyopathy Questionnaire (KCCQ); (5) labora- after administration of FCM or placebo in patients with HF-ID tory data, including hematology parameters, serum electrolytes, using CMR T2* and T1 mapping sequences. parameters evaluating iron status (ferritin and TSAT), creatinine, urea, estimated glomerular filtration rate, and NT-proBNP (N-terminal pro-B-type natriuretic peptide); (6) 2-dimensional Methods echocardiography; and (7) CMR parameters. Overall Study Design 24-hour visit The data that support the findings of this study are available At this visit, after clinical evaluation, the patients were from the corresponding author upon reasonable request. This randomized to receive FCM or placebo. In addition, vital signs, DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 2 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH complete physical examination, and functional class evalua- completion of all baseline study-related assessments. tion (NYHA) were noted. Because FCM is a dark-brown solution that is easily distin- guishable from the saline placebo, study personnel respon- 7- and 30-day visits sible for the preparation and administration of the study drug At these visits, the same explorations/variables were were aware of the group assignments and, therefore, not recorded as at visit 0, except the ECG and echocardiography, involved in any study assessments. which were performed only at the 30-day visit. During the In the placebo group, normal saline (0.9% weight/volume study period, all concomitant medications and clinical adverse NaCl) was administered as per the instructions for active therapy. events (death from all causes or hospitalization for acute HF) To ensure that patients were unaware of the study drug, the were recorded. Optional visits were permitted at the discre- materials used in drug administration were covered with tion of the physician in charge, at which the same information aluminum foil and the injection site shielded from the patient view. was recorded as in the preplanned visits. Concomitant drugs Cardiac magnetic resonance Indications for other HF-related drugs in both treatment CMR studies were performed by 2 experienced operators on a groups were handled according to the current recommenda- 1.5-Tesla MR scanner (Essenza y Avanto, Siemens, Erlangen, tions for clinical practice and included the administration of Germany) using the spine and phased array 6-channel surface angiotensin-converting enzyme inhibitors, angiotensin recep- coils. No contrast media were used. All images were obtained tor blockers, sacubitril/valsartan, b-blockers, mineralocorti- with electrocardiographic gating and breath-holding. Cine coid receptor antagonists, digoxin, ivabradine, diuretics, and images were acquired at rest in short-axis views every 1 cm nitrate agents. Per study protocol, changes in HF therapy with steady-state free precession imaging sequences (time during the study period were discouraged. resolution: 37 ms; voxel size: 1.791.797 mm). The LVEF was calculated by semiautomatic planimetry of endocardial and End Points epicardial borders in short-axis view cine images. Left ventricle diameters and volumes were also determined. Primary end point For T2* analysis, a region of interest was chosen in the mid- The main end point was to noninvasively estimate changes in left ventricular septum. The mean signal intensities of the myocardial iron content as measured by T2* and T1 mapping regions of interest were measured in the series of increasing CMR sequences 7 and 30 days after FCM or placebo echo time images to give an exponential decay curve. The administration. monoexponential decay model and nonlinear curve fitting algorithm were used to fit the curve to obtain the T2* Secondary end points measurement. T1 mapping was performed using Modified The secondary end point was to correlate posttreatment Look-Locker Inversion Recovery sequences with motion correc- changes in myocardial iron content (T2* and T1 mapping) with tion (voxel size: 1.591.597 mm) in 3 short axes (basal, medial, concomitant changes in surrogate markers of disease severity and apical). After T1 maps were generated, a region of interest (LVEF, functional capacity [6MWT and NYHA class], quality of was chosen in the mid-left ventricular septum in the 3 short axes life [KCCQ], NT-proBNP, and blood markers related to iron and the average T1 values were calculated. The same protocol biology [ferritin and TSAT]). was repeated at 7 and 30 days. The technical specifications of the CMR sequences were described elsewhere.20 CMR opera- Safety end points tors were also blinded to treatment allocation. A strict policy was implemented regarding close adverse event surveillance to ensure early detection and appropriate management. Based on previous studies,7,8 the surveillance Trial Intervention specifically focused on (1) general disorders and administra- Eligible patients were randomized to receive FCM or placebo. tion site conditions, (2) skin and subcutaneous tissue All patients received the assigned treatment with no place for disorders, (3) nervous system disorders, (4) gastrointestinal crossover. disorders, (5) vascular disorders, (6) ear and labyrinth disorders, (7) injury, poisoning, and procedural complications, Intravenous FCM or placebo and (8) cardiac disorders. FCM solution (Ferinject [FCM], Vifor Pharma, Glattbrugg, Switzerland) was given as a 20-mL perfusion (equivalent to Subgroup analyses 1000 mg of iron) diluted in a sterile saline solution (0.9% wt/ We also included as part of the analysis the effect of vol NaCl) administered over at least 15 minutes after treatment on changes in T2* and T1 among age (≤75 years DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 3 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH versus >75 years), ischemic heart disease (0/1), and anemia As a prespecified analysis, no adjustment for multiple (0/1) categories. comparisons was made in any of the analyses. Results from linear mixed regression model and linear regression analysis are presented as least-square means with 95% CIs and P values. Follow-Up Missing values in T2* and T1 mapping were imputed using No patients were lost to follow-up. T2* and T1-mapping values a reference-based sensitivity analysis via multiple imputation could not be accurately obtained in 3 and 2 patients, for longitudinal trials with protocol deviation.22 A 2-sided respectively. Reasons for unavailability included rejection for P value of 0.05 was considered significant for all analyses. All repeating the CMR test (n=1 patient) and technical issues in analyses were performed using Stata 15.1 (Stata Statistical image acquisition (n=2 patients). In these cases, T2* and T1 Software, College Station, TX). The multiple imputation mapping values were imputed. procedure was implemented with a special module within Stata called “mimix.” Statistical Analysis All statistical comparisons were made under an intention-to- Results treat principle. Continuous variables were presented as median with interquartile range. Discrete data were expressed Trial Population as frequency and percentages. The v2 test or Wilcoxon rank- From May 2017 to June 2018, a total of 55 patients were sum were used as appropriate to compare baseline charac- preselected for participation in this trial. Fifty-three patients teristics among the 2 treatment groups. were finally randomized to receive FCM (n=27) or placebo The statistical comparisons for the primary efficacy end (n=26) (Figure 1). point tested the null hypothesis of no differences in changes The median age of the study population was 73 (interquar- in myocardial iron content as estimated by T2* and T1 tile range 65–78) years, 75.5% were men, 52% had type 2 mapping CMR in patients treated with intravenous FCM or diabetes mellitus, 43.4% had prior ischemic heart disease, placebo at 30 days. The alternative hypothesis stated differ- 60.4% had a prior admission for acute heart failure in the last ences in either direction. Because of the availability of 2-time 12 months, and most (94.3%) were in NYHA functional class points, the 7-day evaluation was considered a co-primary end II. The median (interquartile range) CMR-LVEF, NT-proBNP, point. and estimated glomerular filtration rate were 39% (33–45), A linear mixed regression model was used for the analysis 1690 pg/mL (1010–2828), and 60 (49.3–72.9) mL/min per of the primary end point. All analyses included adjustments 1.73 m2, respectively. All patients had ID at baseline, with 37 for hospital center (as a cluster variable), the interaction (69.8%) and 16 (30.2%) patients exhibiting absolute and term treatment9visit (7 and 30-day), and the baseline functional ID, respectively. The median (interquartile range) (pretreatment) value of the regressed outcome. The inclusion values of ferritin and TSAT were 63 (33–114) lg/L and 15.7% of other covariates was based on clinical judgment or (11–19.2%), respectively. Anemia (WHO criteria) was present randomization inequalities at baseline. To limit the potential in 16 (30.2%) patients. Baseline ferritin and TSAT did not for increasing type I error rate, we focused strictly on correlate with T2* (Spearman r= 0.08, P=0.552 and Spear- between-group (FMC versus placebo) comparison at 30 and man r= 0.199, P=0.153, respectively) or T1 mapping 7 days, respectively. (Spearman r= 0.02, P=0.903 and Spearman r= 0.173, A similar approach was used for the subgroup analyses P=0.216, respectively). The baseline characteristics of after stratifying for the prespecified variables (age [≤75 years patients in the 2 treatment groups are given in Table 1. No versus >75 years], ischemic heart disease [0/1], and anemia significant differences were found between the treatment [0/1]). Such linear mixed regression model included a 3-level groups. Raw data (CMR parameters [T2*, T1-mapping, and interaction (FCM treatment9visit9subgroup variable). LVEF], KCCQ, and 6MWT at different visits [baseline, 7 and For analysis of the correlations between changes in either 30-day]) across treatment arms are presented in Table S2. T2* or T1 mapping and changes in LVEF, 6MWT, NYHA class, KCCQ, NT-proBNP, ferritin, and TSAT, we used linear regres- sion analysis. For this analysis, the stratification at 7 and Primary End Point 30 days was ignored under the assumption that these Compared with placebo, both 7-day T2* and T1 mapping were correlations may remain the same throughout follow-up. significantly lower in the FCM arm (36.6 ms [34.6–38.7] versus These correlation models included the interaction between 40 ms [38–42.1], P=0.025; and 1061 ms [1051–1072] versus the treatment and the delta of the parameter evaluated. The 1085 ms [1074–1095], P=0.001, respectively; Figure 2A). A normality of residuals was checked. similar reduction was found at 30 days for T2* (36.3 ms [34.1– DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 4 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH 38.5] versus 41.1 ms [38.9–43.4], P=0.003), but this difference (Figure 3C-left). For DT1-mapping, the association with was no longer significant for T1 mapping (1075 ms [1065–1085] D6MWT was not significant (Figure 3C-right). versus 1079 ms [1069–1089], P=0.577; Figure 2B). d. NYHA class: we found a significant lower value at 30 days in patients allocated to FCM (1.72 [1.60–1.85] versus 1.90 [1.80–2.00], P<0.001). However, at 7-day, the differences Secondary End Points were not significant (Table 2). In the FCM-arm, the greater 1. Relationship between CMR changes in T2* and T1 improvement in NYHA class matched the reduction in T1- mapping with concomitant changes in: mapping (Figure 3D-right). However, this correlation was not significant for T2* (Figure 3D-left). a. LVEF: LVEF did not significantly differ between both e. Natriuretic peptides: NT-proBNP did not differ across treatments at 7 or 30-day (Table 2). In the FCM-arm, a treatment strategies at 7 or 30 days (Table 2). In the decrease in T2* was significantly associated with an increase active arm, we found an inverse association between CMR in LVEF (Figure 3A-left). For T1-mapping, the direction of the changes and changes in NT-proBNP (Figure 3E). association was similar and significant (Figure 3A-right). b. Quality of life: At 30 days, higher values of KCCQ were 2. Relationship between CMR changes (T2* and T1 mapping) observed in the FCM-arm (76.9 [73.6–80.1] versus 70 and changes in iron biomarkers. Least-square means [66.8–73.3], P<0.001). However, there were no significant values of ferritin and TSAT values were significantly higher differences across treatment arms at 7-day (Table 2). in the FCM-arm at 7 and 30 days as compared with Furthermore, we found a significant association between placebo (Table 2). Furthermore, in the FCM arm, there was the decrease in T1-mapping with the increase in KCCQ in the an inverse association between DT2* (and DT1-mapping) FCM-arm (Figure 3B-right). The association between T2* with D of surrogates of systemic iron repletion (Figure 4). changes was not significant (Figure 3B-left). c. Functional capacity: We failed to find significant differences in 6MWT across both treatment strategies at both time points Discussion (Table 2). However, we find a significant association between For the first time in a clinical setting, we found that treatment reduction in T2* and increase in 6MWT in the active arm with FCM resulted in significant and short-term changes in Figure 1. Flow chart. FCM indicates ferric carboxymaltose; NT-proBNP, N-terminal pro-B-type natriuretic peptide. DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 5 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH Table 1. Baseline Characteristics Variables Placebo (n=26) Intravenous Iron (n=27) P Value Demographics and medical history Age, y 71 (67, 79) 73.5 (64, 77) 0.957 Male, n (%) 19 (73.1) 21 (77.8) 0.691 Hypertension, n (%) 19 (73.1) 22 (81.5) 0.465 Dyslipidemia, n (%) 16 (61.5) 18 (66.7) 0.697 Diabetes mellitus, n (%) 14 (53.8) 15 (55.6) 0.901 Former smoker, n (%) 16 (61.5) 15 (55.6) 0.659 Coronary artery disease, n (%) 10 (38.5) 13 (48.1) 0.477 Prior admission for AHF in the last year, n (%) 16 (61.5) 16 (59.3) 0.865 COPD, n (%) 6 (23.1) 7 (25.9) 0.810 CKD, n (%) 7 (26.9) 8 (29.6) 0.827 Stroke, n (%) 6 (23.1) 2 (7.4) 0.111 Peripheral artery disease, n (%) 4 (15.4) 4 (14.8) 0.954 NYHA functional class, n (%) 0.080 II 26 (100) 24 (88.9) III 0 3 (11.1) Vital signs Heart rate, bpm 68 (64, 77) 73 (68, 82) 0.262 SBP, mm Hg 125 (113, 146) 117 (109, 132) 0.142 ECG Atrial fibrillation, n (%) 14 (53.8) 10 (37.0) 0.219 LBBB, n (%) 6 (23.1) 6 (22.2) 0.941 LVEF, % 37 (32, 43) 40 (33.5, 45) 0.643 CMR parameters LVEDVI, mL/m2 122.1 (101.5, 137.9) 107 (80.1, 143.9) 0.109 2 LVESVI, mL/m 72.5 (55.1, 87.6) 63.5 (40.6, 84) 0.096 LVEDDI, mm/m2 30.8 (28, 33.5) 30.9 (26.9, 31.9) 0.493 2 LVESDI, mm/m 23.1 (21.1, 26.9) 23.7 (23.0, 26.8) 0.648 LVEF, % 37 (31, 45) 43 (36, 48) 0.128 T2*, ms 37 (31, 42) 40 (34, 45) 0.196 T1-mapping, ms 1072 (1030, 1116) 1082 (1052, 1122) 0.173 Laboratory Hemoglobin, g/dL 13.4 (12.7, 14.6) 13.1 (11.9, 13.4) 0.084 Anemia (WHO), n (%) 6 (23.1) 10 (37.0) 0.268 TSAT, % 15.4 (9.6, 20.0) 15.7 (12.0, 19.2) 0.790 Ferritin, ng/mL 47.8 (23.0, 114.0) 73.0 (56.0, 126.0) 0.072 Absolute iron deficiency, n (%) 19 (73.1) 18 (66.7) 0.611 Sodium, mEq/L 141 (140, 142) 140 (140, 142) 0.669 Potassium, mEq/L 4.6 (4.4, 4.8) 4.7 (4.2, 5.0) 0.852 Urea, mEq/L 59 (45, 84) 59 (45, 77) 0.669 Serum creatinine, mg/dL 1.1 (0.9, 1.5) 1.1 (0.9, 1.4) 0.783 Continued DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 6 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH Table 1. Continued Variables Placebo (n=26) Intravenous Iron (n=27) P Value 2 eGFR, mL/min per 1.73 m 64.1 (48.9, 79.3) 59.4 (50.0, 71.3) 0.854 NT-proBNP, pg/mL 1213 (1010, 2667) 1990 (976, 2830) 0.505 Medical treatment Diuretics, n (%) 24 (92.3) 25 (92.6) 0.969 b-blockers, n (%) 21 (80.8) 25 (92.6) 0.204 ACEI, n (%) 6 (23.1) 7 (25.9) 0.810 ARB, n (%) 4 (15.4) 5 (18.5) 0.761 Sacubitril/valsartan, n (%) 8 (30.8) 10 (37.0) 0.630 Spironolactone, n (%) 3 (11.5) 2 (7.4) 0.607 Eplerenone, n (%) 13 (50.0) 10 (37.0) 0.341 Digoxin, n (%) 4 (15.4) 1 (3.7) 0.146 Ibavradine, n (%) 1 (3.9) 4 (14.8) 0.172 Nitrates, n (%) 2 (7.7) 2 (7.4) 0.969 WHO criteria for anemia: adult male, hemoglobin 13 g/dL; adult, nonpregnant female, hemoglobin 12 g/dL; adult pregnant female, hemoglobin 11 g/dL. Absolute iron deficiency: ferritin <100 ng/mL. Values expressed as median (interquartile range); categorical variables are presented as percentages. ACEI indicates angiotensin-converting enzyme inhibitors; AHF, acute heart failure; ARB, angiotensin II receptor blockers; bpm, beats per minute; CKD, chronic kidney disease; CMR, cardiac magnetic resonance; COPD, chronic pulmonary obstructive disease; eGFR, estimated glomerular filtration rate; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; LVEDDI, left ventricle end-diastolic diameter index; LVEDVI, left ventricle end-diastolic volume index; LVESDI, left ventricle end-systolic diameter index; LVESVI, left ventricle end-systolic volume index; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; SBP, systolic blood pressure; TSAT, transferrin saturation; WHO, World Heart Organization. CMR sequences that are consistent with myocardial iron deficiency and chronic heart failure) study and other studies repletion. Interestingly, these surrogates of myocardial showed that clinical improvement in response to intravenous iron repletion were, in most cases, related to systemic iron iron administration occurs in patients with or without anemia, repletion and short-term improvement in LVEF and other suggesting that the beneficial effect of iron administration is, surrogates of severity such as 6MWT and quality of life. Our at least in part, independent of the erythropoietic response.24 results are in line with prior studies showing the clinical utility of iron supplementation in HF-ID patients, and more impor- Iron Supplementation and Myocardial tantly, provide new insights into the role that myocardial iron Performance in HF Patients repletion may play in these beneficial effects. In the clinical setting, the evidence regarding the myocardial effect of iron supplementation is scarce. For example, in a ID and Heart Failure small randomized trial with HF, ID, and chronic kidney Iron is a micronutrient that plays a crucial role in oxygen disease, Toblli et al25 showed that iron sucrose administration transport and storage, and as a component of the mitochon- translated into a significant 6-month improvement in LVEF drial respiratory chain is involved in energy production.10– estimated by echocardiography (6.6  3.8%). Other studies 13,23 In vitro studies have shown that cellular iron depletion have also shown a significant reduction in the plasma level of in cardiomyocytes is associated with mitochondrial dysfunc- NT-proBNP and attenuation of hypertrophic cardiac remodel- tion, impaired ATP synthesis, increased oxidative stress in ing.26,27 The present study goes a step further in this regard these cells, and that all these factors promote a profound and provides evidence that the improvement is related to impairment of systolic and diastolic properties of the benefits at the cardiac level with myocardial iron repletion cardiomyocytes.12 In the clinical context, ID is highly that translates in improvements in cardiac function and prevalent in patients with HF and commonly associated with patient functioning. adverse outcomes.1–4 In these patients, treatment of ID with FCM improves symptoms, exercise capacity, and quality of life, and reduces the risk of readmission.1,5–8 However, the Quantification of Myocardial Iron Changes by pathophysiological link between exogenous iron repletion and CMR clinical improvement is not totally elucidated. A subanalysis CMR is an accurate and noninvasive technique that enables of the FAIR-HF (Ferrinject assessment in patients with iron the characterization of cardiac structure, function, and risk DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 7 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH Figure 2. T2* and T1 mapping after administration of FCM. A, Seven-day comparison of LSM (95% CIs) between FCM and placebo. B, Thirty- day comparison of LSM (95% CIs) between FCM and placebo. FCM indicates ferric carboxymaltose; LSM, least-square means from a linear mixed regression analysis. stratification.28 This technique has been used to estimate assessment of myocardial iron overload.15,16 More interest- myocardial iron content.15,16 For example, lower T2* CMR ingly, changes in T2* following chelation therapy are sequence values have been shown to provide a reliable strongly related to the response to therapy in patients Table 2. Effect of Intervention on Surrogates of Severity and Iron Status Markers Variables Placebo (n=26) Intravenous Iron (n=27) P Value 7-d LVEF, % 42.6 (40.3–45) 42.5 (40.2–44.8) 0.916 KCCQ 72.2 (66.8–77.6) 77.5 (72.5–82.5) 0.203 6MWT, m 287 (269–304) 297 (280–313) 0.402 NYHA class 1.91 (1.82–2.00) 1.90 (1.84–1.96) 0.700 NT-proBNP, pg/mL 1870 (1609–2131) 2305 (1859–2751) 0.102 Ferritin, ng/mL 102 (71–132) 993 (908–1078) <0.001 TSAT, % 16.1 (14.1–18.1) 41.3 (34.5–48.1) <0.001 30-d LVEF, % 40.9 (38.2–43.7) 44.8 (42.1–47.6) 0.056 KCCQ 70 (66.8–73.3) 76.9 (73.6–80.1) <0.001 6MWT, m 299 (266–332) 299 (279–320) 0.992 NYHA class 1.90 (1.80–2.00) 1.72 (1.60–1.85) <0.001 NT-proBNP, pg/mL 2656 (1891–3421) 2366 (1741–2992) 0.675 Ferritin, ng/mL 96 (68–124) 456 (434–479) <0.001 TSAT, % 15 (14.1–15.8) 30.4 (26.1–34.8) <0.001 Values presented are the least-square means (95% CIs) from each mixed linear regression model. All models were adjusted by hospital center (as a cluster variable), the interaction term Tx9visit (7 and 30-day), baseline value of hemoglobin, and the baseline (pretreatment) value of the regressed outcome. 6MWT indicates distance walked in 6 minutes; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; TSAT, transferrin saturation. DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 8 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH Figure 3. Association of posttreatment changes in myocardial iron content (T2* and T1 mapping) with concomitant changes in surrogate markers of disease severity in the active-arm. A, Changes in CMR sequences and changes in LVEF; B, Changes in CMR sequences and changes in KCCQ; C, Changes in CMR sequences and changes in 6MWT; D, Changes in CMR sequences and changes in NYHA class; E, Changes in CMR sequences and changes in NT-proBNP. Values are the least-square means (95% CIs) from each linear regression analysis (OLS). 6MWT indicates distance walked in 6 minutes; CMR, cardiac magnetic resonance; KCCQ, Kansas City Cardiomyopathy Questionnaire; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association. Figure 4. Association of posttreatment changes in myocardial iron content (T2* and T1 mapping) with concomitant changes in systemic iron status in the active arm. A, Changes in CMR sequences and changes in ferritin; B, A, Changes in CMR sequences and changes in TSAT. Values are the least-square means (95% CIs) from each linear regression analysis (OLS). TSAT indicates transferrin saturation. DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 9 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH with iron overload.29 Regarding ID, in a small case–control limited by the study design, we cannot prove any correlation study, Nagao et al17 suggested that cardiac T2* may also between myocardial histological or myocardial energetic play a role in the quantification of myocardial ID in efficiency aspects with the administration of FCM. Performing nonischemic HF. In addition, these authors reported that a myocardial biopsy to conduct such studies would be T2* CMR was related to an increased risk of adverse considered ethically conflicting. Fourth, in the present study outcomes.17 Furthermore, new CMR techniques, such as T1 we did not evaluate the effect of iron treatment on skeletal mapping, have been found to be a potential alternative tool muscle function, a potential mechanism that may also for myocardial iron quantification.18 To the best of our explain the beneficial effect of iron in HF patients. Fifth, in knowledge, this is the first controlled clinical trial showing order to avoid interference with CMR sequences, patients that treatment with FCM is associated with significant with cardiac devices were excluded from this study. Sixth, short-term decreases in T1 mapping and T2* CMR values, the subgroup analysis was not reported given the small changes that are indicative of myocardial iron repletion. size of the study. Finally, despite the fact that the Indeed, we found a 7-day decrease in both CMR sequences; magnitude of changes we found in surrogates of the however, at 30 days only T2* was decreased. Interestingly, disease (LVEF, quality of life, functional capacity, and these changes were strongly related to a concomitant NYHA class) appears not to be clinically relevant, this improvement in LVEF and other surrogates of disease study was not designed to quantify the effect of FCM nor severity. Unfortunately, our study was not designed to magnitude of these changes. further evaluate this discrepancy among T2* and T1 mapping at 30 days. Beyond the potential role of type II error, we speculate that changes in T1 mapping at later Conclusions times may also reflect changes in other tissue character- In patients with stable HF and ID, administration of FCM led istics. T1-mapping values are influenced by several other to a greater reduction in CMR T2* and T1-mapping values conditions, such as fibrosis, inflammation/edema, amyloid, compared with placebo in the short-term. Both changes are and Fabry disease.18 Despite the fact that all enrolled suggestive of myocardial iron repletion. Further studies are patients exhibited systemic ID, baseline T2* values did not warranted to confirm these findings and to evaluate the correlate with systemic markers of ID. This fact may reflect potential utility of CMR for assessing myocardial iron a lack of agreement between traditional markers of ID and content. myocardial tissue iron, as shown in previous publications30 or, perhaps, a lack of specificity of the baseline values of these CMR sequences for identifying myocardial ID in Appendix clinical practice. We do not believe the present findings have a direct translation into daily clinical practice. Myocardial Iron Study Group Investigators However, given the emerging role of iron biology in the Cardiology Department, Hospital Clınico Universitario de pathophysiology of HF, we believe further research should Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain: test a clinical utility of the present findings or focus on the Julio Nu~nez, MD, PhD, Gema Mi~nana, MD, PhD, Ingrid Cardells, development of more specific and accurate noninvasive MD, Martina Amiguet, MD, Jessika Gonzalez, MD, Ernesto imaging techniques and better biomarkers for estimating Valero, MD, Sergio Garcıa-Blas, MD, Vicent Bodı, MD, PhD, myocardial iron content. This would translate into a better Rafael de la Espriella-Juan, MD, Jorge Navarro, MD, PhD, Juan selection of HF patients who would most benefit from iron Sanchis, MD, PhD, Francisco J. Chorro, MD, PhD, Meritxell supplementation. Soler, MD, Amparo Villaescusa, Jose Civera, Anna Mollar, PhD. Cardiology Department, Hospital General de Castell on. Universitat Jaume I, Castellon, Spain: Patricia Palau, MD, Limitations PhD, Alicia Serrano, MD. This trial has some limitations to be acknowledged. First, Internal Medicine Department, Hospital de Manises, some negative results may be explained by insufficient Manises, Spain: Pau Llacer, MD, PhD, Maria del Carmen statistical power. Second, CMR end points are well-estab- Moreno, MD. lished imaging sequences for evaluating myocardial iron Cardiology Department, Hospital General Universitario de overload but not myocardial iron deficiency. In addition, their Valencia, Valencia, Spain: Lorenzo Facila, MD, PhD, Vicente values and changes are not specific to myocardial iron Montagud, MD, Veronica Vidal, MD. content and may reflect the turnover of other tissue. Neither Cardiology Department, Hospital Universitario La Fe de CMR sequence can discriminate whether tissue changes Valencia, Valencia, Spain: Luis Almenar, MD, PhD, Raquel occur in an intra- or extracellular compartment. Third, as Lopez-Vilella, MD. DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 10 Myocardial Iron Changes After Iron Administration u~nez et al N ORIGINAL RESEARCH Unidad de Imagen Cardiaca (ERESA) Hospital Clınico 4. Nu~ nez J, Comın-Colet J, Mi~ nana G, N ~ez E, Santas E, Mollar A, Valero E, un Garcıa-Blas S, Cardells I, Bodı V, Chorro FJ, Sanchis J. Iron deficiency and risk Universitario de Valencia, Valencia, Spain: Maria P. Lopez- of early readmission following a hospitalization for acute heart failure. Eur J Lereu, MD, PhD, Jose V. Monmeneu, MD, PhD. Heart Fail. 2016;18:798–802. 5. von Haehling S, Ebner N, Evertz R, Ponikowski P, Anker SD. Iron deficiency in Cardiology Department and Heart Failure Unit, Hospital heart failure: an overview. JACC Heart Fail. 2019;7:36–46. Universitari Germans Trias i Pujol, Badalona, Spain. Universitat 6. Anker SD, Comin Colet J, Filippatos G, Willenheimer R, Dickstein K, Drexler H, Autonoma de Barcelona, Barcelona, Spain: Antoni Bayes- L€uscher TF, Bart B, Banasiak W, Niegowska J, Kirwan BA, Mori C, von Eisenhart Rothe B, Pocock SJ, Poole-Wilson PA, Ponikowski P; FAIR-HF Trial Investiga- Genıs, MD, PhD, Josep Lup on, MD, PhD. tors. Ferric carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med. 2009;361:2436–2448. Nephrology Department, Hospital Clınico Universitario de 7. Ponikowski P, van Veldhuisen DJ, Comin-Colet J, Ertl G, Komajda M, Mareev V, Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain: McDonagh T, Parkhomenko A, Tavazzi L, Levesque V, Mori C, Roubert B, Filippatos G, Ruschitzka F, Anker SD; CONFIRM-HF Investigators. Beneficial Jose Luis Gorriz, MD, PhD. effects of long-term intravenous iron therapy with ferric carboxymaltose in Department of Cardiology, Hospital del Mar, Barcelona, patients with symptomatic heart failure and iron deficiency. Eur Heart J. 2015;36:657–668. Spain Heart Diseases Biomedical Research Group, IMIM 8. van Veldhuisen DJ, Ponikowski P, van der Meer P, Metra M, B€ohm M, Doletsky (Hospital del Mar Medical Research Institute), Barcelona, A, Voors AA, Macdougall IC, Anker SD, Roubert B, Zakin L, Cohen-Solal A; Spain. Department of Medicine, Universitat Autonoma de EFFECT-HF Investigators. Effect of ferric carboxymaltose on exercise capacity in patients with chronic heart failure and iron deficiency. Circulation. Barcelona, Spain: Josep Comın-Colet, MD, PhD. 2017;136:1374–1383. 9. Dong F, Zhang X, Culver B, Chew HG Jr, Kelley RO, Ren J. Dietary iron deficiency induces ventricular dilation, mitochondrial ultrastructural aberra- tions and cytochrome c release: involvement of nitric oxide synthase and protein tyrosine nitration. Clin Sci (Lond). 2005;109:277–286. Sources of Funding 10. Kobak KA, Radwa nska M, Dziez gała M, Kasztura M, Josiak K, Banasiak W, Ponikowski P, Jankowska EA. Structural and functional abnormalities in iron- This work was supported in part by an unrestricted grant from depleted heart. Heart Fail Rev. 2019;24:269–277. Vifor Pharma, CIBER Cardiovascular (grant numbers 16/11/ 11. Haddad S, Wang Y, Galy B, Korf-Klingebiel M, Hirsch V, Baru AM, Rostami F, 00420 and 16/11/00403), and Proyectos de Investigacion Reboll MR, Heineke J, Fl€ogel U, Groos S, Renner A, Toischer K, Zimmermann F, Engeli S, Jordan J, Bauersachs J, Hentze MW, Wollert KC, Kempf T. Iron- de la Secci on de Insuficiencia Cardiaca 2017 from Sociedad regulatory proteins secure iron availability in cardiomyocytes to prevent heart Espa~nola de Cardiologıa. failure. Eur Heart J. 2017;38:362–372. 12. Hoes MF, Grote Beverborg N, Kijlstra JD, Kuipers J, Swinkels DW, Giepmans BNG, Rodenburg RJ, van Veldhuisen DJ, de Boer RA, van der Meer P. Iron deficiency impairs contractility of human cardiomyocytes through decreased mitochondrial function. Eur J Heart Fail. 2018;20:910–919. Disclosures 13. Maeder MT, Khammy O, dos Remedios C, Kaye DM. Myocardial and systemic J. Nu~ nez received board speaker fees and travel expenses iron depletion in heart failure implications for anemia accompanying heart failure. J Am Coll Cardiol. 2011;58:474–480. from Novartis, Roche Diagnostics, Abbott, Rovi, Vifor Pharma, 14. Melenovsky V, Petrak J, Mracek T, Benes J, Borlaug BA, Nuskova H, Pluhacek T, Daiichi Sankyo, Boehringer Ingelheim, and Astra-Zeneca Spatenka J, Kovalcikova J, Drahota Z, Kautzner J, Pirk J, Houstek J. Myocardial iron content and mitochondrial function in human heart failure: a direct tissue (modest). L. Facila received speaker fees and travel expenses analysis. Eur J Heart Fail. 2017;19:522–530. from Novartis (modest). J. Sanchis received speaker fees from 15. Anderson LJ, Holden S, Davis B, Prescott E, Charrier CC, Bunce NH, Firmin DN, Astra-Zeneca, Abbott, and Edwards Lifesciences (modest). J. Wonke B, Porter J, Walker JM, Pennell DJ. Cardiovascular T2-star (T2*) magnetic resonance for the early diagnosis of myocardial iron overload. Eur L. Gorriz received board membership fees, speaker fees, and Heart J. 2001;22:2171–2179. consulting fees from Novartis, Astra-Zeneca, and Vifor 16. He T. Cardiovascular magnetic resonance T2* for tissue iron assessment in the heart. Quant Imaging Med Surg. 2014;4:407–412. Fresenius Medical Care Renal Pharma (modest). J. Comın- 17. Nagao M, Matsuo Y, Kamitani T, Yonezawa M, Yamasaki Y, Kawanami S, Abe Colet received speaker fees from Vifor Pharma and an K, Mukai Y, Higo T, Yabuuchi H, Takemura A, Yoshiura T, Sunagawa K, Honda H. Quantification of myocardial iron deficiency in nonischemic heart failure unrestricted grant from Vifor Pharma (modest). A. Bayes- by cardiac T2* magnetic resonance imaging. Am J Cardiol. 2014;113:1024– Genıs received board membership fees and travel expenses 1030. from Novartis, Roche Diagnostics, Vifor Pharma, and Critical 18. Taylor AJ, Salerno M, Dharmakumar R, Jerosch-Herold M. T1 mapping: basic techniques and clinical applications. JACC Cardiovasc Imaging. 2016;9: Diagnostics (modest). The remaining authors have no disclo- 67–81. sures to report. 19. N ~ez J, Monmeneu JV, Mollar A, Nu~ un nez E, Bodı V, Mi~ nana G, Garcıa-Blas S, Santas E, Ag€uero J, Chorro FJ, Sanchis J, L opez-Lereu MP. Left ventricular ejection fraction recovery in patients with heart failure treated with intravenous iron: a pilot study. ESC Heart Fail. 2016;3:293–298. References 20. Mi~nana G, Cardells I, Palau P, Llacer P, Facila L, Almenar L, L opez-Lereu MP, Monmeneu JV, Amiguet M, Gonzalez J, Serrano A, Montagud V, L opez-Vilella R, 1. Rocha BML, Cunha GJL, Menezes Falc~ao LF. The burden of iron deficiency in Valero E, Garcıa-Blas S, Bodı V, de la Espriella-Juan R, Sanchis J, Chorro FJ, heart failure: therapeutic approach. J Am Coll Cardiol. 2018;71:782–793. Bayes-Genıs A, Nu~ nez J; Myocardial-IRON Investigators. Changes in myocardial 2. Comın-Colet J, Enjuanes C, Gonzalez G, Torrens A, Cladellas M, Mero~ no O, iron content following administration of intravenous iron (Myocardial-IRON): Ribas N, Ruiz S, G omez M, Verdu JM, Bruguera J. Iron deficiency is a study design. Clin Cardiol. 2018;41:729–735. key determinant of health-related quality of life in patients with chronic 21. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, heart failure regardless of anaemia status. Eur J Heart Fail. 2013;15:1164– Gonzalez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, 1172. Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, 3. Jankowska EA, Rozentryt P, Witkowska A, Nowak J, Hartmann O, Ponikowska Ruschitzka F, Rutten FH, van der Meer P; Authors/Task Force Members; B, Borodulin-Nadzieja L, Banasiak W, Polonski L, Filippatos G, McMurray JJ, Document Reviewers. 2016 ESC guidelines for the diagnosis and treatment of Anker SD, Ponikowski P. Iron deficiency: an ominous sign in patients with acute and chronic heart failure: the Task Force for the diagnosis and treatment systolic chronic heart failure. 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Leszek P, Sochanowicz B, Szperl M, Kolsut P, Brzoska K, Piotrowski W, Rywik 25. Toblli JE, Di Gennaro F, Rivas C. Changes in echocardiographic parameters in TM, Danko B, Polkowska-Motrenko H, R oz_ a nski JM, Kruszewski M. Myocardial iron deficiency patients with heart failure and chronic kidney disease treated iron homeostasis in advanced chronic heart failure patients. Int J Cardiol. with intravenous iron. Heart Lung Circ. 2015;24:686–695. 2012;159:47–52. DOI: 10.1161/JAHA.119.014254 Journal of the American Heart Association 12 SUPPLEMENTAL MATERIAL Table S1. Inclusion and exclusion criteria. Inclusion criteria ▪ Outpatients with chronic HF ▪ Oder than 18 years ▪ NYHA II-III with optimal medical treatment in the last 4 weeks, without dose changes of HF treatment in the last 2 weeks (except for diuretics) ▪ NT-proBNP >400 pg/mL ▪ LVEF <50% in the last 12 months ▪ ID, defined as: serum ferritin <100μg/L, or 100-299μg/L if TSAT <20% and Hemoglobin <15 g/dL ▪ Participants are willing and able to give informed consent for participation in the study Exclusion criteria ▪ Known intolerance to FCM ▪ History of acquired iron overload ▪ Severe valve disease or cardiac surgery scheduled in the next 30 days ▪ ACS, TIA, or ictus in the 3 previous months ▪ CABG, major surgery, or cardiac, cerebrovascular or aortic percutaneous intervention (diagnostic angiography is allowed) in the 3 previous months ▪ Scheduled revascularization in the next 30 days ▪ Scheduled CRTD implantation in the next 30 days ▪ Active bleeding in the last 30 days ▪ Active infection or malignancy ▪ Immediate need for transfusion or hemoglobin ≥15g/dL ▪ Anemia for reasons other than ID ▪ Immunosuppressive therapy or dialysis ▪ History of treatment with erythropoietin, intravenous iron, or transfusion in the previous 12 weeks ▪ Treatment with oral iron at doses >100mg/day in the previous week ▪ Contraindications to MRI, including non-compatible pacemakers or defibrillators, cochlear implants, cerebral aneurysm clips, claustrophobia, or abdominal obesity not allowing the realization of the test due to a physical space problem. ▪ Pregnant or lactating women ▪ Subject of childbearing age who is unwilling to use adequate contraceptive measures during the study and up to 5 half-lives after the administration of study treatment ▪ Participation in another trial at the time of inclusion or in the previous 30 days ▪ Any disorder that compromises the ability to sign informed consent and/or comply with study procedures ACS: acute coronary syndrome; CABG: coronary artery by-pass surgery,CRTD: cardiac resynchronization therapy device; HF: heart failure; NT-proBNP: amino- terminal pro-brain natriuretic peptide; FCM: ferric carboxymaltose, ID: iron deficiency; LVEF: left ventricle ejection fraction; NYHA: New York Heart Association; TIA: transient ischemic attack, TSAT: transferrin saturation. Table S2. Patients’ characteristics by visit. Patients’ Baseline 7-day visit 30-day visit Omnibus characteristics Placebo Iron p- Placebo Iron p- Placebo Iron p- p-value (n=26) (n=27) value (n=26) (n=27) value (n=26) (n=27) value CMR T1- 1071.5 1082 (1052, 0.395 1071 (1038, 1064 (1048, 0.919 1068.5 1081 (1066, 0.471 <0.001 mapping, msec (1030, 1116) 1122) 1112) 1095) (1040, 1088) 1109) CMR T2*, msec 37 (31, 42) 40 (34, 45) 0.217 39 (35, 42) 38 (35, 41) 0.644 38.5 (34, 45) 38 (36, 42) 0.769 0.001 CMR LVEF, % 36 (31, 45) 44 (36, 49) 0.242 39 (34, 49) 43 (35, 53) 0.365 40 (31, 46) 45 (38, 53) 0.129 0.017 6MWT, m 273 (228, 312 (221, 0.869 286.5 (240, 306 (240, 0,881 297.5 (264, 312 (228, 0.738 0.014 342) 383) 360) 362) 384) 372) KCCQ, overall 72.7 (54.3, 75.0 (63.0, 0.426 78.3 (53.6, 82.3 (70.5, 0.300 75.3 (51.0, 84.4 (68.8, 0.140 0.012 summary score 91.1) 92.2) 88.3) 94.3) 86.3) 91.7) TSAT, % 15.4 (9.6, 15.7 (12.0, 0.472 15.0 (11.0, 39.0 (27.0, 0.001 14.8 (10.0, 27.2 (23.0, <0.001 0.001 20.0) 19.2) 21.7) 44.8) 20.0) 36.8) Ferritin, pg/mL 47.8 (23.0, 73.0 (56.0, 0.217 45.5 (21.0, 944.0 (790.8, <0.001 55.5 (29.3, 447.0 (294.0, <0.001 <0.001 114.0) 126.0) 109.0) 1356.0) 107.0) 632.3) Hemoglobin, 13.4 (12.7, 13.1 (11.9, 0.267 13.3 (12.6, 12.6 (12.1, 0.315 13.1 (12.3, 13.1 (12.5, 0.943 0.178 g/dL 14.6) 13.4) 14.4) 13.6) 14.1) 14.2) NT-proBNP, 1213.5 1990 (976, 0,960 1328.5 (821, 1790 (1009, 0,422 1409 (805, 2111 (858, 0.500 0.856 pg/mL (1010, 2667) 2830) 3268) 2973) 2978) 3122) CMR: cardiac magnetic resonance; KCCQ: Kansas City Cardiomyopathy Questionnaire; LVEF: left ventricle ejection fraction; NT-proBNP: amino-terminal pro-brain natriuretic peptide; TSAT: transferrin saturation; 6MWT: 6-minute walking test. Continuous values are expressed as median (interquartile range).