Cor Vasa 2026, 68(3):349-361

Pathophysiology of Anemia in Heart Failure: Mechanisms and Clinical Implications

Viktória Maľováa, b
a Department of Hematology and Transfusion Medicine, Nemocnica Poprad, Poprad, the Slovak Republic
b Faculty of Medicine, Pavol Jozef Šafárik University in Košice, Košice, the Slovak Republic

Anemia is a common complication of heart failure (HF) and provides independent prognostic information. It affects up to half of patients and is frequently accompanied by alterations in erythrocyte indices that reflect underlying systemic dysregulation. The pathophysiology of anemia in HF is multifactorial and involves congestion-related hemodilution; impaired erythropoietin (EPO) production and marrow responsiveness due to renal hypoperfusion, inflammation, and uremic milieu; hepcidin-mediated functional iron deficiency; nutritional and medication-related influences; reduced red blood cell lifespan; and oxidative and mitochondrial dysfunction. These interacting mechanisms are captured by routinely available laboratory parameters, including hemoglobin, mean corpuscular indices, red cell distribution width (RDW), ferritin, and transferrin saturation, which provide insight into erythropoietic activity, iron availability, and red blood cell turnover. RDW, in particular, integrates disturbed erythropoiesis and impaired erythrocyte survival and consistently associates with adverse outcomes across HF phenotypes. Overall, anemia in HF represents a dynamic manifestation of multisystem dysregulation rather than an isolated hematologic disorder. Interpretation of hemoglobin values therefore requires integration with volume status and iron metabolism rather than isolated correction. Future research should prioritize biomarker-guided phenotyping to better delineate dominant pathophysiological drivers of anemia in heart failure.

Keywords: Anemia, Heart failure, Hepcidin, Iron deficiency, Oxidative stress

Received: January 24, 2026; Revised: January 24, 2026; Accepted: April 10, 2026; Prepublished online: June 2, 2012; Published: July 1, 2026  Show citation

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Maľová V. Pathophysiology of Anemia in Heart Failure: Mechanisms and Clinical Implications. Cor Vasa. 2026;68(3):349-361.
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