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Heart failure & cardiomyopathiesMeta-analysis

Anaemia and all-cause mortality in contemporary heart failure with preserved ejection fraction (left ventricular ejection fraction ≥50%): an updated systematic review and meta-analysis

ESC Heart FailPublished

  • systematic review and meta-analysis
  • updated
  • PRISMA 2020
  • Paule-Mandel random-effects models
  • Hartung-Knapp-Sidik-Jonkman variance correction
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Authors' conclusion

WHO-defined anaemia is independently associated with a ∼40-50% higher all-cause mortality in HFpEF, preserved under the contemporary LVEF ≥50% definition and robust to extensive sensitivity, Bayesian, and bias-correction analyses. These findings support incorporating anaemia into HFpEF risk assessment and motivate mortality-powered trials in rigorously defined HFpEF, while not implying that anaemia correction improves outcomes.

Study context

Population
Patients with heart failure with preserved ejection fraction (HFpEF) in cohort studies reporting an adjusted hazard ratio for binary World Health Organization (WHO)-defined anaemia vs all-cause mortality17 studies contributing to the co-primary pools (20 studies included of 6123 records) · legacy pool (left ventricular ejection fraction (LVEF) ≥40%), studies k = 17 · contemporary pool (LVEF ≥50%), studies k = 12
Participants
109,909 patients patients
Comparison
WHO-defined anaemia vs No anaemia
Outcome
All-cause mortality (two pre-specified co-primary pools)
Follow-up
12-72 months

Pooled result

As reported in the abstract

WHO-defined anaemia vs No anaemiaAdjusted hazard ratio (95% CI)
≥40% pool; 95% PI 1.07-2.09; I2 = 85%
1.49(1.35–1.66)
≥50% pool; PI 1.06-1.87; I2 = 83%
1.41(1.26–1.57)

Further pooled results

All-cause mortality, pre-specified sensitivity analyses

Estimate range across 12 pre-specified sensitivity analyses
1.45-1.52
No influential study

All-cause mortality, Bayesian analyses

Posterior median aHR across four Bayesian priors
1.39-1.49
Posterior probability of harm
≥.999
Robust Bayesian model-average aHR
1.41 (95% credible interval 1.17-1.58)

Small-study effects

Egger P
P = 0.03
PEESE aHR
1.39
  • bias-corrected estimate essentially unchanged

Per-1 g/dL lower-haemoglobin dose-response (k = 6)

aHR per 1 g/dL lower haemoglobin
1.17 (1.08-1.27)

Information size and certainty

Accrued sample exceeded the diversity-adjusted required information size
GRADE certainty moderate under the prognostic-factor framework

Anaemia prevalence

Anaemia prevalence
26%-70%

Original publication

Anaemia and all-cause mortality in contemporary heart failure with preserved ejection fraction (left ventricular ejection fraction ≥50%): an updated systematic review and meta-analysis. ESC Heart Fail. Published 8 September 2026. doi:10.1093/eschf/xvag213
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Summarised from the published abstract; every number is checked against it