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Abstract   Aims  Whether and how iron deficiency (ID) impacts patients with heart failure (HF) with preserved ejection fraction (HFpEF) remain unclear. The aim of our study was to investigate the impact of ID on functional status, exercise capacity, and prognosis in HFpEF.    Methods and results  The study population consisted of 300 HFpEF patients. ID was defined as serum ferritin &lt;100 μg/L or 100–300 μg/L and transferrin‐saturation &lt;20%. Baseline functional status, quality of life (HADS score and EQ 5D index), 6 min walking test, echocardiography, and outcome (all‐cause mortality and combined all cause‐mortality and HF hospitalization) were evaluated. ID was found in 159 (53%) patients. Patients with ID had a worse prognosis with a higher combined endpoint of all‐cause mortality and HF hospitalization after 4 years of follow‐up (log rank = 0.008). Pulmonary hypertension, depression, and thyroid disease were more prevalent in the ID group. Multivariable analysis showed that ID was independently associated with body mass index ( P  = 0.003), pulmonary hypertension ( P  = 0.008), and thyroid disease ( P  = 0.01). Although patients with ID had a lower exercise capacity compared with patients without ID (393 m [294–455] vs. 344 m [260–441],  P  = 0.008), there was no significant correlation after multivariable correction for age, BMI, NT‐proBNP, DM, and depression.    Conclusions  Heart failure with preserved ejection fraction patients with ID have a worse prognosis and impaired exercise capacity compared with those without ID. However, although a trend was observed, after multivariable correction ID was no longer significantly associated with a reduced exercise capacity. This reflects that impaired exercise capacity in HFpEF is complex and seems multifactorial. Interestingly, pulmonary hypertension was an independent predictor of both ID and exercise capacity.

Iron deficiency impacts prognosis but less exercise capacity in heart failure with preserved ejection fraction