Aims Anaemia and iron deficiency (ID) are frequently found in patients with chronic heart failure (CHF) and associated with adverse outcome. However, it is unclear whether absolute [transferrin saturation (TSAT) 20%, ferritin 100?μg/L] or inflammation‐driven functional ID (TSAT 20%, ferritin 100?μg/L) with and without anaemia had similar or different consequences for such patients. Methods and results Within this retrospective cohort study, 2223 patients (1601 men and 622 women) with CHF, referred to our department, between 2000 and 2018, were followed for a median time of 84?months. Anaemia was found in 393 patients and was an independent predictor for an adverse outcome [HR 2.164 (95% CI 1.865–2.512), P??0.001]. In 674 patients with available parameters of iron metabolism, ID was present in 228 patients and was associated with an unfavourable outcome [HR 1.499 (95% CI 1.158–1.940), P?=?0.002]. ID was best predicting an adverse outcome in men ≤59?years, with heart failure with reduced ejection fraction, preserved kidney function, no inflammation, and a body mass index (BMI) ≥25.5?kg/m2. Functional ID in women and absolute ID in men were associated with poor prognosis. Of note, TSAT 20% but not low ferritin levels were predictive for an adverse outcome. Anaemic patients with high ferritin levels, advanced inflammation, older age, low BMI, male gender, and reduced glomerular filtration rate had the worst prognosis. Conclusions Anaemia and low tissue iron availability as reflected by TSAT 20% are negative predictors of outcome in patients with CHF. Systemic inflammation, renal function, BMI, age, and gender are important contributors for the clinical course.
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