Systematic review and meta-analysis of erythropoiesis-stimulating agents in chronic heart failure and anaemia

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European journal of heart failure Published May 3, 2026 Medically reviewed May 9, 2026 Study authors: Bunting Karina V, Tica Otilia, Champsi Asgher, Perrett Madeleine, von Lueder Thomas G, van Veldhuise… PubMed ↗ DOI ↗ By Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

Key Takeaway

Consider ESAs for anaemic CHF patients at high risk of recurrent hospital admissions despite moderate evidence quality.

This systematic review and meta-analysis assessed the efficacy and safety of any erythropoiesis-stimulating agent at any dose compared with placebo or no treatment in adults with chronic heart failure and anaemia. The analysis included 3128 patients followed for 5604 person-years. The primary outcome was first CHF hospitalization, while secondary outcomes included total CHF hospitalization, all-cause mortality, incident adverse events, haemoglobin level, exercise tolerance, and NYHA class.

Regarding primary outcomes, there was no significant difference in first CHF hospitalization, with a Peto odds ratio of 0.93 (95% CI 0.78-1.10, P = .37). Conversely, ESAs significantly reduced total CHF hospitalization, with an incidence rate ratio of 0.81 (95% CI 0.73 to 0.90, P < .001). This corresponds to 622 events per 2698 person-years in the ESA group versus 761 per 2914 person-years in the control group.

Secondary outcomes showed that ESAs increased haemoglobin level by a mean difference of 1.6 g/dL (95% CI 1.6-1.7, P < .001) and improved exercise tolerance by a mean difference of 69 metres (95% CI 17-122, P = .009). There were no significant differences in all-cause mortality (odds ratio 1.01, 95% CI 0.86-1.18, P = .88) or incident adverse events. The authors note moderate quality of evidence for most outcomes and variable risk of bias.

Practice relevance suggests that including ESAs in CHF management could be considered in patients with anaemia at high risk of recurrent hospital admissions. The certainty of the evidence is moderate, and serious adverse events were not reported.

Study Details

Study typeMeta analysis

Sample sizen = 3,128

EvidenceLevel 1

PublishedMay 2026

PMID41771081

View Original Abstract ↓

AIMS: Anaemia is common in patients with chronic heart failure (CHF), worsening functional status and prognosis. The role of erythropoiesis-stimulating agents (ESAs) to reduce hospitalization remains unclear. METHODS AND RESULTS: A pre-registered systematic search was performed of randomized controlled trials in adults with CHF and anaemia, comparing any ESA at any dose versus placebo or no treatment.Fourteen trials were included with 3128 participants, with moderate quality of evidence for most outcomes and variable risk of bias. Meta-analysis during 5604 person-years of follow-up demonstrated no significant difference in first CHF hospitalization comparing ESAs with control: Peto odds ratio (OR) 0.93, 95% CI 0.78-1.10, P = .37; trial heterogeneity I2 = 36%. ESAs significantly reduced total CHF hospitalization with 622 events/2698 person-years, compared with 761/2914 person-years for control: incidence rate ratio 0.81, 95% CI 0.73 to 0.90, P < .001; no heterogeneity between trials, I2 = 0%. There were no significant differences between treatment groups for all-cause mortality (OR 1.01, 95% CI 0.86-1.18, P = .88; I2 = 35%) or incident adverse events. Patients randomized to ESAs increased their haemoglobin level [mean difference (MD) 1.6 g/dL compared with control, 95% CI 1.6-1.7, P < .001] and exercise tolerance (MD 69 metres, 95% CI 17-122, P = .009), with lower NYHA class on follow-up (MD -0.73 class, 95% CI -1.11 to -0.36, P < .001). CONCLUSION: ESA treatment in patients with CHF and mild anaemia can reduce recurrent CHF hospitalization and improve functional capacity, without any impact on adverse events. Including ESAs in CHF management could be considered in patients with anaemia at high risk of recurrent hospital admissions.