Skeletal Muscle Abnormalities and Iron Deficiency in Chronic Heart Failure An Exercise 31 P Magnetic Resonance Spectroscopy Study of Calf Muscle

Circ Heart Fail. 2018 Sep;11(9):e004800. doi: 10.1161/CIRCHEARTFAILURE.117.004800.


Background: Heart failure (HF) is often associated with iron deficiency (ID). Skeletal muscle abnormalities are common in HF, but the potential role of ID in this phenomenon is unclear. In addition to hemopoiesis, iron is essential for muscle bioenergetics. We examined whether energetic abnormalities in skeletal muscle in HF are affected by ID and if they are responsive to intravenous iron.

Methods and results: Forty-four chronic HF subjects and 25 similar healthy volunteers underwent 31P magnetic resonance spectroscopy of calf muscle at rest and during exercise (plantar flexions). Results were compared between HF subjects with or without ID. In 13 ID-HF subjects, examinations were repeated 1 month after intravenous ferric carboxymaltose administration (1000 mg). As compared with controls, HF subjects displayed lower resting high-energy phosphate content, lower exercise pH, and slower postexercise PCr recovery. Compared with non-ID HF, ID-HF subjects had lower muscle strength, larger PCr depletion, and more profound intracellular acidosis with exercise, consistent with an earlier metabolic shift to anaerobic glycolysis. The exercise-induced PCr drop strongly correlated with pH change in HF group ( r=-0.71, P<0.001) but not in controls ( r=0.13, P=0.61, interaction: P<0.0001). Short-term iron administration corrected the iron deficit but had no effect on muscle bioenergetics assessed 1 month later.

Conclusions: HF patients display skeletal muscle myopathy that is more severe in those with iron deficiency. The presence of ID is associated with greater acidosis with exercise, which may explain early muscle fatigue. Further study is warranted to identify the strategy to restore iron content in skeletal muscle.

Keywords: heart failure; iron; magnetic resonance spectroscopy; metabolism; muscles.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acidosis / metabolism
  • Acidosis / physiopathology
  • Administration, Intravenous
  • Adult
  • Aged
  • Biomarkers / blood
  • Case-Control Studies
  • Energy Metabolism* / drug effects
  • Exercise Test*
  • Female
  • Ferric Compounds / administration & dosage
  • Heart Failure / diagnosis
  • Heart Failure / drug therapy
  • Heart Failure / metabolism*
  • Heart Failure / physiopathology
  • Humans
  • Iron / blood
  • Iron / deficiency*
  • Isometric Contraction*
  • Leg
  • Magnetic Resonance Spectroscopy / methods*
  • Male
  • Maltose / administration & dosage
  • Maltose / analogs & derivatives
  • Middle Aged
  • Muscle, Skeletal / drug effects
  • Muscle, Skeletal / metabolism*
  • Muscle, Skeletal / physiopathology
  • Phosphorus Isotopes*
  • Predictive Value of Tests
  • Time Factors
  • Treatment Outcome


  • Biomarkers
  • Ferric Compounds
  • Phosphorus Isotopes
  • ferric carboxymaltose
  • Maltose
  • Iron