An international, double-blind, placebo-controlled trial published in The BMJ tested whether intravenous iron given before elective cardiac surgery could improve outcomes for patients with anemia. Researchers enrolled 955 adults with anemia across 33 hospitals in 10 countries between July 2016 and December 2023. Participants, with an average age of 66 years and 60% male, were randomly assigned to receive intravenous iron or placebo one to 26 weeks before surgery.
The primary outcome was the number of days alive and at home up to 90 days after surgery. Among 921 patients assessed, those who received intravenous iron averaged 81 days at home compared with 80 days for the placebo group, a difference of one day.
Red blood cell transfusions during the hospital stay were given to 61% of patients in the iron group versus 68% in the placebo group. The researchers calculated that intravenous iron saved approximately 44 units of blood products for every 100 patients treated.
There were no statistically significant differences between groups in major postoperative complications or length of hospital stay. The trial also measured patient-centered outcomes such as quality of recovery and quality of life, with findings consistent across additional analyses.
The study authors acknowledged several limitations. Patients were enrolled based on anemia without requiring confirmation of absolute iron deficiency, and the one-day difference in days at home over a 90-day period was described as a very small treatment effect. Strengths included a low dropout rate and the focus on outcomes that matter to patients.
About one-third of patients undergoing cardiac surgery are anemic, and 20% to 50% receive a blood transfusion after surgery, which is associated with higher risks of complications, longer stays, and death. Previous research suggested intravenous iron could raise hemoglobin levels, but evidence that it improves patient-centered outcomes had been lacking.
The investigators concluded that intravenous iron repletion before cardiac surgery increased preoperative hemoglobin concentration, reduced the need for red cell transfusion, and resulted in an extra day at home in the first 90 days after surgery. The trial was registered as ITACS and published with DOI 10.1136/bmj-2026-100407.
Iron transfusion before heart surgery reduces complications and boosts recovery, clinical trial finds
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