A single infusion of intravenous iron before cardiac surgery can reduce the need for red cell transfusions and support post-operative recovery, according to findings from the ITACS randomised controlled trial published today in The BMJ. The international trial involved 955 adults with anaemia across 33 hospitals in 10 countries. Patients awaiting elective cardiac surgery received either a 1,000 mg dose of IV iron or a placebo between 1 and 26 weeks before their operation.
Patients given IV iron spent a median of 81.1 days alive and out of hospital within the 90 days following surgery, compared with 80.0 days for the placebo group. The proportion of patients requiring a red cell transfusion fell from 68.2%–61.1%, with researchers estimating that treating 100 patients saves approximately 44 units of blood products. Furthermore, the treatment was well tolerated, with no evidence of an increase in serious adverse events.
Addressing a widespread surgical risk
Anaemia affects roughly 1 in 3 cardiac surgery patients, elevating the risk of complications, intensive care placement, longer hospital stays, and transfusion dependence. While blood transfusions remain lifesaving, donated supplies are finite. The study highlights preoperative anaemia as a modifiable risk factor. These findings arrive as international blood systems face summer red cell shortages and European vulnerabilities regarding imported plasma. Implementing early detection and treatment could reduce avoidable demand on supplies without replacing the fundamental need for donors.
Systemic challenges and policy recommendations
Current NICE blood guidance in the UK recommends oral iron first, followed by referral to specialist clinics if oral treatment fails. However, within a stretched NHS, these specialist clinics are not routine and face long delays. Conversely, IV iron is already used routinely in Australian primary care. The findings build upon the UCL-led PREVENTT trial in major abdominal surgery, with medical experts arguing that early screening and IV iron infusions should now become a standard perioperative pathway for all surgical patients with iron deficiency.
Expert commentary
Professor Toby Richards, senior author, director of The Iron Clinic, and global iron deficiency expert, said: “ITACS should be a turning point in how we manage anaemia in patients for surgery. This landmark trial shows that a single IV iron infusion before heart surgery can reduce the need for donated blood and help patients recover better. At a time when the NHS is under intense pressure and blood supplies remain vulnerable, failing to diagnose and treat anaemia in preparation and recovery for surgery is no longer tenable. NICE should now review its guidance so that anaemia screening and effective treatment, including IV iron, become routine NHS practice. NICE currently says refer to specialist services; this needs to be changed to IV iron as a routine service.”
The Iron Clinic is calling for NICE guidance to reflect this new evidence so that preoperative anaemia identification and treatment become routine across the NHS.