Intravenous Iron Treatment in Patients With Heart Failure and Iron Deficiency: IRONMAN

Inclusion criteria 1. Age ≥18 years 2. LVEF ≤45% within the prior two years using any conventional imaging modality (this should be the most recent assessment of LVEF) 3. New York Heart Association (NYHA) class II - IV 4. Iron deficient - defined as TSAT \<20% and/or ferritin \<100 ug/L 5. Evidence of being in a higher risk HF group: (a) Current (with the expectation that patient will survive to discharge) or recent (within 6 months) hospitalisation for HF, OR (b) Out-patients with NT-proBNP \>250 ng/L in sinus rhythm or \>1,000 ng/L in atrial fibrillation (or BNP of \> 75 pg/mL or 300 pg/mL, respectively) 6. Able and willing to provide informed consent Exclusion criteria 1. Haematological criteria: ferritin \>400ug/L; haemoglobin \<9.0, or \>13 g/dL in women or \>14g/dL in men; (B12 or folate deficiency should be corrected but do not exclude the patient) 2. MDRD/CKD-EPI estimated glomerular filtration rate (eGFR) \<15ml/min/1.73m2 3. Already planned to receive IV iron 4. Likely to need or already receiving erythropoiesis stimulating agents (ESA) 5. Any of the following apply: (a) planned cardiac surgery or revascularisation; (b) within 3 months of any of the following: a primary diagnosis of type 1 myocardial infarction (excluding small troponin elevations in the context of heart failure admissions), cerebrovascular accident (CVA), major CV surgery or percutaneous coronary intervention (PCI), or blood transfusion; (c) on active cardiac transplant list; (d) left ventricular assist device implanted. 6. Any of the following comorbidities: active infection (if the patient is suffering from a significant ongoing infection as judged by the investigator recruitment should be postponed until the infection has passed or is controlled by antibiotics), other disease with life expectancy of \<2 years, active clinically relevant bleeding in the investigator's opinion, known or suspected gastro-intestinal malignancy 7. Pregnancy, women of childbearing potential (i.e. continuing menstrual cycle) not using effective contraception (see Appendix 3) or breast-feeding women 8. Contra-indication to IV iron in the investigator's opinion according to current approved Summary of Product Characteristics: hypersensitivity to the active substance, to Monofer® or any of its excipients (water for injections, sodium hydroxide (for pH adjustment), hydrochloric acid (for pH adjustment)); known serious hypersensitivity to other parenteral iron products; non-iron deficiency anaemia (e.g. haemolytic anaemia); iron overload or disturbances in utilisation of iron (e.g. haemochromatosis, haemosiderosis); decompensated liver disease. 9. Participation in another intervention study involving a drug or device within the past 90 days (co-enrolment in observational studies is permitted)