Variable aetiologies contributing to the anaemia of systolic heart failure are important to individual patient management.

The anaemia of chronic left ventricular systolic dysfunction (LVSD) or systolic heart failure is common, increases over time, and is linked with a bad clinical outcome. It is often considered an expression of the chronic vascular inflammation of endstage disease similar to that seen in conjunction with many other chronic disease states. Failure of haematinic function, particularly renal erythropoietin (Epo) synthesis and release, is also seen as a key mechanism and is cited as a major justification for considering exogenous Epo therapy in this disease. Westenbrink et al. from Groningen contribute a simple but critical clinical paper highlighting that variable mechanisms contribute to this clinical setting. By defining these carefully, Westenbrink shows that notwithstanding the impact of altered Epo kinetics and dynamics, many of these patients might also have ‘simple’ dilutional anaemia related to poorly perceived and asymptomatic fluid imbalance. This simple finding has important implications for management.