The Association Between Anemia (Hemoglobin Level) and Cardiomegaly Based On Chest Radiograph and Echocardiography
Conditions: Anemia in Children, Cardiomegaly
Sponsor: Universitas Sumatera Utara

 
 
01 April 2023 
The Association Between Anemia (Hemoglobin Level) and Cardiomegaly Based On Chest 
Radiograph and Echocardiography 
Putri Amelia*1, Bastian Lubis2, Rizky Adriansyah1 
1 Department of Pediatrics, Faculty of Medicine, Universitas Sumatera Utara 
2 Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Universitas Sumatera Utara  
 
Corresponding author: Putri Amelia, Department of Pediatrics, Faculty of Medicine, Universitas 
Sumatera Utara. Address : Jl. Dr. Mansyur No.5, Medan 20155, Sumatera Utara, Indonesia. 
Phone: +62 852 6100 0273. Email address: putri.amelia@usu.ac.id. ORCID ID: 
https://orcid.org/0000-0001-9941-2555 
 
 

 
 
ABSTRACT 
Background : Anemia is one of the major global problems that continues to this day. According 
to World Health Organization (WHO) data, anemia is found in 1.62 billion people or equivalent 
to 24.8% of the world's population while, the prevalence of anemia in children under 6 years of 
age in Indonesia reached 38.4%. Anemia, if undiagnosed or untreated for a long period of time 
can lead to multiorgan failure. The cardiovascular system is the most commonly affected system 
in chronic anemia. Between one-third and two-thirds of patients with severe anemia have 
cardiomegaly and this will return to normal within a few weeks after the anemia is well 
managed. This abnormality can be evaluated on chest radiograph or echocardiography. 
Objective : This study aims to evaluate the association between anemia and cardiomegaly. 
Methods : This was a cross-sectional which was carried out in the pediatric ward and pediatric 
cardiology outpatient clinic in the year 2022. The research subjects were children diagnosed with 
anemia, then they would undergo chest radiograph and echocardiography to assess whether there 
is cardiomegaly or not.  
Results : Eighty one children were included in this study. The majority of them were girl, with a 
total of 43 people (53.1%). The median age of patients in this study was 7.75 years old. In 
addition, this study also found that the median of patients’ body weight and height were 18.3 kg 
and 116 cm. In this study, the median hemoglobin level was 10.3 g/dL. For the echocardiography 
parameters in this study, the median of LA/Ao, EF and FS were 1.24, 65% and 35% respectively. 
Conclusion : There is no association beteween anemia and cardiomegaly based on chest 
radiograph or echocardiography. 
 
Keywords : Anemia, echocardiography, chest radiograph, cardiomegaly, heart enlargement 

 
 
INTRODUCTION 
 
Anemia is a condition where there is a decrease in the number of erythrocytes or 
hemoglobin concentration. Hemoglobin is needed to carry oxygen and if the number of 
erythrocytes or hemoglobin levels are too low or abnormal, there will be a decrease in the blood's 
capacity to carry oxygen to the body tissues. Anemia is a serious global health problem 
especially in children and pregnant women.1 The World Health Organization (WHO) estimates 
that 42% of children under 5 years of age and 40% of pregnant women worldwide are anemic. 
According to (WHO) data, anemia is found in 1.62 billion people (95% CI: 1.50-1.74 billion), 
which is equivalent to 24.8% of the world's population (95% CI: 22.9-26.7%).2 In Indonesia, the 
prevalence of anemia in children under 6 years of age in 2019 reached 38.4%.1 
 
Despite the relatively high prevalence of anemia, its clinical implications tend to be 
underestimated in anemic individuals without significant medical problems. Clinical and 
hemodynamic changes due to short-lasting acute anemia are reversible. However, if undiagnosed 
or untreated for a long period of time it can lead to multiorgan failure. The cardiovascular system 
is the most commonly affected system in chronic anemia. Anemia causes hypoxia due to 
decreased hemoglobin levels, and there are several nonhemodynamic (increased erythopoetin 
production, decreased hemoglobin affinity for oxygen due to increased 2,3-diphosphoglycerate) 
and hemodynamic compensatory mechanisms.3,4 Anemia increases cardiac output,leading to left 
ventricular hypertrophy. Increased left ventricular performance results due to increased preload 
(Frank-Starling mechanism) and increased inotropic state associated with sympathetic activity.3 
Chronic anemia leads to progressive cardiac enlargement and left ventricular hypertrophy due to 
volume overload which can be seen on thoracic x-ray or echocardiography.3-6 
 
Between one-third and two-thirds of patients with severe anemia have cardiomegaly on 
chest radiographs. Echocardiography has also shown some hemodynamic changes in anemic 
patients. Diastolic and systolic left ventricular chamber size will enlarge to increase cardiac 
output, aiming to improve systemic oxygen delivery.4 It should be remembered that anemia has 
an adverse impact on the cardiovascular system and is associated with a poor cardiovascular 
prognosis.6 To date, published data on the correlation between hemoglobin (Hb) concentration 
and cardiac enlargement are scarce. 
METHODS 
 This is an observational study with cross-sectional design which was done in the pediatric 
ward and pediatric cardiology outpatient clinic in the year 2022. The sampling technique used 
was consecutive sampling, with minimum sample of 56 subjects. The population in this study 
were all children diagnosed with anemia. Inclusion criteria were anemic patients aging maximal 
18 years old and had undergone chest x-ray and echocardiography. These two tests were done in 
order to evaluate whether the patient develop cardiomegaly or not. Exclusion criteria were 
patients who had undergone definitive surgery, patients who had took iron supplementation in 
the last 3 months, as well as those who had other anemic conditions such as chronic kidney 
disease or hemolitic anemia. 

 
 
This research was conducted after obtaining informed consent from patients regarding the 
study and data that were going to be collected. The data collected were patient’s identity (name, 
age, body weight and height), patient’s hemoglobin level, patient’s cardiomegaly status (based 
on chest x-ray and echocardiography) and patient’s echocardiography parameters (LA/Ao, EF, 
and FS). The diagnosis of anemia is based on the hemoglobin range by WHO.7 
Data were then tabulated into master table using SPSS software. Categoric data were 
presented in proportion and frequency, while numerical data were presented in either 
mean±standard deviation or median depends on the results of the normality test. The correlation 
between mean perfussion pressure and renal resistive index will be analyzed using Spearman 
correlation test. 
RESULTS 
 
Characteristics of Study Subjects 
 
There were a total of 81 subjects in this study. The characteristics of the subjects of this 
study are shown in table 1. 
Table 1. Characteristics of Study Subjects 
Characteristics 
Median (Min-Max) 
Gender, n(%) 
 
Boy 
 
Girl 
Age (years)         
Body Weight (kg)      
Body Height (cm)         
Hemoglobin (g/dL)      
LA/Ao 
EF (%) 
FS (%) 
 
38 (46.9%) 
43 (53.1%) 
7.75 (0.3 – 17.75 ) 
18.3 (3.8 – 71.4) 
116 (50 – 167.5) 
10.3 (3.8 – 15.4) 
1.24 (1.10 – 1.46) 
65 (45 – 89) 
35 (21 – 58) 
 
Based on table 1, it was found that the majority of subjects were girl, with a total of 43 
people (53.1%). The median age of patients in this study was 7.75 years old. In addition, this 
study also found that the median of patients’ body weight and height were 18.3 kg and 116 cm. 
In this study, the median hemoglobin level was 10.3 g/dL. For the echocardiography parameters 
in this study, the median of LA/Ao, EF and FS were 1.24, 65% and 35% respectively. 

 
 
Association Between Anemia and Cardiomegaly Based on Chest Radiograph 
Table 2. Association between anemia and cardiomegaly based on chest radiograph 
Anemia 
Chest Radiograph 
Total 
p value 
Normal 
Cardiomegaly 
Normal 
35 (43.2%) 
1 (1.2%) 
36 (44.4%) 
0,093* 
Anemia 
39 (48.1%) 
6 (7.4%) 
45 (55.6%) 
Total 
74 (91.4%) 
7 (8.6%) 
81 (100%) 
*Chi Square test 
 
Based on the Chi Square test in table 2, there is no significant association between 
anemia and cardiomegaly based on chest radiograph where the p value is > 0.05. 
DISCUSSION 
 
In this study, there was no association between anemia and cardiomegaly based on either 
chest radiograph or echocardiography. The association between anemia and cardiomegaly in 
children is still being considered. From several studies, there are also no studies that specifically 
discuss the association between cardiomegaly and anemia. Some studies have only linked 
cardiomegaly as one of the clinical manifestations of pediatric cardiac disorders (such as heart 
failure, cardiomyopathy, or myocarditis) with anemia. For example, studies conducted by Puri et 
al and Isezuo et al. Puri et al stated that anemia can increase the risk of heart failure in children 
and worsen heart damage due to cardiomyopathy in pediatric patients with heart failure, while 
Isezuo et al supported the results of the study from Puri et al by stating that anemia can be the 
most common cause of heart failure in children, including other causes such as congenital heart 
disease, bronchopneumonia, rheumatic heart disease, and dilated cardiomyopathy.8,9 
 
Anemia itself consists of various types, with iron deficiency anemia being the most 
common anemia in children. According to Wittekind et al, iron deficiency anemia can cause 
secondary cardiomyopathy which can lead to cardiomegaly, but the pathogenesis of 
cardiomyopathy is still unclear. This statement is in accordance with research conducted by 
Shalby et al, who stated that the cardiovascular system can be affected by the occurrence of 
anemia as a non-hematological manifestation in pediatric patients with iron deficiency anemia. 
Cardiomegaly, arrhythmia, left ventricular hypertrophy, and heart failure can occur when the 
state of iron deficiency anemia continues. Odeyemi et al also agree with this statement, stating 
that anemia can worsen the damage that has occurred to the heart, especially the myocardium, if 
iron deficiency anemia is not treated immediately.10,11 
 
Shalby et al in their study explained that iron deficiency anemia and cardiomegaly are 
interrelated. According to Shalby et al, the cardiovascular system can occur as a non-
hematological clinical manifestation in patients with iron deficiency anemia due to increased 
cardiac output. Cardiac output that occurs is a compensation for meeting the oxygen needs of the 
tissues. Compensation occurs in the form of increased blood volume, pulse frequency, and stroke 

 
 
volume. If these three things left untreated, it could cause cardiomegaly, arrhythmia, left 
ventricular hypertrophy, and heart failure.12 
 
Wittekind et al also further discussed the relationship between iron deficiency anemia and 
cardiac dysfunction in their case report. In the case report, the cardiac dysfunction found was left 
ventricular and atrial enlargement. Wittekind et al said that left ventricular enlargement is caused 
by iron deficiency cardiomyopathy, while left atrial enlargement occurs due to increased 
pressure during chronic blood filling of the left ventricle. Wittekind et al did not elaborate on the 
pathophysiology of cardiomegaly in the patient and only stated that iron deficiency anemia and 
dilated cardiomyopathy occurred simultaneously.10 
 
In addition to iron deficiency anemia, thiamin response megaloblastic anemia (TRMA) 
can also cause cardiomegaly. Zaferanloo et al have published a case report of a 2-year-old girl 
with Thiamin Response Megaloblastic Anemia (TRMA). The report showed that the patient's Hb 
was 8.9 g/dL and there was enlargement of the ventricle and right atrium. On echocardiogram 
examination, the patient was found to have cardiomegaly. The pathophysiology of cardiomegaly 
or other cardiovascular complaints has not been explained in the report, but Zaferanloo et al 
stated that 27% of patients with TRMA also experienced other cardiovascular complaints such as 
sudden death, stroke, heart failure, proximal atrial tachycardia, atrial fibrillation, and congenital 
heart disease (ventricular or atrial fibrillation).13 
 
Lipshultz et al assessed the association of cardiomegaly due to cardiomyopathy with 
different types of anemia than some of the studies listed above. Lipshultz et al discussed the 
association of cardiomegaly secondary to cardiomyopathy with iron overload in pediatric 
patients with hereditary anemia (sickle cell disease, thalassemia α and β), leukemia, sideroblastic 
anemia, or renal failure. Iron overload in these cases can occur either due to multiple blood 
transfusions or due to increased absorption in the gut when the body's erythropoesis is impaired. 
Lipshultz et al stated that cardiomyopathy occurs due to free radicals that cause lipid membrane 
peroxidation and oxidative damage to nucleic acids in cardiomyocytes. The free radicals 
themselves are formed due to excessive amounts of iron in the blood circulation because the 
amount of iron is not proportional to the transferrin iron binding capacity.14 
 
Lipshultz et al also explained how thiamin deficiency can cause cardiomegaly due to 
cardiomyopathy. According to Lipshultz et al, thiamin deficiency causes vasodilation of blood 
vessels. This vasodilation can cause right heart failure and pulmonary hypertension resulting in 
an increase in cardiac output. If not treated immediately, depression of myocardial function will 
occur and cause cardiomyopathy with one of the symptoms being cardiomegaly.14 
 
 

 
 
CONCLUSION 
There is no association between anemia and cardiomegaly based on either chest 
radiograph or echocardiography. 
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