Clinical Effects of Anemia

Patients with anemia usually seek medical attention because of decreased work or exercise
tolerance, shortness of breath, palpitations, or other signs of cardiorespiratory adjustments to
anemia. At times, they feel fine, but their friends or family may note pallor. It is not uncommon
that anemia in a child is first recognized by a visiting relative, the process sometimes occurring
so slowly as to not be noted by parents or other immediate family members.
Cardiovascular and Pulmonary Features of Anemia
The clinical manifestations of anemia depend on the magnitude and rate of reduction in the
oxygen-carrying capacity of the blood, the capacity of the cardiovascular and pulmonary systems
to compensate for the anemia, and the associated features of the underlying disorder that resulted
in the development of anemia. The Hb concentration is not the only determinant of the observed
symptoms. Coexistent cardiovascular or pulmonary disease, particularly in older individuals,
may exaggerate the symptoms associated with a degree of anemia that would be well tolerated
under other circumstances.
If the anemia has been insidious in onset and there is no cardiopulmonary disease, the patients
adjustment may be so effective that the blood Hb concentration may fall to 8 g/dl or even lower
before the patient experiences enough symptoms to appreciate the situation (19). In cases of iron
deficiency anemia, pernicious anemia, or other types of slowly developing anemia, Hb
concentrations may reach levels of 6 g/dl or lower before patients are motivated to seek medical
attention (20). This is particularly true in children where no limitations of physical activity may
be apparent despite the existence of very severe anemia (21). The physiologic adjustments that
take place with a slowly falling red cell mass chiefly involve the cardiovascular system and
changes in the Hboxygen dissociation curve.
In many patients, respiratory and circulatory symptoms are noticeable only after exertion;
however, when anemia is sufficiently severe, dyspnea and awareness of vigorous or rapid heart
action may be noted even at rest. When anemia develops rapidly, shortness of breath,
tachycardia, dizziness or faintness (particularly upon arising from a sitting or recumbent
posture), and extreme fatigue are prominent. In chronic anemia, only moderate dyspnea or
palpitation may occur, but in some patients, congestive heart failure (22), angina pectoris, or
intermittent claudication (23) can be the presenting manifestation. In patients with severe chronic
anemia, tachycardia and postural hypotension may not be present because the total blood volume
actually may be increased due to an expanded plasma volume. In the elderly particularly,
cardiovascular adaptation to anemia is predominantly by increasing stroke volume, rather than
by heart rate (24). It is in these cases that rapid administration of a blood transfusion may
precipitate congestive heart failure by aggravating an already expanded blood volume. Concern
about this possibility should not preclude expansion of the bloods oxygen-carrying capacity by
transfusion if necessary; rather, the judicious use of diuretics in the peritransfusion period should
be considered in patients with clinical signs of volume overload.
Heart murmurs are a common cardiac sign associated with anemia. They usually are systolic in
time and best heard in the pulmonic area (25, 26, 27). Often, they are moderate in intensity, and
at times may be rough in quality and raise suspicion of organic valvular heart disease. In a recent
study in Bosnia, 25% of the heart murmurs investigated in a pediatric cardiology clinic were
attributable to anemia, and resolved with its correction (28).
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Pallor

Pallor is a sign of anemia, but many factors other than Hb concentration affect skin color. These
include the degree of dilation of peripheral vessels, the degree of pigmentation, and the fluid
content of the subcutaneous tissues. Certain people routinely have pale-appearing skin without
being anemic. Patients with myxedema may manifest pallor without anemia. In simple vasovagal
syncope, pallor results from cutaneous vasoconstriction and is not a sign of anemia. Jaundice,
cyanosis, racial skin pigmentation, and dilation of the peripheral vessels all can mask the pallor
of anemia.
The pallor associated with anemia is best detected in the mucous membranes of the mouth and
pharynx, the conjunctivae, the lips, and the nail beds. In the hands, the skin of the palms first
becomes pale, but the creases may retain their usual pink color until the Hb concentration is <7
g/dl.
A distinctly sallow color implies chronic anemia. A lemon-yellow pallor suggests pernicious
anemia, but it is observed only when the condition is well advanced. Definite pallor associated
with mild scleral and cutaneous icterus suggests hemolytic anemia. Marked pallor associated
with suggests more generalized bone marrow failure due to acute leukemia, aplasia, or
myelodysplastic syndromes.
Ophthalmologic Findings