Albumin, urea‐to‐albumin ratio, or the albumin‐to‐creatinine ratio to predict outcomes in heart failure with mildly reduced ejection fraction

Background This study investigates the prognostic impact of albumin, the urea‐to‐albumin ratio ( UAR ), and albumin‐to‐creatinine ratio ( ACR ) in patients with heart failure with mildly reduced ejection fraction ( HFmrEF ), since hypoalbuminemia, renal disease and malnutrition often coincide with heart failure ( HF ). Methods Consecutive patients hospitalized with HFmrEF at one university medical centre were retrospectively included from 2016 to 2022. Patients were stratified into quartiles based on albumin, the UAR , and ACR . The primary endpoint was all‐cause mortality at 30 months (median follow‐up), key secondary endpoint was long‐term HF ‐related rehospitalization. Results The study cohort comprised 2,061 patients with HFmrEF with a median albumin level of 32.4 g/L. Albumin levels, the UAR and ACR were predictive for the risk of long‐term all‐cause mortality, which was still observed after multivariable adjustment (albumin Q1 vs. Q4 : HR = 2.260; 95% CI 1.623–3.148; p = .001 / UAR Q4 vs. Q1 : HR = 1.507; 95% CI 1.071–2.119; p = .019/ ACR Q1 vs. Q4 : HR = 2.208; 95% CI 1.528–3.190; p = .001). However, neither albumin nor the UAR or ACR predicted the risk of HF ‐related rehospitalization (albumin Q1 vs. Q4 : HR = 1.117; 95% CI .678–1.842; p = .664 / UAR Q4 vs. Q1 : HR = 1.589; 95% CI .922–2.738; p = .095 / ACR Q1 vs. Q4 : HR = 1.112; 95% CI .624–1.981; p = .720). Conclusions Hypoalbuminemia is common in hospitalized HFmrEF patients. Low albumin levels, ACRs , and elevated UARs independently predicted long‐term all‐cause mortality, but not HF ‐related rehospitalization. The UAR and ACR did not provide a clinically significant predictive advantage over albumin levels alone. Trial Registration ClinicalTrials.gov Identifier: NCT05603390 (date of registration: 10.10.2020)