Albuminuria and heart failure

Albuminuria, typically measured by urinary albumin-to-creatinine ratio, is present in nearly half of all patients with heart failure. Even at low levels, albuminuria is a well-established, independent risk marker for incident heart failure and adverse outcomes in those with pre-existing heart failure. Currently, routine urinary albumin-to-creatinine ratio screening is not universally recommended in heart failure guidelines, unlike in guidelines for Type 2 diabetes, chronic kidney disease, and hypertension. Emerging data suggest that this may limit opportunities for early detection, risk stratification, and pharmacologic intervention to improve outcomes. Clinical trials of guideline-directed therapies, including renin-angiotensin inhibitors, sodium-glucose cotransporter 2 inhibitors and finerenone show that reductions in urinary albumin-to-creatinine ratio is associated with risk reductions for cardiovascular, heart failure, and chronic kidney disease outcomes, indicating that albuminuria may function as both a marker of risk and potentially a modifiable factor. This review evaluates the role of albuminuria in predicting heart failure development and progression, its potential as a modifiable risk factor, approaches for measurement, current guideline recommendations for testing, and how heart failure therapies influence albuminuria and associated outcomes.