Cardio-hepatic injury phenotypes and short-term outcomes in acute decompensated heart failure

Background Abnormal liver biochemistry is common in acute decompensated heart failure (ADHF), yet most studies evaluate individual markers rather than clinically meaningful patterns of hepatic involvement. We examined whether cardiohepatic injury phenotypes derived from routine liver tests identify distinct short-term prognostic profiles in patients hospitalized with ADHF. Methods In this retrospective cohort study, we included consecutive adults hospitalized with ADHF between December 2006 and 2017. Using peak in-hospital values of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin, patients were classified into four phenotypes: no hepatic injury, hepatocellular injury, cholestatic injury, or combined injury. Associations with in-hospital mortality were evaluated using multivariable logistic regression. Post-discharge outcomes (30-day mortality, readmission, and their composite) were analyzed using Cox and Fine–Gray models. Results Among 8332 ADHF admissions, 6792 (81.5%) had sufficient data for phenotype classification: 58.1% had no hepatic injury, 22.1% hepatocellular injury, 13.1% cholestatic injury, and 6.7% combined injury. In-hospital mortality differed markedly across phenotypes (3.5%, 16.3%, 9.0%, and 24.3%, respectively; p < 0.001). After adjustment, all injury phenotypes independently predicted in-hospital death compared with no injury. Among 6128 patients included in adjusted post-discharge analyses, hepatocellular and combined injury were independently associated with higher 30-day mortality and the composite outcome, whereas isolated cholestatic injury was not. Hepatocellular and combined injury independently predicted 30-day readmission. Conclusions Routine liver test patterns identify clinically meaningful cardiohepatic phenotypes in ADHF. While all hepatic injury phenotypes are associated with increased in-hospital mortality, only phenotypes with hepatocellular involvement predict adverse early post-discharge outcomes. Pattern-based interpretation of liver tests may improve early risk stratification in patients hospitalized with ADHF.