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

## TL;DR

The study finds that low albumin levels and related ratios predict mortality in heart failure patients with mildly reduced ejection fraction.

## Contribution

The study introduces new insights into the prognostic value of albumin and related ratios in heart failure with mildly reduced ejection fraction.

## Key findings

- Low albumin levels independently predicted long-term all-cause mortality in HFmrEF patients.
- The urea-to-albumin ratio and albumin-to-creatinine ratio also predicted mortality but not rehospitalization.
- Albumin levels alone provided similar predictive value as the calculated ratios.

## Abstract

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).

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.

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).

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.

ClinicalTrials.gov Identifier: NCT05603390 (date of registration: 10.10.2020)

Among 2061 hospitalized HFmrEF patients, low albumin, albumin‐to‐creatinine ratios (ACR), and elevated urea‐to‐albumin ratios (UAR) 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.