Albumin, Urea-to-Albumin Ratio or the Albumin-to-Creatinine Ratio to Predict Outcomes in Heart Failure with Mildly Reduced Ejection Fraction

Clin Res Cardiol (2026). DOI 10.1007/s00392-026-02870-1
A. Schmitt (Mannheim)¹, I. Akin (Mannheim)¹, M. Reinhardt (Mannheim)², N. Abel (Mannheim)¹, F. Lau (Mannheim)³, J. Dudda (Mannheim)¹, M. Abumayyaleh (Mannheim)¹, K. J. Weidner (Mannheim)¹, T. Bertsch (Nürnberg)⁴, D. Dürschmied (Mannheim)¹, M. Behnes (Mannheim)¹, T. Schupp (Mannheim)^1
1Universitätsklinikum Mannheim GmbH I. Medizinische Klinik Mannheim, Deutschland; ²Universitätsklinikum Mannheim I. Medizinische Klinik Mannheim, Deutschland; ³Medizinische Fakultät Mannheim der Universität Heidelberg I. Medizinische Klinik Mannheim, Deutschland; ⁴Klinikum Nürnberg Nord Institut für klinische Chemie und Laboratoriumsmedizin und Transfusionsmedizin Nürnberg, Deutschland

Background: This study investigates the prognostic value 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 2016–2022. 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 32.4g/L. Albumin levels, the UAR and ACR were predictive for the risk of long-term all-cause mortality, which was still observed after multivariable adjustments (albumin Q1 vs. Q4: HR=2.260; 95% CI 1.623–3.148; p=0.001 / UAR Q4 vs. Q1: HR=1.507; 95% CI 1.071–2.119; p=0.019 / ACR Q1 vs. Q4: HR=2.208; 95% CI 1.528–3.190; p=0.001). However, neither albumin nor the UAR or ACR predicted the risk of HF-related rehospitalization (albumin Q1 vs. Q4: HR=1.117; 95% CI 0.952–2.247; p=0.664 / UAR Q4 vs. Q1: HR = 1.589; 95% CI 0.922–2.738; p=0.095 / ACR Q1 vs. Q4: HR=1.112; 95% CI 0.624–1.981; p=0.720).
Conclusions: Low albumin levels, ACRs and elevated UARs predicted the risk of long-term all-cause mortality, but not HF-related rehospitalization in hospitalized HFmrEF patients. The UAR and ACR did not provide a clinically significant predictive advantage over albumin levels alone.