Prognostic factors associated with In-Hospital Mortality Among Heart Failure Patients in a Private Tertiary Hospital in Sierra Leone: A Five-Year Cohort Study

Abstract Background Evidence on in-hospital mortality among adults with heart failure (HF) in Sierra Leone is limited. We evaluated prognostic factors associated with all-cause in-hospital mortality and described mortality patterns during admission over five years. Methods This retrospective study analysed decompensated HF patients admitted to a private hospital in Sierra Leone from 2021 to 2025. Only the index admission per patient was included to summarize baseline characteristics, estimate in-hospital survival, and examine associations with mortality using Cox regression. Covariates violating the proportional hazards assumption were modelled with linear time interactions. Results Among the 765 patients studied [median age 53 years (IQR 42–61); 55.3% male], all 88 deaths occurred within the first week of admission, resulting in a mortality rate of 11.5% (95% CI 9.3–13.9). The annual mortality rate decreased from 19.7% in 2021 to 7.1% in 2025 (overall heterogeneity p = 0.008). A cold-wet haemodynamic profile was present in 77.3% of patients who died and 6.4% of survivors (unadjusted comparison, p < 0.001). In the final model, underweight [aHR = 2.44, (95% CI 1.46–4.07)], overweight [aHR = 1.93, (95% CI 1.05–3.57)], recurrent HF [aHR = 1.71, (95% CI 1.14–2.58)], and dilated cardiomyopathy (DCM) in women [aHR = 15.25, (95% CI 6.66–34.93)] were associated with higher mortality, whereas hypertensive heart disease (HHD) was associated with a lower hazard [aHR = 0.20, (95% CI 0.07–0.52)]. Baseline anaemia, chronic kidney disease (CKD) and Atrial Fibrillation (AF) showed non-proportional associations with mortality. Estimates from the complex final model are exploratory because 88 deaths supported 22 model degrees of freedom. Conclusions The in-hospital mortality rate among HF patients was relatively high but gradually decreased over the study period. Most deaths were reported within the first seven days and were associated with several comorbidities. These findings underscore the importance of early risk assessment and targeted management to reduce mortality in under-resourced settings.