Fibrinogen-to-albumin ratio and major adverse cardiovascular events in older patients with heart failure: a retrospective cohort study

Objective The fibrinogen-to-albumin ratio (FAR) integrates information on coagulation, systemic inflammation, and nutritional status; however, its prognostic significance for major adverse cardiovascular events (MACE) in older patients with heart failure (HF) remains insufficiently characterized. Methods This single-center retrospective cohort study included 834 consecutive patients aged ≥ 60 years with HF who were hospitalized at Henan Provincial Chest Hospital between July 2022 and January 2026. FAR was calculated as plasma fibrinogen divided by serum albumin and was analyzed as a continuous variable per 0.01 increase, a standardized variable per 1-standard deviation (SD) increase, and according to tertiles. Multivariable Cox regression, subgroup and sensitivity analyses, Kaplan–Meier curves, time-dependent receiver operating characteristic (ROC) analysis, and restricted cubic spline (RCS) analysis were performed to evaluate the association between FAR and MACE. Results During the median follow-up period of 33.5 months, 158 patients (18.9%) experienced MACE. The incidence of MACE increased progressively across FAR tertiles, from 9.0% in T1 to 18.7% in T2 and 29.1% in T3 ( P < 0.001), and higher FAR tertiles were associated with significantly lower MACE-free survival (log-rank P < 0.001). In the fully adjusted model, each 0.01 increase in FAR was associated with a 6.0% higher risk of MACE (HR = 1.060, 95% CI: 1.031–1.089, P < 0.001), while each 1-SD increase was associated with a 29.5% higher risk (HR = 1.295, 95% CI: 1.144–1.466, P < 0.001). Compared with T1, the adjusted risks of MACE were higher in T2 (HR = 2.012, 95% CI: 1.237–3.274, P = 0.005) and T3 (HR = 2.763, 95% CI: 1.742–4.383, P < 0.001). No significant interactions were observed across predefined subgroups, and the findings remained stable in multiple sensitivity analyses. The time-dependent AUCs (area under the curves) of FAR for MACE were 0.643, 0.655, and 0.670 at 12, 24, and 36 months, respectively, while ROC analysis showed that FAR had higher discriminatory performance than fibrinogen and albumin alone (AUC = 0.660, 0.638, and 0.616, respectively), and adding FAR to the clinical model improved the AUC from 0.749 to 0.767 ( P = 0.016). RCS analysis showed a significant overall association between FAR and MACE, with no significant evidence of nonlinearity ( P for nonlinearity = 0.068). Conclusions Higher FAR was independently associated with an increased risk of MACE in older patients with HF.