C-Reactive Protein-to-Albumin Ratio and Heart Failure Rehospitalization After Decompensation: A Competing-Risk Cohort Study

Background/Objectives: Patients discharged after decompensated heart failure (HF) remain at high risk of rehospitalization. We examined which established, routinely available clinical, laboratory and echocardiographic markers are associated with this risk. Methods: We followed 556 patients discharged after decompensated HF (309 with HFrEF, 247 with HFpEF) for 24 months. Predictors of first HF rehospitalization were assessed with cause-specific Cox regression, with death as a competing event. Results: During follow-up, 234 patients (42.1%) were rehospitalized for HF and 202 (36.3%) died. Atrial fibrillation, LVEF, eGFR and E/e′ were independently associated with first HF rehospitalization. NT-proBNP showed an unexpected inverse association. The C-reactive protein-to-albumin ratio (CAR) emerged as an independent predictor (adjusted HR per unit lnCAR 1.215, 95% CI 1.073–1.375; p = 0.002). The 24-month cumulative incidence of rehospitalization rose across CAR tertiles (30.1%, 40.2% and 41.9%; p = 0.023). The association was significant in HFpEF but not in HFrEF (interaction p = 0.152). Conclusions: In this hypothesis-generating study, CAR, a simple ratio of CRP to serum albumin, was associated with rehospitalization risk beyond established predictors, although its incremental discriminative value was modest. These findings require validation in larger prospective studies, which should also test whether this risk is modifiable.