Advanced Cirrhosis Is Independently Associated With Increased In-Hospital Mortality in Heart Failure With Reduced...

Background Advanced cirrhosis is associated with systemic hemodynamic changes that may be associated with worse outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, national‑level estimates of the independent association between advanced cirrhosis and in‑hospital mortality in this population remain limited. Methods We conducted a retrospective cross‑sectional analysis of the 2022 National Inpatient Sample (NIS). Adults hospitalized with a primary diagnosis of HFrEF (ICD 10 I50.22) were included. Advanced cirrhosis was defined as cirrhosis with at least one decompensating feature: ascites, hepatic encephalopathy, portal hypertension, variceal bleeding, or hepatorenal syndrome. The primary outcome was in‑hospital mortality. Multivariable logistic regression was adjusted for demographics, hospital characteristics, and all Elixhauser comorbidities. Results Among 254,571 weighted HFrEF hospitalizations, 5,346 (2.1%) met criteria for advanced cirrhosis. Compared to those without advanced cirrhosis, affected patients were younger (mean age: 58.4 versus 71.2 years; p<0.001) and more frequently male (68.2% versus 54.9%; p<0.001). Unadjusted in‑hospital mortality was higher in the advanced cirrhosis group (9.7% versus 3.8%; p<0.001). After multivariable adjustment, advanced cirrhosis remained independently associated with increased mortality (adjusted odds ratio (aOR): 2.18; 95% confidence interval (CI): 1.79‑2.64; p<0.001). Using a stricter definition requiring two or more decompensating features, the association strengthened (aOR: 2.59; 95% CI: 2.04‑3.29). Conclusion In this nationally representative sample of HFrEF hospitalizations, advanced cirrhosis was independently associated with more than double the odds of in‑hospital death. This association persisted across age and sex subgroups and showed a dose‑response relationship with disease severity. Early recognition and multidisciplinary management involving cardiology, hepatology, and critical care is reasonable to consider. Prospective studies are needed to determine whether specific therapeutic strategies can improve survival in this high‑risk population.