Clinical and prognostic implications of prolonged hospital stay in acute heart failure: identifying patients at risk
A Vilchez Alcocer, A Fraile Sanz, N Gil Mancebo, P Rodriguez Montes, M De La Serna Real De Asua, S Humanes Ybanez, M Gutierrez Munoz, E F Parrales Sanchez, B Izquierdo Coronel, M Martin Munoz, J Alonso MartinAbstract
Introduction
Acute decompensated heart failure (ADHF) remains a leading cause of hospitalisation and healthcare expenditure. Prolonged length of stay (LoS) is associated with increased costs and in-hospital complications, yet contemporary predictors of extended hospitalisation are not fully characterised.
Purpose
To identify clinical, echocardiographic and therapeutic factors associated with prolonged hospital stay in patients admitted with ADHF.
Methods
We conducted a retrospective observational study including consecutive patients admitted for ADHF to a cardiology department between 2020 and 2025. Median LoS was 7 days; prolonged hospitalisation was defined as >7 days. Clinical, laboratory, pharmacological, demographic and echocardiographic variables were analysed. Median follow-up was 9 months (IQR 4–18).
Results
A total of 446 patients were included; 237 (53.3%) had prolonged hospitalisation. Mean age (78 vs 76 years), sex distribution and comorbidity burden (Charlson index 6) were similar between groups. Patients with prolonged stay had lower LVEF (40% vs 46%) and higher admission BNP, creatinine, urea and ferritin levels, with lower albumin (all p≤0.003). Prior HF admissions and a predominantly right-sided HF phenotype were more frequent in the prolonged group, whereas left-sided HF was not associated with longer stay. Markers of greater severity—including acute pulmonary oedema, low cardiac output, diuretic resistance and need for vasoactive drugs—were significantly more prevalent. Hypertensive cardiomyopathy, cardiac amyloidosis, prior tricuspid regurgitation and severe aortic stenosis were also associated with prolonged hospitalisation, along with greater LV dilation, hypertrophy and higher E/e′ ratio. At discharge, patients with prolonged stay more frequently received MRAs and calcium-channel blockers and exhibited persistently higher BNP, creatinine, urea, troponin and CA-125 levels, with lower sodium. During follow-up, BNP and CA-125 remained elevated. Prolonged hospitalisation was not associated with differences in mortality or HF readmission.
Conclusion
Prolonged hospitalisation in ADHF identifies a distinct, difficult-to-stabilise phenotype characterised by reduced LVEF, right-sided involvement, persistent congestion and higher disease severity, rather than age or comorbidity burden. Early recognition of these predictors may help reduce in-hospital complications and improve healthcare efficiency.TABLE 1For image description, please refer to the figure legend and surrounding text.TABLE 2For image description, please refer to the figure legend and surrounding text.