DOI: 10.38053/acmj.1988655 ISSN: 2718-0115

Prognostic value of the blood urea nitrogen to albumin ratio in patients with heart failure with reduced ejection fraction

Ahmet Genç, Gülsüm Meral Yılmaz Öztekin, Şükriye Uslu, Rauf Avcı
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Aims: This study evaluated the prognostic value of several novel laboratory-derived indices: red blood cell distribution width (RDW), blood urea nitrogen-to-albumin ratio (BAR), Systemic Immune-Inflammation Index (SII), Model for End-Stage Liver Disease excluding the international normalized ratio (MELD-XI), uric acid-to-albumin ratio (UAR), and estimated plasma volume status (ePVS) in patients with heart failure with reduced ejection fraction (HFrEF). Their incremental contributions beyond conventional risk factors were compared.Methods: This retrospective single-center study included 1.314 patients with HFrEF. RDW, BAR, SII, MELD-XI, UAR, and ePVS were each added separately to a fixed reference model including age, left ventricular ejection fraction (LVEF), log10 transformed N-terminal pro-B-type natriuretic peptide (NT-proBNP), estimated glomerular filtration rate (eGFR), New York Heart Association (NYHA) functional class, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) or angiotensin receptor-neprilysin inhibitor (ARNI) use, beta-blocker use, mineralocorticoid receptor antagonist (MRA) use, and loop diuretic use. Age and LVEF were modeled with restricted cubic splines. Prognostic performance was assessed using Harrell’s concordance index (C-index), continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI), with bootstrap internal validation and 3-year calibration.Results: During follow-up, 428 patients (32.6%) died from all causes. Among the evaluated biomarkers, addition of log10transformed BAR produced the largest improvement in discrimination, increasing the C-index from 0.7489 (95% CI: 0.7256-0.7725) to 0.7585 (95% CI: 0.7355-0.7816), with a paired ΔC-index of 0.0096 (95% CI: 0.0021-0.0168). Bootstrap internal validation showed that BAR was the most frequently selected biomarker, although the optimism-corrected incremental improvement remained modest. Kaplan-Meier analysis demonstrated progressively worse survival across increasing L_BAR quartiles (log-rank p

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