Red cell distribution width-to-albumin ratio as an independent predictor of in-hospital mortality in ICD-implanted patients hospitalised with acute decompensated HFrEF
E Yencilek, C Tunca, Y Oz, E Elifoglu, M T Ozkan, T K Altuner, F Basyigit, V O TanikAbstract
Background
Patients with implantable cardioverter-defibrillators (ICDs) hospitalised for acute decompensated heart failure with reduced ejection fraction (ADHF-HFrEF) constitute a distinct high-risk population with persistently high in-hospital mortality despite contemporary guideline-directed therapy. Conventional risk stratification models show limited discriminatory ability in ICD recipients. The red cell distribution width–to–albumin ratio (RAR), integrating systemic inflammation and nutritional status, has emerged as a promising prognostic biomarker, yet its role in ICD-implanted patients with ADHF-HFrEF remains undefined.
Purpose
To determine whether admission RAR independently predicts in-hospital mortality in ICD-implanted patients hospitalised with ADHF-HFrEF and to compare its prognostic performance with the neutrophil-to-lymphocyte ratio (NLR).
Methods
This retrospective study included 514 consecutive ICD-implanted patients admitted with ADHF-HFrEF between January 2022 and March 2025. Laboratory parameters obtained within the first 24 hours of admission were used to calculate RAR (RDW [%]/albumin [g/dL]). The primary endpoint was in-hospital all-cause mortality. Independent predictors were identified using multivariable logistic regression, and discriminative performance was assessed using receiver operating characteristic (ROC) analysis.
Results
In-hospital mortality occurred in 78 patients (15.2%). Admission RAR values were significantly higher in non-survivors. After multivariable adjustment, RAR >4.05 emerged as the strongest independent predictor of in-hospital mortality (OR 5.81, 95% CI 3.25–10.40; p<0.001), alongside age and serum creatinine. In contrast, NLR was not independently associated with mortality. RAR demonstrated excellent discriminative performance (AUC 0.813), significantly outperforming NLR (AUC 0.696; p=0.003).
Conclusion
Admission RAR is a powerful and independent predictor of in-hospital mortality in ICD-implanted patients hospitalised with ADHF-HFrEF. By enabling early, admission-based risk stratification beyond conventional clinical models, RAR may support timely triage, intensified monitoring, and individualised management strategies, thereby holding potential to improve short-term outcomes in this particularly vulnerable population.Baseline data and predictorsFor image description, please refer to the figure legend and surrounding text.ROC analysis of RAR and NLRFor image description, please refer to the figure legend and surrounding text.