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We examined the prevalence, temporal patterns, and clinical outcomes associated with electrolyte abnormalities in hospitalized heart failure patients. Retrospective cohort study of 30,678 heart failure patients (80,408 admissions) from the MIMIC-IV database (2008\u20132022). Clinically significant electrolyte abnormalities (CSEA) were defined as patients whose potassium remained consistently &lt;\u20093.5 or &gt;\u20095.0\u00a0mEq\/L, or whose sodium remained consistently &lt;\u2009135 or &gt;\u2009145\u00a0mEq\/L throughout all measurements during hospitalization. Primary outcomes were 30-day all-cause readmission and mortality. We developed a clinical risk score incorporating electrolyte abnormalities and examined temporal electrolyte patterns. CSEA occurred in 950 patients (3.1%) in the full cohort, of whom 713 (2.3%) survived to discharge and constituted the primary analysis cohort for post-discharge outcomes. Patients with abnormalities had paradoxically lower 30-day readmission (3.9% vs 15.3%; adjusted HR 0.29, 95% CI 0.21\u20130.40) but substantially higher mortality (15.4% vs 7.0%; adjusted HR 1.93, 95% CI 1.57\u20132.38), reflecting competing mortality risk. Individual electrolyte abnormalities were independently associated with mortality: hypokalemia HR 1.45 (1.28\u20131.65), hyperkalemia HR 1.67 (1.48\u20131.89), hyponatremia HR 1.34 (1.19\u20131.51). Temporal analysis revealed biphasic patterns\u2014initial correction followed by recurrence\u2014identified the highest-risk subset (composite event rates 27.6% for potassium, 28.5% for sodium). A five-variable risk score (electrolyte abnormality, age\u2009\u2265\u200975, chronic kidney disease, multiple admissions, coronary artery disease) achieved C-statistic 0.593. CSEA are independently associated with mortality in heart failure patients despite paradoxically lower readmission rates due to competing risks. Biphasic electrolyte patterns identify particularly high-risk patients. Simple risk stratification using routinely collected electrolyte data may enhance post-discharge risk prediction and inform targeted monitoring strategies.<\/jats:p>","DOI":"10.1038\/s41598-026-55290-6","type":"journal-article","created":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T15:47:18Z","timestamp":1780501638000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Electrolyte abnormalities and clinical outcomes in heart failure patients: a retrospective cohort study using MIMIC-IV database"],"prefix":"10.1038","volume":"16","author":[{"given":"Shankar","family":"Biswas","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bilal","family":"Qammar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yashasvi","family":"Srivastava","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chaudhari Mahendrakumar","family":"Achlaram","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mirza Mohammad Ali","family":"Baig","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ibrahim","family":"Manzoor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bilal","family":"Tariq","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad","family":"Umar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad Aqib Farooq","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jamal S.","family":"Rana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,3]]},"reference":[{"key":"55290_CR1","doi-asserted-by":"publisher","first-page":"618","DOI":"10.1186\/s12872-024-04276-1","volume":"24","author":"AA Abdi","year":"2024","unstructured":"Abdi, A. 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