{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T17:45:10Z","timestamp":1790790310084,"version":"4.1.0"},"reference-count":40,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T00:00:00Z","timestamp":1754438400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"\nBackground<\/jats:title>\nCommon comorbidities in heart failure (HF), including chronic kidney disease (CKD), diabetes mellitus (DM), ischemic heart disease (IHD), and atrial fibrillation, are frequently presumed to predict hospital readmission. However, recent studies have challenged their predictive strength, raising questions about their clinical utility for risk stratification.<\/jats:p>\n<\/jats:sec>\n\nMethods<\/jats:title>\nWe conducted a retrospective cohort study of 7,652 patients admitted with acute decompensated heart failure (ADHF) at a tertiary center between 2007 and 2017. Associations between comorbidities and readmission at 30 and 100 days were assessed using Fine-Gray competing risk models, with death as a competing event. Subdistribution hazard ratios (sHRs) were reported. Model performance was evaluated using receiver operating characteristic (ROC) analysis and area under the curve (AUC) values, assessing individual comorbidities and incremental combinations. All comorbidities were included irrespective of univariable significance, based on clinical relevance.<\/jats:p>\n<\/jats:sec>\n\nResults<\/jats:title>\nSeveral comorbidities were significantly associated with readmission, including CKD (sHR 1.16\u20131.23), DM (sHR 1.18\u20131.27), IHD (sHR 1.10\u20131.15), and anemia (sHR 1.11). However, predictive power was poor. For 30-day readmission, AUC values ranged from 0.516 (COPD) to 0.529 (CKD), with a maximal AUC of 0.555 when combining the four strongest predictors. For 100-day readmission, AUC values ranged from 0.528 (DM) to 0.545 (CKD), with a maximal combined AUC of 0.593.<\/jats:p>\n<\/jats:sec>\n\nConclusions<\/jats:title>\nDespite consistent statistical associations, common comorbidities perform poorly as predictive tools for identifying individual patients at risk of HF readmission. These findings highlight the need for more robust risk models integrating dynamic clinical, laboratory, and patient-centered factors.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0329829","type":"journal-article","created":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T17:27:07Z","timestamp":1754501227000},"page":"e0329829","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Limited predictive value of traditional comorbidities for readmission in acute decompensated heart failure"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5719-7225","authenticated-orcid":true,"given":"Gil","family":"Marcus","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-0163-6929","authenticated-orcid":true,"given":"Antoinette","family":"Monayer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gil","family":"Moravsky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shmuel","family":"Fuchs","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Avishay","family":"Grupper","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eran","family":"Kalmanovich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sa\u2019ar","family":"Minha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,8,6]]},"reference":[{"issue":"17","key":"pone.0329829.ref001","doi-asserted-by":"crossref","first-page":"3272","DOI":"10.1093\/cvr\/cvac013","article-title":"Global burden of heart failure: a comprehensive and updated review of epidemiology","volume":"118","author":"G Savarese","year":"2023","journal-title":"Cardiovasc Res"},{"key":"pone.0329829.ref002","doi-asserted-by":"crossref","DOI":"10.15420\/cfr.2023.05","article-title":"Global public health burden of heart failure: an updated review","volume":"9","author":"B Shahim","year":"2023","journal-title":"Card Fail Rev"},{"issue":"8","key":"pone.0329829.ref003","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2024.28964","article-title":"Trends in Mortality After Incident Hospitalization for Heart Failure Among Medicare Beneficiaries","volume":"7","author":"AS Vohra","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"2","key":"pone.0329829.ref004","first-page":"157","article-title":"Burden of hospitalization for heart failure in the United States: a systematic literature review","volume":"28","author":"KM Osenenko","year":"2022","journal-title":"J Manag Care Spec Pharm"},{"key":"pone.0329829.ref005","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/j.ijcard.2020.12.020","article-title":"Cost of inpatient heart failure care and 30-day readmissions in the United States","volume":"329","author":"CS Kwok","year":"2021","journal-title":"Int J Cardiol"},{"key":"pone.0329829.ref006","article-title":"Heart failure population health considerations","volume":"27","author":"J Patel","year":"2021","journal-title":"Am J Manag Care"},{"issue":"3","key":"pone.0329829.ref007","article-title":"Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: a quality improvement initiative","volume":"12","author":"R Nair","year":"2020","journal-title":"Cureus"},{"issue":"1","key":"pone.0329829.ref008","doi-asserted-by":"crossref","first-page":"498","DOI":"10.1186\/s12872-023-03527-x","article-title":"Relationship between comorbidity and health outcomes in patients with heart failure: a systematic review and meta-analysis","volume":"23","author":"KS Lee","year":"2023","journal-title":"BMC Cardiovasc Disord"},{"issue":"5","key":"pone.0329829.ref009","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1016\/j.jacc.2023.05.040","article-title":"Global comparison of readmission rates for patients with heart failure","volume":"82","author":"F Foroutan","year":"2023","journal-title":"J Am Coll Cardiol"},{"issue":"1","key":"pone.0329829.ref010","doi-asserted-by":"crossref","first-page":"22477","DOI":"10.1038\/s41598-023-49390-w","article-title":"Analysis and prediction of readmissions for heart failure in the first year after discharge with INCA score","volume":"13","author":"A Rubini","year":"2023","journal-title":"Sci Rep"},{"issue":"1","key":"pone.0329829.ref011","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0296527","article-title":"Comorbidities in heart failure patients that predict cardiovascular readmissions within 100 days-An observational study","volume":"19","author":"M Scholten","year":"2024","journal-title":"PLoS One"},{"issue":"4","key":"pone.0329829.ref012","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"61","author":"E von Elm","year":"2008","journal-title":"J Clin Epidemiol"},{"issue":"446","key":"pone.0329829.ref013","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1080\/01621459.1999.10474144","article-title":"A Proportional Hazards Model for the Subdistribution of a Competing Risk","volume":"94","author":"JP Fine","year":"1999","journal-title":"J Am Statistical Assoc"},{"issue":"2","key":"pone.0329829.ref014","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1161\/01.CIR.0000052622.51963.FC","article-title":"Anemia is common in heart failure and is associated with poor outcomes: insights from a cohort of 12 065 patients with new-onset heart failure","volume":"107","author":"JA Ezekowitz","year":"2003","journal-title":"Circulation"},{"issue":"23","key":"pone.0329829.ref015","doi-asserted-by":"crossref","first-page":"1437","DOI":"10.1093\/eurheartj\/ehv010","article-title":"The kidney in heart failure: an update","volume":"36","author":"K Damman","year":"2015","journal-title":"Eur Heart J"},{"issue":"11","key":"pone.0329829.ref016","doi-asserted-by":"crossref","first-page":"1377","DOI":"10.1093\/eurheartj\/ehn153","article-title":"Impact of diabetes on outcomes in patients with low and preserved ejection fraction heart failure: an analysis of the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme","volume":"29","author":"MR MacDonald","year":"2008","journal-title":"Eur Heart J"},{"issue":"9","key":"pone.0329829.ref017","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.124.037915","article-title":"Coronary Artery Disease Doubles Excess Mortality in Patients With Heart Failure With Reduced Ejection Fraction","volume":"14","author":"N Anker","year":"2025","journal-title":"J Am Heart Assoc"},{"issue":"1","key":"pone.0329829.ref018","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.112.005694","article-title":"Atrial fibrillation and outcomes in heart failure with preserved versus reduced left ventricular ejection fraction","volume":"2","author":"DD McManus","year":"2013","journal-title":"J Am Heart Assoc"},{"issue":"2","key":"pone.0329829.ref019","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.ahj.2012.10.029","article-title":"Clinical characteristics, response to exercise training, and outcomes in patients with heart failure and chronic obstructive pulmonary disease: findings from Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION)","volume":"165","author":"RJ Mentz","year":"2013","journal-title":"Am Heart J"},{"issue":"12","key":"pone.0329829.ref020","doi-asserted-by":"crossref","first-page":"1195","DOI":"10.1016\/j.hlc.2016.04.002","article-title":"The Prognostic Value of Peripheral Artery Disease in Heart Failure: Insights from a Meta-analysis","volume":"25","author":"B Wei","year":"2016","journal-title":"Heart Lung Circ"},{"issue":"1","key":"pone.0329829.ref021","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1002\/ejhf.30","article-title":"Co-morbidities in patients with heart failure: an analysis of the European Heart Failure Pilot Survey","volume":"16","author":"VM van Deursen","year":"2014","journal-title":"Eur J Heart Fail"},{"issue":"9","key":"pone.0329829.ref022","doi-asserted-by":"crossref","first-page":"1257","DOI":"10.1002\/ejhf.1202","article-title":"Prevalence and prognostic impact of non-cardiac co-morbidities in heart failure outpatients with preserved and reduced ejection fraction: a community-based study","volume":"20","author":"A Iorio","year":"2018","journal-title":"Eur J Heart Fail"},{"issue":"12","key":"pone.0329829.ref023","article-title":"Risk Factors for Readmission in Heart Failure Within 90 Days","volume":"15","author":"A S Alsulymani","year":"2023","journal-title":"Cureus"},{"issue":"3","key":"pone.0329829.ref024","doi-asserted-by":"crossref","first-page":"159","DOI":"10.36628\/ijhf.2023.0015","article-title":"Etiologies and Predictors of 30-Day Readmission in Heart Failure: An Updated Analysis","volume":"5","author":"A Jain","year":"2023","journal-title":"Int J Heart Fail"},{"issue":"9","key":"pone.0329829.ref025","doi-asserted-by":"crossref","first-page":"882","DOI":"10.1093\/aje\/kwh101","article-title":"Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker","volume":"159","author":"MS Pepe","year":"2004","journal-title":"Am J Epidemiol"},{"issue":"1","key":"pone.0329829.ref026","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1097\/EDE.0b013e3181c30fb2","article-title":"Assessing the performance of prediction models: a framework for traditional and novel measures","volume":"21","author":"EW Steyerberg","year":"2010","journal-title":"Epidemiology"},{"key":"pone.0329829.ref027","doi-asserted-by":"crossref","first-page":"1359255","DOI":"10.3389\/fendo.2024.1359255","article-title":"Endothelial dysfunction in vascular complications of diabetes: a comprehensive review of mechanisms and implications","volume":"15","author":"D-R Yang","year":"2024","journal-title":"Front Endocrinol (Lausanne)"},{"issue":"3","key":"pone.0329829.ref028","doi-asserted-by":"crossref","first-page":"728","DOI":"10.3390\/biomedicines13030728","article-title":"Targeting Diabetic Atherosclerosis: The Role of GLP-1 Receptor Agonists, SGLT2 Inhibitors, and Nonsteroidal Mineralocorticoid Receptor Antagonists in Vascular Protection and Disease Modulation","volume":"13","author":"M Rroji","year":"2025","journal-title":"Biomedicines"},{"issue":"5","key":"pone.0329829.ref029","doi-asserted-by":"crossref","first-page":"1371","DOI":"10.1183\/09031936.00015608","article-title":"Pulmonary hypertension in COPD","volume":"32","author":"A Chaouat","year":"2008","journal-title":"Eur Respir J"},{"issue":"3","key":"pone.0329829.ref030","doi-asserted-by":"crossref","DOI":"10.69863\/dim.2024.e359","article-title":"Right ventricular strain: cardiovascular challenges in pulmonary diseases","volume":"1","author":"N Rahmianti","year":"2024","journal-title":"Deka in Medicine"},{"issue":"7","key":"pone.0329829.ref031","doi-asserted-by":"crossref","first-page":"2049","DOI":"10.3390\/jcm13072049","article-title":"Anemia and its connections to inflammation in older adults: a review","volume":"13","author":"E Wacka","year":"2024","journal-title":"J Clin Med"},{"issue":"1","key":"pone.0329829.ref032","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1111\/nyas.14092","article-title":"Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries","volume":"1450","author":"CM Chaparro","year":"2019","journal-title":"Ann N Y Acad Sci"},{"issue":"2","key":"pone.0329829.ref033","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1002\/ehf2.12610","article-title":"Sacubitril\/valsartan in patients listed for heart transplantation: effect on physical frailty","volume":"7","author":"F Cacciatore","year":"2020","journal-title":"ESC Heart Fail"},{"issue":"12","key":"pone.0329829.ref034","doi-asserted-by":"crossref","first-page":"1001","DOI":"10.1016\/j.jchf.2019.10.005","article-title":"Frailty Is Intertwined With Heart Failure: Mechanisms, Prevalence, Prognosis, Assessment, and Management","volume":"7","author":"A Pandey","year":"2019","journal-title":"JACC Heart Fail"},{"issue":"3","key":"pone.0329829.ref035","doi-asserted-by":"crossref","first-page":"1371","DOI":"10.1002\/ehf2.12688","article-title":"Physical vs. multidimensional frailty in older adults with and without heart failure","volume":"7","author":"G Testa","year":"2020","journal-title":"ESC Heart Fail"},{"issue":"1","key":"pone.0329829.ref036","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1186\/s12877-021-02072-6","article-title":"Frailty related all-cause mortality or hospital readmission among adults aged 65 and older with stage-B heart failure inpatients","volume":"21","author":"P-P Zheng","year":"2021","journal-title":"BMC Geriatr"},{"issue":"7","key":"pone.0329829.ref037","doi-asserted-by":"crossref","first-page":"110281","DOI":"10.1016\/j.isci.2024.110281","article-title":"Explainable machine learning for predicting 30-day readmission in acute heart failure patients","volume":"27","author":"Y Zhang","year":"2024","journal-title":"iScience"},{"issue":"5","key":"pone.0329829.ref038","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1016\/j.cardfail.2024.10.440","article-title":"Prognostic Utility and Cutoff Differences in NT-proBNP Levels Across Subgroups in Heart Failure With Preserved Ejection Fraction: Insights From the PURSUIT-HFpEF Registry","volume":"31","author":"D Sakamoto","year":"2025","journal-title":"J Card Fail"},{"issue":"2","key":"pone.0329829.ref039","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1519\/JPT.0000000000000243","article-title":"Frailty and function in heart failure: predictors of 30-day hospital readmission?","volume":"44","author":"TJ Keeney","year":"2021","journal-title":"J Geriatr Phys Ther"},{"issue":"6","key":"pone.0329829.ref040","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.115.002606","article-title":"Medication adherence interventions improve heart failure mortality and readmission rates: systematic review and meta-analysis of controlled trials","volume":"5","author":"TM Ruppar","year":"2016","journal-title":"J Am Heart Assoc"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0329829","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T17:27:11Z","timestamp":1754501231000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0329829"}},"subtitle":[],"editor":[{"given":"Pasquale","family":"Abete","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,8,6]]},"references-count":40,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8,6]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0329829","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,6]]}}}