Background: Patients with heart failure and reduced ejection fraction presenting with acute heart failure (HFrEF-AHF) carry a high in-hospital mortality. Conventional predictors do not fully capture the interplay between hepatic dysfunction, systemic inflammation, and nutritional decline. The platelet–albumin–bilirubin (PALBI) score, originally developed in hepatology, may offer incremental prognostic information in this setting.

Methods: A total of 401 patients hospitalized with HFrEF-AHF were retrospectively studied. Baseline demographic, clinical, and laboratory data were collected. Platelet–albumin–bilirubin and albumin–bilirubin (ALBI) scores were calculated. The primary endpoint was all-cause in-hospital mortality.

Results: In-hospital mortality occurred in 47 patients (11.7%). Non-survivors were older, more frequently had chronic kidney disease (CKD), and showed lower albumin but higher bilirubin and N-terminal pro-B-type natriuretic peptide (NT-proBNP). Both PALBI and ALBI were significantly higher in non-survivors. In multivariable Cox analysis, PALBI independently predicted mortality (hazard ratio = 2.638, 95% CI: 1.177-4.099, P < .001), along with age, CKD, and NT-proBNP. Receiver operating characteristic analysis showed that PALBI demonstrated slightly better performance than conventional predictors and, compared with ALBI (area under the curve = 0.737 vs. 0.708), yielded a modest but significant net reclassification improvement (~10%). Kaplan–Meier curves demonstrated clear separation in survival across PALBI strata (log-rank, P < .001), and restricted cubic spline analysis confirmed a graded, continuous association with risk.

Conclusion: The PALBI score independently predicts in-hospital mortality in patients with HFrEF-AHF and may represent a simple and clinically useful tool for early risk stratification. External validation in larger, multicenter cohorts is warranted.