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A retrospective MIMIC-IV study of 1,839 hospitalized CHF patients evaluated guideline-based definitions and a combined Ferritin-TSAT model to predict 365-day mortality, using adjusted Cox 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Retrospective MIMIC-IV Analysis of Risk Stratification and Mortality  \nAbdulla Zahi Hourani 1,2,*, Arman David Sürmeli 1 and Sai Keertana Devarapalli 1  \nAcademic Editors: Pedro Caravaca-Pérez and Marta Farrero-Torres  \nReceived: 28 November 2025  \nRevised: 17 December 2025  \nAccepted: 22 December 2025  \nPublished: 28 December 2025  \nCopyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license.  \n1 Faculty of Medicine, English Division, Medical University of Warsaw, 02-091 Warsaw, Poland; [armansuermeli@gmail.com](armansuermeli@gmail.com) (A.D.S.)  \n2 Department and Clinic of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland  \n* Correspondence: [abdulla.hourani@wum.edu.pl](abdulla.hourani@wum.edu.pl)  \nAbstract  \nBackground: Iron deficiency (ID) is prevalent in congestive heart failure (CHF), worsening outcomes. While European guidelines recommend screening using ferritin and transferrinsaturation (TSAT), inconsistent diagnostic criteria, especially regarding functional deficiency (ferritin 100–299 µg/L + TSAT \u003C 20%) and hyperferritinemia, limit prognostic accuracy. This study evaluated iron status definitions, including guideline criteria and a combined Ferritin-TSAT model, for predicting 365-day mortality in hospitalised CHF patients. Methods: This retrospective analysis used MIMIC-IV data from 1839 CHF patients. Iron status within 24 h of admission was categorised using: (1) Guideline ID vs. nonID; (2) Ferritin categories; (3) TSAT categories; (4) Combined Ferritin-TSAT model (Low: guideline ID; Intermediate: ferritin 100–299 + TSAT ≥ 20%; High: ferritin ≥ 300 µg/L) . Adjusted Cox models assessed mortality associations. Results: Guidelines-defined iron deficiency (33.66% prevalence) independently associated with higher 1-year mortality (56.1% vs. 29.4%; adjusted HR 4.36, 95% CI 3.35–5.34) . The combined Ferritin-TSAT model showed significant prognostic value, differentiating true iron deficiency (reference) from hyperferritinemia (adjusted HR 0.50 vs. iron deficiency) and intermediate group (adjusted HR 0.36 vs. ID), indicating varying risk relative to the most deficient group. This combined model better distinguished hyperferritinemic and iron-replete subgroups than the binary guideline definition. Conclusions: Iron status, including deficiency and hyperferritinemia, independently predicts 1-year mortality in CHF. While guideline iron deficiency is a strong predictor, a combined Ferritin-TSAT classification offers finer risk stratification by identifying distinct phenotypes (true deficiency, hyperferritinemia, intermediate) . Nuanced iron status assessment could improve prognostic evaluation and guide personalised therapies (e.g., IV iron for deficiency, investigation for hyperferritinemia) to enhance CHF outcomes.  \nKeywords: iron deficiency; heart failure; transferrin saturation; ferritin; MIMIC-IV; mortality  \n1. Introduction  \nIron deficiency anaemia is a significant global public health concern and affects a substantial proportion of patients with congestive heart failure (CHF), with estimates suggesting that as many as 34–63% of individuals with chronic heart failure may be irondeficient [1] . Iron deficiency itself can adversely influence outcomes, by contributing to poor exercise tolerance, diminished health-related quality of life, and increased risks  \nof hospitalisation and mortality, even in the absence of anaemia [2,3] . Recognising the central role of iron deficiency in exacerbating congestive heart failure symptoms, the European Society of Cardiology has formally acknowledged iron deficiency as an important comorbidity and now recommends routine testing of iron status for all newly diagnosed heart failure patients [4,5] .  \nIron d","cbCaiot7stWjfoez","https://ap.wps.com/l/cbCaiot7stWjfoez","pdf",724431,23,"English","# Abstract\n# 1. Introduction\n## Background and clinical relevance\n## Forms of iron deficiency in CHF\n## Rationale for screening and treatment\n## Need for standardized iron status definitions","[{\"question\":\"What was the main purpose of evaluating different iron status definitions in CHF patients?\",\"answer\":\"To determine how guideline-based and combined ferritin-TSAT definitions predict 365-day mortality in hospitalized CHF patients.\"},{\"question\":\"How was iron status categorized in the retrospective MIMIC-IV analysis?\",\"answer\":\"Within 24 hours of admission, patients were grouped by guideline ID vs non-ID, ferritin categories, TSAT categories, and a combined Ferritin-TSAT model distinguishing low, intermediate, and high ferritin phenotypes.\"},{\"question\":\"What did the combined Ferritin-TSAT model add beyond the binary guideline definition?\",\"answer\":\"It showed significant prognostic value and better differentiated true iron deficiency, hyperferritinemia, and an intermediate group, producing different adjusted hazard ratios versus the most deficient reference group.\"}]","Prognostic Value of Different Iron Status Definitions in Congestive Heart Failure - A Retrospective MIMIC-IV Analysis of Risk Stratification and Mortality | PDF",1790764266,58]