Hemoglobin to red blood cell distribution width ratio inversely associated with heart failure in NHANES 2011–2018

Hemoglobin-to-red cell distribution width ratio (HRR), a composite index reflecting both oxygen-carrying capacity and erythrocyte heterogeneity, has recently been proposed as a prognostic biomarker in cardiovascular disease. However, its association with heart failure (HF) in the general population remains unclear. We analyzed data from NHANES 2011–2018, applying survey-weighted logistic regression and restricted cubic spline (RCS) models to examine the association between HRR and self-reported HF. Discriminative ability was evaluated using receiver operating characteristic (ROC) curves. Higher HRR was independently and nonlinearly associated with lower prevalence of HF after adjustment for demographics, laboratory indices, cardiometabolic risk factors, and comorbidities. ROC analysis showed that HRR (AUC = 0.671, p < 0.01) had greater discriminative ability than hemoglobin (AUC = 0.600), BMI (AUC = 0.620), and triglycerides (AUC = 0.557), though slightly inferior to red cell distribution width (RDW) (AUC = 0.694). In a nationally representative sample, HRR demonstrated an independent inverse association with HF and provided additional discriminative value beyond hemoglobin alone. These findings suggest that HRR may serve as a readily available biomarker to aid in HF risk stratification.