Bilirubin Levels May Help Guide Heart Failure Treatment | ACC 2025

Bilirubin is known as a marker for worse outcomes in heart failure, particularly in hospitalized patients.

However, it’s not routinely measured in clinical practice to guide treatment decisions, according to John W. Ostrominski, M.D., fellow in cardiovascular and obesity medicine at Brigham and Women’s Hospital and Harvard Medical School.

"Bilirubin, I would say, is not necessarily incorporated in clinical guidelines to routinely measure, especially in individuals within a stable outpatient (setting), or stable inventory individuals with heart failure,” Ostrominski told editors of Managed Healthcare Executive. “But it’s been widely recognized in individuals with worsening heart failure that leads to hospitalization."

Elevated bilirubin levels in these patients are often linked to congestion caused by increased right-sided heart pressures, leading to passive congestion of the liver

Though, in these cases, bilirubin levels often improve with proper decongestion through diuretics and guideline-directed medical therapies.

Ostrominski mentioned that recent findings from the FINEARTS-HF analysis suggest even stable outpatients may have residual congestion, which could be reflected in bilirubin levels.

While more research is needed to confirm this, these findings display a potential role for bilirubin in guiding congestion and treatment effectiveness.

Although bilirubin is not currently used to customize treatment pathways, Ostrominski noted that if measured in routine care, elevated levels might serve as an additional indicator of congestion.

In addition, he shared this insight could contribute to more holistic discussions about treatment intensification in heart failure management.