Risk stratification in patients suffering chronic congestive heart failure (CHF) is based on a variety of clinical and laboratory variables. Indeed, several prognostic parameters have been identified, including age, New York Heart Association (NYHA) class, renal function, comorbidity such as atrial fibrillation, diabetes mellitus and ischemic heart disease [1]. In acute decompensated heart failure (ADHF) episodes, the degree of renal dysfunction and arterial hypotension easily stratified patients with worst clinical outcome [2]. A single determination of Brain Natriuretic Peptide (BNP) plasma level represents a reliable risk stratification procedure and its increase is considered a sensitive diagnostic marker of left ventricular dysfunction [3,4] and predicted cardiovascular events in congestive heart failure (CHF) patients [5–8] and even in asymptomatic subjects [9]. The objective of this study was to analyse if renal dysfunction and plasma BNP predict mid-term clinical outcome in CHF patients discharged after an ADHF episode. This prospective cohort study, approved by the local ethics committees, included 237 patients (64.5% males, age 71) with a diagnosis of CHF after an acute decompensation episode discharged from the Heart Failure Unit fromApril 2008 up to August 2010. Death by any cause, cardiac transplantation andworsening heart failure requiring readmission to the hospital were considered cardiovascular events [events group 34 (14.3%) subjects and a no-event group 203 (85.7%) patients]. The follow-up of this study lasted 408±255 days. BNP at discharge resulted 401.3±501.7 pg/ml. During the 14-month follow-up 15 (6.3%) patients died, one (0.4%) underwent cardiac transplantation and 18 (7.6%)were readmitted for CHF (event group); in 203 (85.6%) no eventswere observed (no-event group). HigherNYHAclass (2.1±0.7 vs 1.9±0.4 p=0.01), BNP at discharge (750.2±527.3 pg/ml vs 340.7± 474.3 pg/ml, p=0.002) and impaired renal function (creatinine 1.7± 0.6 vs 1.2±0.8 mg/dl, p=0.004) were noticed in the event group. At multivariate Cox analysis only LVEF (p=0.0009), plasma creatinine (p=0.006) and BNP at discharge (p=0.001) were significantly associated with adverse mid-term outcome. The Kaplan–Meier survival curves demonstrated that adding two parameters (creatinine bor N1.5 mg/dl and BNPbor N250 pg/ml), four different survival curves were obtained (p=0.0001; log rank 21.09), inwhich the clinical weight of renal function clearly emerged (Fig. 1). From this study emerged that CHF patients discharged after an acute decompensation had a severe adverse clinical outcome (death, cardiac transplantation and hospital readmission) in 14.3% during a follow-up lasted 14 months. Elderly patients with CHF represent most of subjects (70%) admitted to hospitals for acute cardiac decompensation; the length of hospitalization lasts usuallyN2 weeks in geriatric wards and readmission is frequent [10]. Recently, the OPTIMIZE -HF study [11] included more than 30,000 CHF patients discharge from 215 hospitals, described the short length of hospitalization (4 days) but a 21.3% of rate of readmission within 30-day. The study evidenced as an early (oneweek) outpatient clinical follow-up after discharge had lower probability to be readmitted within 30-day. The first strong prognostic parameter in those patients was a plasma BNP value at discharge≥250 pg/ml (p=0.001, log rank 10.7). This data confirm previous reports [8,12] in which the pre-discharge values of BNP identified an adverse outcome (death or hospital re-admission) at 6-month follow-up. According to the practical approaches to treating CHF patients published by Maisel [13], it could be identified a ‘wet BNP’ in patients with CHF and fluid overload and a ‘dry BNP’ after optimization of therapy. In our population only the ‘dry BNP’ (at discharge) predicted cardiovascular events, because it identified the real state of neurohormonalmodulation due to the systolic, diastolic heart dysfunction and left ventricle enlargement. The second strong predictor of adverse outcomewas renal dysfunction. The presence of a chronic cardio-renal syndrome, recently classified as type 2 of the cardio-renal syndromes [14], has been reported in 63% of patients admitted for CHF [15,16]. Moreover, the ADHERE registry highlighted as the in-hospital mortality risk incredibly increased in patients with urea nitrogen≥43 mg/dl and plasma creatinine≥2.75 mg/dl [17]. In our population serum creatinine was higher in the event group (pb0.01) and alone identified (divided into three groups b1.5 mg/dl, between 1.5–2 mg/dl and finally N2 mg/dl) three different cumulative survival curves. Moreover, adding data of renal function with discharge plasma BNP, four different cumulative survival curves emerged (BNPb250 pg/ml and creatinineb1.5 mg/dl, BNPb250 pg/ml and creatinineN1.5 mg/dl, BNPN250 pg/ml and creatinineb1.5 mg/dl and finally BNPN250 pg/ml and creatinineN1.5 mg/dl), in which clearly appeared the prognostic weight of a serum creatinineN1.5 mg/dl. Therefore, this analysis identified a simple and practical combination of two markers for identifying a high-risk CHF patient at discharge for a medium-term follow-up, which should be strictly monitored and controlled in order to avoid adverse clinical outcome. The authors of themanuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [18].