Abstract Background Heart failure (HF) hospitalizations foreshadow a very gloomy outcome. In the first 3 months, the vulnerable period, mortality is around 10% and 28% of patients die in the first-year post hospitalization. Reports on 10-year survival are scarce. Purpose We assessed the 10-year survival rate in a 21st century cohort of acute HF patients and studied survival predictors. Methods We studied a cohort of HF patients that were included in an acute HF registry between March 2009 and December 2010. All patients hospitalized in the Internal Medicine Ward with the primary diagnosis of acute HF were eligible. Both patients with left ventricular systolic dysfunction and those with HF with preserved ejection fraction were included. As part of the registries protocol all patients had a complete examination and a venous blood sample collection both at admission and discharge. Patients were followed up to 10 years and all-cause mortality was the endpoint under analysis. A multivariate Cox-regression model was used to assess variables independently associated with 10-year death. A Receiver operator characteristic (ROC) curve was used to choose the best brain natriuretic peptide (BNP) cut-off for mortality prediction. Results A total of 591 patients surviving an HF decompensation episode were included in the analysis. Mean age was 76 (±12) years, 44.8% were male and 37.9% had preserved ejection fraction. Comorbidity burden was high: 76.6% had arterial hypertension and 50.6% had diabetes. Only 69 (11.7%) patients were alive 10-years post discharge. Survivors were younger (63 vs 78 years), less often presented diabetes, they had higher haemoglobin and albumin levels, better renal function and lower BNP and uric acid levels. Independent predictors of 10-year mortality were higher BNP, increasing age, lower albumin and atrial fibrillation. The area under the ROC curve for the association of BNP with 10-year death was of 0.71 (0.65–0.77), p<0.001. The best BNP cut-off for 10-year mortality prediction was 800pg/mL with a sensitivity of 50.4%, specificity=85.3%, positive predictive value (PPV) =96.3% and negative predictive value (NPV) of 18.6%. Patients with BNP≥800pg/mL have 96.6% probability of dying in the upcoming 10-years, and a HR of 1.95 (1.60–2.38), p<0.001 than those with lower values. Using a discharge BNP cut-off of 50pg/mL the negative predictive value is 66.0% and a PPV is 89.9% of being dead at 10-years. The PPV of dying in the upcoming 10-years was of 100% for patients with discharge BNP≥1864pg/mL. Conclusions The ten year survival rate of a real-world acute HF population was of 11.7%. The variables more strongly associated with 10-year mortality were higher BNP and age. Patients discharged with BNP ≥800pg/mL have 2-fold higher risk of dying in the upcoming 10 years than the remaining. All patients discharged with BNP ≥1864pg/mL were dead 10-years later. Funding Acknowledgement Type of funding sources: None.