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BACKGROUND: Malnutrition is common in heart failure (HF) and is associated with poor outcomes; however, longitudinal changes in the nutritional status of patients with HF are poorly investigated.OBJECTIVES: To assess the prognostic impact of changes in Controlling Nutritional Status (CONUT) score and identify predictors of malnutrition improvement in hospitalized patients with HF.METHODS: We analyzed data on 4,016 patients from a nationwide acute HF registry in Japan (UMIN ID: UMIN000036592). We identified 812 patients with moderate or severe malnutrition at admission (CONUT score ≥5) and stratified them into an improvement (IMP, n = 168) or non-improvement (Non-IMP, n = 644) group based on in-hospital change in CONUT score. The primary outcome was all-cause mortality; the secondary outcome was a composite endpoint of all-cause mortality and HF rehospitalization.RESULTS: Over a median follow-up of 712 days (IQR, 392-768 days), all-cause mortality was significantly lower in the IMP group than in the Non-IMP group (11.90% vs. 30.12%; log-rank P < 0.0001). The composite endpoint was also lower in the IMP group (29.76% vs. 47.98%; log-rank P < 0.0001). After propensity score matching, the IMP group had consistently lower all-cause mortality and composite endpoints than the Non-IMP group (log-rank P = 0.0002; log-rank P = 0.041). Multivariable Cox proportional hazards model for all-cause mortality with overlap weighting demonstrated that CONUT improvement was associated with lower all-cause mortality (HR, 0.357; 95% CI, 0.205-0.624; P = 0.0003).CONCLUSION: In hospitalized patients with acute HF and moderate to severe malnutrition, improvement in CONUT score during hospitalization was associated with lower post-discharge mortality and rehospitalization.