The aim of this study was to evaluate the association between heart rate turbulence (HRT) parameters and clinical, biochemical, echocardiographic, and electrocardiographic measures of heart failure (HF) in a large, prospectively enrolled population of patients with HF to determine whether HRT could be considered a marker of HF advancement and progression, giving insight into hemodynamic changes as well as changes of the autonomic nervous system. In 487 patients with HF (mean age 63 years), the following tests were performed: 12-lead surface electrocardiography, echocardiography, chest x-rays, N-terminal-pro-brain natriuretic peptide levels, and 24-hour Holter monitoring for HRT and heart rate variability analyses. Most patients were in New York Heart Association class II (82%) and had a mean left ventricular (LV) ejection fraction of 37 +/- 14%. Both HRT parameters, but especially turbulence slope, were significantly correlated with clinical indexes of HF (the third heart sound, peripheral edemas, jugular distension, and pulmonary congestion). Patients in New York Heart Association class III had significantly lower turbulence slopes and greater turbulence onset values than those in class II. Significant correlations were found between HRT parameters and the LV ejection fraction as well as with LV diameters. HRT parameters were significantly correlated with N-terminal-pro-brain natriuretic peptide levels (r = -0.47, p <0.001 for turbulence slope). Multivariate analyses showed that abnormal HRT parameters were independent predictors of HF severity measured by New York Heart Association class III and a LV ejection fraction <40%. In conclusion, the findings indicate that in patients with HF, HRT reflects well the severity of HF and associated LV dysfunction, which were verified in this study by a series of established clinical, echocardiographic, and biochemical parameters.