Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of < or = 100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.