Background:Cold hemodynamic profile assessed on physical examination predicts survival, although it has low specificity and low reproducibility. We herein propose a new cold profile definition (Cold Modified 2014), including renal and hepatic damage. The aim of the study was to evaluate the additional prognostic value of clinical and laboratory identification of hypoperfusion over hypotension in the setting of advanced acute heart failure (AHF).Methods and Results:After preliminary analysis on derivation cohort, we studied 223 consecutive NYHA III–IV patients admitted with AHF requiring intensive care. Cold Modified 2014 definition included non-invasive hemodynamic assessment, renal and hepatic injury. Primary endpoint was a composite of cardiac death, urgent heart transplantation and mechanical circulatory support at 6 months. In the validation cohort (age, 60.5±12.8 years; ejection fraction 25.6±8.2%, systolic blood pressure [SBP] 104.3±26.1 mmHg) 77 reached the composite endpoint. Among SBP, ADHERE model, cold profile at admission and INTERMACS profile at 48 h, cold profile had the best diagnostic accuracy. On multivariate analysis only cold profile and INTERMACS predicted events, while SBP <115 mmHg and high risk on ADHERE did not. Cold Modified 2014 was more accurate than the old definition. Net reclassification improvement for Cold Modified 2014 over the old definition was 25.8%.Conclusions:This prospective study demonstrated the additional prognostic role of hypoperfusion assessment over hypotension in patients with AHF. Cold Modified 2014 improved risk stratification in advanced AHF patients. (Circ J 2015; 79: 398–405)