Aim: Ischemic hepatitis (IH), also called hypoxic hepatitis, is a form of acute hepatocellular injury often seen in advanced heart failure (HF) with hemodynamic compromise. However, its prevalence and prognostic significance in emergency department (ED) patients with decompensated HF remain insufficiently defined. This study aimed to investigate the prevalence of IH, clinical and laboratory outcomes, intensive care unit (ICU) admission, and in-hospital mortality associated with IH in this patient group. Material and Methods: This retrospective study included adult patients aged ≥18 years with NYHA class III-IV decompensated HF who presented to the ED between January 2020 and January 2024. IH was defined as ≥10-fold elevation of AST and/or ALT above the upper normal limit after excluding alternative hepatocellular injury causes. Clinical, laboratory, ultrasonographic data, and outcomes were compared between IH (+) and IH (–) patients. Results: Among 378 patients, 45 (11.9%) developed IH. IH (+) patients had lower systolic/diastolic blood pressures and higher heart rates, along with significantly elevated AST, ALT, INR, bilirubin, troponin, and creatinine, but reduced albumin and sodium levels, compared with IH (–) patients (all p<0.001). ICU admission (75.6%, n=34) vs. (21.6%, n=72), and in-hospital mortality (35.6%, n=16) vs. (6.0%, n=20), were markedly higher in IH (+) patients (p<0.001). Multivariable analysis identified elevated transaminases, INR, bilirubin, troponin, and tachycardia as independent predictors of IH. Conclusion: IH is a relatively frequent yet severe complication in ED patients with advanced decompensated HF, strongly associated with increased ICU need and mortality. Prompt recognition and hemodynamic stabilization may improve survival outcomes.