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Red cell distribution width (RDW) has been associated with cardiovascular disease, but the relation to heart failure (HF) is unclear. We investigated the association between RDW and incidence of first hospitalization due to HF in a population-based cohort.Red cell distribution width was measured in 26 784 subjects (aged 45–73 years, 61% women), without history of myocardial infarction (MI), stroke or HF, who participated in the Malmö Diet and Cancer study during 1991–1996. Incidence of HF was identified from the national Swedish hospital discharge register during a mean follow-up of 15 years and studied in relation to RDW. During follow-up, 773 subjects (55% men) were hospitalized due to HF, of whom 166 had an MI before or concurrent with the HF. After adjustment for potential confounding factors (including history of coronary revascularization, biological, lifestyle, and socio-economic factors), the hazard ratios (HR) for HF were 1.47 (95% CI: 1.14–1.89) in the top compared with the bottom quartile of RDW (P for trend 0.005), censoring subjects with incident MI before HF. The results were similar when all hospitalized HF cases were included (HR: 1.33, 1.07–1.66), (P for trend 0.020). After additional adjustment for N-terminal pro-B-type natriuretic peptide, cystatin C and high-sensitive C-reactive protein in a randomly selected subcohort (n= 4761), HR was 1.64 (CI: 0.90–3.00) comparing the top vs. bottom quartile of RDW.Red cell distribution width was found to be associated with long-term incidence of first hospitalization due to HF among middle-aged subjects.