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Background: Heart failure with reduced ejection fraction (HFrEF) poses a significant global public health challenge, characterized by frequent episodes of acute decompensation that necessitate hospitalization and carry high morbidity and mortality risks. In India, the rising prevalence of HFrEF underscores the need to identify context-specific triggers of acute decompensation to develop targeted interventions for improving patient outcomes. Material & Methods: This hospital-based, observational study analyzed triggers of acute decompensation in 336 HFrEF patients admitted to two tertiary care hospitals in India from January to April 2024. Data were retrospectively extracted from medical records, including demographic information, clinical characteristics, and details on decompensation triggers. Outcomes recorded were length of hospital stay, in-hospital mortality, and ICU admission. Statistical analysis involved chi-square tests, t-tests, and multivariate logistic regression. Results: The mean age of the patients was 65.3 years, with 60.1% being male. Common triggers included excessive salt and water consumption (30.1%), non-adherence to medication (25%), acute infections (19.9%), myocardial ischemia (17.6%), and systemic hypertension (14.9%). The mean hospital stay was 7.2 days, in-hospital mortality was 7.4%, and 20.2% required ICU admission. Excessive salt and water consumption and non-adherence to medication were significantly associated with ICU admission (p < 0.001). Independent predictors of in-hospital mortality included age (OR: 1.05, p < 0.001), excessive salt and water consumption (OR: 2.5, p = 0.007), non-adherence to medication (OR: 2.1, p = 0.021), and renal failure (OR: 3.0, p = 0.005). Conclusion: This study identifies critical triggers of acute decompensation in HFrEF patients, particularly dietary noncompliance and medication non-adherence. Emphasizing patient education and adherence support is essential for managing heart failure effectively. Addressing these factors through comprehensive care plans can reduce hospitalizations and improve patient outcomes. Future research should validate these findings through prospective studies and explore tailored interventions to mitigate the risks associated with acute decompensation. [ABSTRACT FROM AUTHOR]