BACKGROUND Higher body mass index (BMI) is associated with improved heart failure (HF) survival, but the role of waist circumference (WC) in HF outcomes has not been studied. RESULTS A total of 344 patients with advanced systolic HF had WC and BMI measured at presentation. High WC was defined as ≥88 cm in women and ≥102 cm in men, and high BMI as ≥25 kg/m(2). Two-year urgent heart transplant (UT)-free survival in high vs normal WC groups was 77.9% vs 64.3% (P = .025) and in high vs normal BMI was 89.8% vs 58.2% (P < .001). After multivariable adjustment, normal WC compared with high WC was associated with higher all-cause mortality (risk ratio [RR] 2.76, 95% confidence interval [CI] 1.34-5.71) and higher risk of death/UT (RR 2.14, 95% CI 1.25-3.68). The best outcomes were seen in those with both high WC and high BMI. CONCLUSIONS High WC, an alternative anthropometric index of obesity more specific to abdominal adiposity, high BMI, and the combination of high WC/high BMI were each associated with improved outcomes in this advanced HF cohort, lending further support for an obesity paradox in HF. The role of body composition in HF survival should be a focus of future investigation.